Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Lindsay Innes, MD PGY2
September 20, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 58 year old man with a
medical history significant for acute
myelogenous leukemia (AML) complaining
of one week of tooth and throat pain, rigors
beginning the evening prior to admission,
and fever of 101°F on the day of
presentation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Diagnosed with AML 9 months prior to
presentation (trisomy 10), underwent 7:3
induction chemotherapy with rituximab,
cyclophosphamide and dexamethasone and
day 28 bone marrow biopsy showed complete
remission
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Over the following 3 months, treated at
Bellevue Hospital with 3 cycles high-dose
cytarabine (HiDAC).
•His course was complicated by multiple
episodes of neutropenic sepsis requiring
hospitalization.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Repeat bone marrow biopsy in June 2011 showed
persistent disease.
•The patient was subsequently treated with 5
cycles of decitabine in the 4 months prior to
admission with the last cycle 3 days prior to
admission
•Repeat bone marrow biopsy in September
showed persistent disease.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient was last admitted again early
September for neutropenic fever and multifocal
pneumonia. He improved with empiric
antifungal treatment and was discharged with
an 8 week course of voriconazole.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient had returned to his usual state of
health although complaining of persistent throat
and tooth pain since the time of his last discharge.
•The night prior to admission, the patient
developed rigors, and the following morning, his
wife measured his temperature as 101°F.
•He came to oncology clinic and was referred to
the emergency department.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical/Surgical History:
•Hypertension
•Stroke in 2003 without residual deficits
•Atrial fibrillation
•Social History:
•Non-smoker, rare alcohol use
•Originally from the Phillipines, he moved to New York in October
2010 after his diagnosis of AML to seek medical care. He lives with
his wife. He had been a lawyer in the Phillipines.
•Family History:
•Per report, he had a niece and first cousin with leukemia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•No known drug allergies
•Medications:
•digoxin 0.125mg daily
•tamsulosin 0.4mg daily
•furosemide 20mg daily
•aspirin 81mg daily
•nexium 40mg daily
•simvastatin 20mg at night
•metoprolol 200mg daily
•acyclovir 400mg daily
•voriconazole 200mg twice daily (8 week course)
•oxycodone 5mg as needed every 4 hours
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: the patient appeared ill although in no
acute distress
•Vital Signs: list T: 98.6°F BP: 119/76 HR: 104
RR: 16 and O2 sat: 100% on room air
•Exam was significant for irregularly irregular heart
rate and bibasilar rales on lung auscultation. A left
internal jugular central venous catheter was in
place.
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: WBC 0.9, Absolute neutrophil count 18,
Hemoglobin 8, Hematocrit 22.6, Platelets 109
•Basic Metabolic panel: Sodium 127, Magnesium
1.2
•Remainder of basic was within normal limits
•Hepatic panel: within normal limits
•Urinalysis was negative for signs of current
infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Chest X-Ray: significant for resolving
multifocal pneumonia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Neutropenic fever of unknown etiology,
including, but not limited to the following
sources:
– Central line-associated infection
– Oropharyngeal infection
– Persistent pulmonary infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Treatment with a course of vancomycin
and cefepime was initiated and the patient
was continued on voriconazole and
acyclovir
– He continued to have fever to 101°F
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2:
– The patient was evaluated by oral and
maxillofacial surgery and the etiology of his
systemic illness was determined not to be
related to a dental or oropharyngeal
infection
– He defervesced and remained afebrile
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient remains afebrile and is clinically
improving but remains neutropenic. All
cultures are negative to date.
• He is awaiting evaluation for possible
allogeneic stem cell transplant. Discussion of
re-induction of chemotherapy is also ongoing.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Neutropenic fever in the setting of
treatment refractory AML
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS