Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Rachel Solomon, PGY-3
March 13, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
43 year old Chinese male with fever, chills,
and cough for two weeks; admitted with
new diagnosis of acute myelogenous
leukemia on CBC with 33% blasts, Auer
rods, hemoglobin 5.8 and platelets of
62,000.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 2 weeks prior to admission:
• private MD with fever, chills, cough
• also increased weakness / fatigue x 1 mo
• treated for pneumonia
• Day of admission to Bellevue Hospital Center:
•
admitted to Oncology service with new dx: AML
•
HD #2: initiation of chemotherapy with cytarabine, idarubicin
•
HD#8: T104°F, HR126, BP116/69, RR26, SaO2 mid-
80%RA Acutely ill-appearing with cough, hemoptysis, and
diffuse rales on auscultation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Studies
• CBC:
• WBC 0.9, 83% neutrophils: ANC 747
• hemoglobin 6.7mg/dl, platelets 14,000
•ABG: pH 7.48, CO2 27, O2 55, HCO3 20, SpO2 90%
•Chest X-Ray:
dense perihilar consolidation in right upper lung field
 focal airspace opacity in left upper lung field


Urinalysis: no protein, glucose, blood

Blood Cultures:

4/4 bottles, Klebsiella Pneumoniae
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chest X-ray: HD #1 and HD#8
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course

Working Diagnosis:
• Neutropenic Fever and Multi-focal Pneumonia

MICU Day 1:
• Intubated, pressors
• Antibiotics: vancomycin, imipenem, amikacin
• Chemotherapy held
• Lung-protective ventilation for likely ARDS

MICU Day #6:
• pressors discontinued, extubated
• Continued fevers: caspofungin
•
HD #19: CT chest, ill-defined diffuse densities suggest aspergillosis
• Started on amphotericin
• Fever curve downtrended
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
CT Chest – HD #19
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course

HD #35: discharged to home to complete
course of oral voriconazole
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Neutropenic Sepsis
•
Klebsiella bacteremia
• complicated by ARDS and presumed
aspergillosis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS