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NYU Medical Grand Rounds Clinical Vignette. Benjamin Eckhardt, MD PGY-3 October 6, 2010. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. - PowerPoint PPT Presentation
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NYU Medical Grand Rounds Clinical Vignette
Benjamin Eckhardt, MD
PGY-3
October 6, 2010
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 39-year-old man presenting with three days of fever, cough, and shortness of breath.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
•The patient reported abrupt onset of subjective fevers, chills and headaches three days prior to admission.
•He noted his cough to be progressively worsening with minimal sputum production.
•On the day of admission, the patient’s symptoms progressed to include shortness of breath.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Additional History
•Past Medical History:
•None
•Past Surgical History:
•None
•Social History:
•From China, came to the United States four years prior to admission
•Works in a restaurant
•Denies recent travel or sick contacts
•Denies toxic habits
•Family History:
•noncontributory
•Allergies: No Known Drug Allergies
•Denies any Medications
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Physical Examination
•General: Ill-appearing man in moderate respiratory distress•Vital Signs: T:103.9 BP:104/49 HR:126 RR:25
O2 Sat: 83% on room air → 97% on
100% non-re-breather•Course rhonchi throughout lung fields, no wheezing•Cool extremities •The remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Laboratory Findings
CBC: White blood cells 7, 88% Neutrophils
Remainder of CBC was within normal limits
Hepatic Function Panel: AST: 98, ALT: 64
Remainder of LFTs were within normal limits
Basic Metabolic Panel was within normal limits
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Laboratory Findings
Lactate Dehydrogenase: 629 (110-225)
Influenza A Ag: positiveInfluenza B Ag: negative
Blood cultures and Urine cultures: No Growth
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Admission Chest X-Ray
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Cat Scan
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Cat Scan
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Cat Scan
Influenza pneumonia with Acute Respiratory Distress Syndrome
Working or Differential Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient’s respiratory status worsened in the emergency room requiring intubation
• The patient was started broad spectrum anti-microbials, and admitted to the medical intensive care unit.
• The antimicrobials included: – Oseltamivir 150mg twice daily– Vancomycin 1g twice daily– Piperacillin/tazobactam 4.5g four times daily– Azithromycin 500mg daily
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient remained febrile and dependent on ventilatory support after completing a five day course of oseltamivir and azithromycin
• Hospital 7: Due to the patient’s persistent fevers he was
switched to imipenem and restarted on the anti-virals oseltamivir and rimantidine
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Hospital day 8:Oseltamivir was replaced by intravenous peramiver
after being acquired from the Centers for Disease Control
• Blood cultures, urine cultures, tracheal aspirate cultures, Human Immunodeficiency Virus testing, sputum Acid Fast Bacilli testing and urine legionella antigen were all negative
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Hospital Day 12:A bronchoscopy was performed with negative gram
stain, Acid Fast Bacilli, Respiratory Syncytial Virus Polymerase Chain Reaction, bacterial culture and viral culture
• Hospital Day 15:Antibiotics and antivirals were discontinued for
worsening pancytopenia
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Hospital Day 16:Antiobiotics were restarted (cefepime then tigecycline) for neutropenic fever
• Hospital Day 19-34: The patient’s Hemodynamics improved and vasopressors were weaned off. His fevers abated
and his respiratory status improved allowing for capping of his tracheostomy. Additionally the patient’s blood counts improved and the patient was discharged home on hospital day 34.
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
•Influenza pneumonia complicated by acute respiratory distress syndrome
•Pancytopenia likely secondary to infection versus medication effect.
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS