Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Han Na Kim
PGY-3
February 7, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•The patient is a 43-year-old Chinese
man who presents with fatigue and
weakness for 3 weeks.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Over the past month, he has been feeling weak and lightheaded. He
has had decreased appetite and 4 lb weight loss.
• A week prior to presentation, he was diagnosed with pneumonia when
he presented to the Gouverneur clinic with fevers and cough. He was
treated with 5 day course of azithromycin.
• One day prior to admission, he presented to clinic for follow-up of his
symptoms. During the visit, labs were drawn and results were notable
for white blood cell count of 8 with 38% blasts, hemoglobin of 6.4, and
platelet count of 63.
•The patient was sent to the Bellevue emergency department for further
inpatient workup and management.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
• Hypertension
•Past Surgical History:
• None
•Social History:
• Denies use of tobacco and drinks alcohol occasionally
• From China, lives with wife and three children, works as food
deliverer
•Family History:
•Father: Gastric Cancer
•Allergies:
•No Known Drug Allergies
•Medications:
• None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: pale Asian man lying in no acute distress
Vital Signs:
T 98.0 ºF BP126/87 HR 78 RR 16 O2 sat 100%
HEENT: pale conjunctiva
Guaiac was negative
Remainder of the physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC:
7.8 > 5.8/16.9 < 62
diff : Neut 31%, Band 5%, Lymph 21%, Mono 3%, Meta 1%, Myel 2%,
Promyel 4%, Blast 33%
smear: Auer Rods
• Basic Metabolic panel: within normal limits
• Hepatic panel: within normal limits
• PT/INR: 1.15
• Haptoglobin: 292 (30-200)
• LDH: 468 (110-225)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
PTT: within normal limits
Fibrinogen: 443 (152-427)
Uric Acid: 6.8 (3.6-7.7)
Working Diagnosis
• The working diagnosis at this time was
acute myeloid leukemia.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient was transfused and bone marrow biopsy was
performed revealing acute myeloid leukemia. He was
immediately started on induction chemotherapy.
• On hospital day 7, he developed neutropenic fever to 104 ºF
thought to be from pneumonia and possible phlebitis.
• He was started on broad spectrum antibiotics with
vancomycin/cefepime and blood cultures later grew out gram
negative rods.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The next day, he further decompensated with new hemoptysis,
persistent high fevers, tachycardia, tachypnea and severe
hypoxia with arterial blood gas of 7.48/27/55/20/2.0.
• He was transferred to the intensive care unit and intubated for
hypoxic respiratory failure.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging Study
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• His chest x-ray was concerning for acute respiratory distress
syndrome and he was ventilated with lung protective strategy
on volume control of 450 ml, RR 20, PEEP 12, FiO2 of 70%.
• He was further treated for septic shock with
vancomycin/imipenem/metronidazole and norepinephrine.
• Gram negative rods on blood cultures were finalized as
pansensitive Klebsiella pneumoniae and his antibiotics were
narrowed.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• By hospital day 12, ARDS dramatically improved requiring
minimal PEEP and FiO2. Sepsis improved and he was
weaned off of norepinephrine.
• The next day, he was successfully extubated after a week of
intubation and on hospital day 15, he was transferred to the
Hematology service for further care.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• The final diagnosis of the patient is acute myeloid leukemia
complicated by neutropenic fever and septic shock secondary
to pneumonia, phlebitis and Klebsiella bacteremia leading to
acute respiratory distress syndrome.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS