Transcript Journal Club

NYU Medicine Grand Rounds
Clinical Vignette
Elizabeth Park PGY2
Oct 16th 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• Mr. M is a 67 year-old male with a past
medical history of melanoma who presented
to an urgent care center with confusion,
mental "cloudiness," left hand weakness and
clumsiness for 3 days.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient’s melanoma was originally
diagnosed in 1998 by excisional biopsy.
• He had stable disease until 2008 when he
had a second lesion resected measuring 0.8
mm (pT1a (0.8) N0 M0 Stage 1A).
• He then presented again in April 2013 with
a large lesion on the right upper back with
fine needle aspiration demonstrating
malignant melanoma, + BRAF mutation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• CT chest and brain MRI revealed
metastatic disease in June and the patient
was begun on vemurafenib with good
systemic response.
• However the treatment was stopped at the
end of July secondary to skin rash and
transient transaminitis.
• He was then transitioned to ipilimumab
systemic therapy in August.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The day after his first infusion he began
experiencing confusion, mental "cloudiness,"
and left hand weakness.
• After his second ipilimumab infusion, he
was referred to urgent care for his
neurological symptoms.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Past Medical History:
• Melanoma
• Hypertension
• Hyperlipidemia
• Asthma
• Obstructive sleep apnea
• Benign prostate hypertrophy
• Past Surgical History:
• Uvulopalatopharyngoplasty and septoplasty in 2011
• Soft palate reduction 2008
• Skin excision 1998
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Social History:
• No history of smoking. Drinks about 4 glasses of wine
per week.
• Family History:
• No family history of melanoma
• Allergies:
• No known drug allergies
• Medications:
• simvastatin 40 mg daily
• losartan 50 mg daily
• tamsulosin 0.4 mg daily
• albuterol MDI as needed
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: alert and oriented to person, place
and time. In no acute distress.
•Vital Signs: list T: 98.4 BP: 156/99 HR: 74 RR:
16 and O2 sat: 97%
•Left pronator drift
•Finger to nose movement: dysmetric L>R
•Rapid alternating hand/foot movements and
fine finger movements: slower on L
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: Hgb 12.5 Hct 37.5
•Remainder of CBC was within normal limits
•Basic Metabolic panel: glucose 121
•Remainder of basic was within normal limits
•Hepatic panel:
•Hepatic panel was within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• MRI brain demonstrated multiple supra-and
infratentorial enhancing lesions in the bilateral
frontal, parietal, occipital and right temporal lobes,
as well as bilateral cerebellum. There was
apparent interval progression of disease
manifested by new lesions and increase in size of
the previously demonstrated lesions as well as
hemorrhage conversion of multiple lesions with
local vasogenic edema and mass effect.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Metastatic melanoma with acute
hemorrhages of brain metastases
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was started on dexamethasone 4
mg every 8 hours and levetiracetam 500 mg
twice a day
• Hospital Day 2:
– The patient was restarted on vemurafenib at
the recommendation of his primary medical
oncologist
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Stage 4 Metastatic Melanoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS