Transcript Clinical Vignette - Clinical Correlations

Department of Medicine
Grand Rounds
Clinical Vignette
Ilana Bragin
January 14 th, 2009
NYU Langone Medical Center
Internal Medicine Residency Program
Chief Complaint
The patient is a 61 year old Caucasian male who
presented with 2 weeks of increasing edema
and decreased urine output.
History of Present Illness
Approximately one year prior to presentation,
the patient presented with new onset ascites.
Work-up at that time included a diagnostic
paracentesis, which revealed atypical cells.
Subsequent CT scan showed a 6 cm mass at
the pancreatic tail and 3 cm omental caking.
Core biopsy showed moderately differentiated
adenocarcinoma consistent with
pacreaticoviliary cancer.
History of Present Illness
He was enrolled in a clinical trial and started on
Gemcitabine (Gemzar), Bevacizumab (Avastin), and
Erlotinib (Tarceva). He was also started on aldactone
for his ascites.
A follow up CT scan showed some improvement in
the size of the mass and the amount of ascites.
Six months later, routine labs revealed an increased
creatinine of 2.2 from his baseline of 1. The aldactone
was discontinued.
One week later, he presented to clinic with increased
edema (legs, hands, face), fatigue, and decreased
urine output. His creatinine at that time was 2.6.
Chemotherapy was held.
Additional History
Past Medical History:
– Hypothyroidism
– Benign Prostatic Hypertrophy
– Coronary Artery Disease
Past Surgical History:
– Coronary Artery Bypass Grafting, 4 years ago
Social History:
– No toxic habits
Family History:
– Non-contributory
Medications:
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Atorvastatin 20 mg at night
Aspirin 81 mg daily
Levothyroxine 125 mcg daily
Famotidine 20 mg twice daily
Darbepoetin alfa 200 mcg weekly
Gemcitabine, Bevacizumab, Erlotinib (HELD)
Physical Exam
Gen: sitting comfortably, no acute distress
Vital Signs: T 98, HR 80, BP 160/90, RR 16
Extremities: 3+ pitting edema bilaterally
The remainder of the physical exam was
normal
Laboratory
CBC: WBC- 2 Hgb-10.2 Platelets-13
– MCV 99, Differential: 44% Neut, 38% Lymph, 16% Monos
– Smear: occasional schistocytes
Basic Metabolic: BUN 44 Creatinine 2.6
– Remainder of values were within normal limits
Liver Function Panel: AST-152 ALT-106 Albumin 2.7
– Remainder of values were within normal limits
Coagulation Panel: INR-1.02 PTT-28.9
Fibrinogen-595
D-dimer-734
Fibrin Degradation Products >5
LDH 1951
Urinalysis: large blood, 3+ protein, 11-25 RBCs
Differential Diagnosis
Obstruction secondary to mass
Thrombotic Thrombocytopenic Purpura
(TTP)
Acute Tubular Necrosis (ATN) secondary
to chemotherapy regimen or infection
Glomerulonephritis
Nephrotic syndrome
Renal artery thrombosis
Hospital Course
A renal ultrasound was done:
– Kidneys normal in size, echotexture and parenchymal
thickness. No solid mass, hydronephrosis, shadowing
calculi or perinephric abnormality.
A renal MRI:
– Patent renal veins
Renal Biopsy:
– changes of thrombotic microangiopathy consistent
with TTP
Final Diagnosis
Renal Thrombotic Microangiopathy
consistent with Thrombotic
Thrombocytopenic Purpura (TTP)