Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Lisa Parikh, MD
PGY 2
5/8/2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 65 year old man who presents with a
cough x 1 week.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•He was in his usual state of good health until 4 weeks ago when
he traveled to Shelter Island in New York.
•Noted erythema on his right arm thought to be from a bug bite,
and when evaluated by a physician, was treated with a 10 day
course of cefalexin with resolution of the rash.
•In the following days, he then developed dry cough and
intermittent fevers, as high as 102F.
•Went to PMD the day prior to admission and was given a
prescription for moxifloxacin 400mg daily.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•On the morning of admission, patient rose from bed, felt dizzy,
and lost consciousness for 1 minute. He was diaphoretic and
dizzy when he awoke.
•Wife took him to his PMDs office where his blood pressure was
90/60 with heart rate in the 130s. An EKG showed atrial
fibrillation with rapid ventricular response.
•He was sent to the ER at Tisch hospital for evaluation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Family History:
•HTN
•None
•HLD
• Allergies:
•Rheumatoid Arthritis
•No Known Drug Allergies
•Gout
•Medications:
•Past Surgical History:
•lisinopril 5 mg daily
•None
•aspirin 81 mg daily
•Social History:
•ezetimibe/simvastatin 10mg/20mg
daily
•Former smoker,quit 35 yrs ago
•allopurinol 300mg daily
•No children at home
•moxifloxacin 400 mg daily
•Has pet cat x 1 year
•No recent travel
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•Well-nourished, well-developed man resting
comfortably in bed
•Vital Signs:
T:100.2 F, BP:119/73, HR:114,
RR:20 and SaO2: 99% room air
•Cardiovascular: irregularly irregular, 2/6 systolic
murmur at left lower sternal border and apex
•Pulmonary: decreased breath sounds at bases
bilaterally
•The remainder of the physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: hemoglobin 13.1
•Basic Metabolic panel: Sodium 130
•Hepatic panel: total bilirubin 1.5, AST 69
•Troponin: <.02
The remainder of the CBC, BMP and hepatic panels were
within normal limits.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•ECG: atrial fibrillation, ventricular rate 118,
left atrial dilitation, left ventricular
hypertrophy
•Chest X-Ray: no acute cardiopulmonary
disease
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Infection triggered atrial fibrillation
– Differential diagnosis of infection: upper
respiratory tract infection versus pneumonia
caused by viral or bacterial origin; tick-borne
illness
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Days 1-3
– Started on diltiazem 90mg q6hr for rate control
– Initially, moxifloxacin was continued, but changed
to ceftriaxone and azithromycin on hospital day 2.
– The patient continued to be febrile.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 4
–
–
–
–
–
Blood parasites positive for babesia with 1.0% parasitemia
Ceftriaxone was discontinued
Azithromycin 1g daily continued
Atovaquone 750mg was initiated
Chest CT showed a right upper lobe 4mm nodule, mild
upper lobe predominant centrilobular emphysema, areas of
non-segmental atelectasis involving both lower lobes
• Hospital Day 5
– Patient discharged home to complete 7 days of azithromycin
and atovaquone
Outpatient Follow-Up
• Day 1 after discharge
– Lyme Ab total blood: 5.4 (normal <0.91)
– Lyme IgM Ab titer: 5.59 (normal <0.91)
– Lyme western blot IgM: positive
Final Diagnosis
• Final diagnosis: Co-infection with Lyme
disease and babesiosis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS