nyu medical grand rounds clinical vignette pavan bhatraju md, pgy-ii october 11, 2011 u nited s...
TRANSCRIPT
NYU Medical Grand Rounds Clinical Vignette
Pavan Bhatraju MD, PGY-II
October 11, 2011
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 38 y/o M Firefighter presented 13 days after the 9/11 World Trade Center attack with 2 days of
• myalgias • fever • dry cough • pleuritic chest pain • progressive dyspnea with minimal exertion
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
•Usual state of good health when he arrived at the World Trade Center terrorist attack 20 minutes after the first tower collapsed
•Worked 16 hr days and did not use respiratory protection for 10 of 13 days
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 11 days PTA he developed a productive cough with blackish sputum that self-resolved in one day
• 2 days PTA he developed, cough, fever, myalgias, anterior pleuritic chest discomfort, and dyspnea on exertion with less than one block
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Additional History•Past Medical and
•None
•Surgical History•None
•Social History:•Smoking – 5 pack year history, stopped 20 years ago
•Family History:•Non-contributory
•Allergies: •None
•Medications:•none
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Physical Examination•General: muscular adult male, diaphoretic, in moderate distress
•Vital Signs: • T:38.6 BP:130/90 HR:120 RR:35 • O2 sat: 90% on room air
•Pulmonary: accessory muscle use, bibasilar decreased breath sounds
•Remainder of Physical Exam was Normal.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Laboratory Findings•CBC:
•WBC – 22,600 cells/mm3, • Differential (N = 91%, L = 3% M = 5% E = 1%)
•Remainder of CBC was within normal limits
•Basic Metabolic panel and Hepatic Panel: •Within normal limits
•Arterial Blood Gas on Room Air:•pH 7.46 •paO2 53 mmHg •paCO2 32 mmHg •HC03 23 mEq/L •O2 sat 89%
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Other Studies
•Chest X-Ray and CT Scan:
• Patchy ground glass opacifications
• Thickening of respiratory airways
• Bilateral pleural effusions.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Lung Injury– Dust Induced– Infection Related
• Bioterrorism induced Pneumonia (Anthrax)
Differential Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Hospital Day 1:– He was admitted to the MICU and treated with
• oxygen • levofloxacin • methylprednisolone
– Bronchoalveolar Lavage - 730,000 cells/ml (normal <250,000 cells/ml)
• Differential E = 70%, M = 18%, L = 8% N = 4%
– Total IgE was 58 ng/ml (normal <180 ng/ml)
– BAL fluid IgE was 0.4 ng/ml
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
MgFe
AuCa
SiAsbestos
GlassFly Ash
Elemental Analysis
• Hospital Day 9:– Clinically improved with repeat CT showing near complete
resolution.
– He was discharged with 3 weeks of corticosteroid therapy
• Pulmonary Function Tests:• FEV1 = 2.6 L (71%)
• FVC = 3.8 L (86%)
• FEV1/FVC = 68%
• DLCO = 23.1 ml/mmHg/min (77%)
• His oxygen saturation at rest (94%) dropped to 87% after a brisk walk of 150 ft.
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Worked as a firefighter for the next 3 years
• Developed increasing dyspnea and irritant sensitivity
• Repeat PFTs showed worsening airflow obstruction with a bronchodilator response
• Received disability retirement for reactive airways disease
Post-Discharge
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Acute Eosinophilic Pneumonia
• Subsequent onset of reactive airways disease
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS