Transcript Metabolic Syndrome Biomarkers and Lung Dysfunction Post 9/11

NYU Medical Grand Rounds
Clinical Vignette
Pavan Bhatraju MD, PGY-II
October 11, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 38 y/o M Firefighter presented 13 days after the
9/11 World Trade Center attack with 2 days of
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myalgias
fever
dry cough
pleuritic chest pain
progressive dyspnea with minimal exertion
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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
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
• O2 sat: 90% on room air
RR:35
•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
Differential Diagnosis
• Lung Injury
– Dust Induced
– Infection Related
• Bioterrorism induced Pneumonia (Anthrax)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Asbestos
Si
Elemental Analysis
Mg
Fe
Ca
Glass
Au
Fly Ash
Hospital Course
• Hospital Day 9:
– Clinically improved with repeat CT showing near complete
resolution.
– He was discharged with 3 weeks of corticosteroid therapy
• Pulmonary Function Tests:
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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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Post-Discharge
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Acute Eosinophilic Pneumonia
• Subsequent onset of reactive airways
disease
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS