Transcript Journal Club

NYU Medicine Grand Rounds
Clinical Vignette
Ben Milgrom, PGY-2
11/13/13
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• Mr. C is a 64 year old man with a history of
COPD who presented with 1 week history of
gnawing epigastric pain
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient has been admitted multiple times over the
previous year for COPD exacerbations.
•Most recent admission was 3 weeks prior to the
current admission.
•At that time, he was treated with nebulizers, steroids,
and antibiotics with improvement in his respiratory status
•He was discharged with prescriptions for a prednisone
taper, fluticasone/salmeterol and albuterol inhalers, and
azithromycin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Following discharge, the patient’s respiratory status improved
to baseline
•The patient reports an episode of unprotected sex 2 weeks ago
(1 week following hospital discharge)
•Shortly thereafter, he developed a nontender ulcerated lesion
on the glans penis
•He then developed a maculopapular rash across his chest and
abdomen
•Skin lesions were asymptomatic so the patient did not seek
medical care
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•One week prior to admission, he developed gnawing epigastric
pain which had become progressively more severe.
•Pain was described as constant, nonradiating, and not
associated with food.
•He also had numerous watery bowel movements daily, without
blood or melena
•He denied nausea or vomiting, change in skin or eye color,
change in medications other than the prescribed azithromycin
and prednisone.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•COPD (GOLD stage III)
•Hypertension
•Past Surgical History:
•Hemorrhoidectomy
•Social History:
•30 pack year smoking history quit 6 years ago
•Denies alcohol or illicit drug use
•Immigrated from Ghana 40 years ago, has not
left NYC in 5 years
•Works as a musician
•Lives with alone in an apartment in Manhattan
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Family History:
•No known family medical history
•Allergies:
•No known drug allergies
•Medications:
• 15 day prednisone course and 5 day
azithromycin course recently completed
•Fluticasone/salmeterol inhaler BID
•Amlodipine 10 mg PO daily
•Albuterol inhaler PRN dyspnea
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: African American man resting in no distress
•Vital Signs: Temperature 101.5 F, blood pressure 95/65,
heart rate 105, RR 16, 98% O2 saturation on room air
• Maculopapular eruption on face, neck, torso, abdomen,
and arms
• Hepatomegaly 5 cm below costal margin, tenderness in
epigastrium with guarding, no rebound, abdomen soft
•Ulcerated lesion on glans penis without discharge
•Remainder of physical exam was within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: Platelets 30
•Remainder of CBC was within normal limits
•Basic Metabolic panel:
•Sodium 130, Potassium 5.7, Chloride 98, CO2 24,
BUN 40, Creatinine 1.7
•Hepatic panel:
•AST 11,126, ALT 7, 840, Alkaline Phosphatase 239,
Total Bilirubin 2.0, Direct Bilirubin 1.3, Total Protein 5.4,
Albumin 2.8
•Lipase 175 (< 66), INR 2.9,
salicylates/acetaminophen/ethanol levels negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•ECG: Sinus tachycardia
•Chest X-Ray: No infiltrate or effusion
•CT Abdomen/Pelvis w/o contrast: Low attenuation
of the liver which may be due to fatty infiltration
versus edema/inflammation
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Acute liver failure
• Differential diagnosis is acute viral
hepatitis, reactivation hepatitis in setting of
steroid use, versus toxic medication effect
from previous azithromycin use
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Sepsis alert was called and patient received
IV normal saline, vancomycin and
piperacillin/tazobactam
– N-Acteylcysteine IV was given
• Hospital Day 2:
– Tzanck smear performed on skin lesion which
was positive
– Viral hepatitis serologies were negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
– Papular lesions developed into vesicles
– Viral culture of penile lesion confirmed HSV-1
– HIV, CMV, VZV serologies negative
• Hospital Day 4:
– Synthetic liver function continue to worsen,
total bilirubin > 30, INR 5.0
– Transplant surgery confirmed patient would
not be a candidate given disseminated HSV
infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 5-8:
– Clinical status continued to deteriorate
– Patient developed respiratory distress
requiring intubation and mechanical
ventilation
– Chest CT showed multifocal infiltrates
concerning for pneumonia versus ARDS
– Hypotension developed requiring vasopressor
support
– Renal failure developed requiring
hemodialysis
Hospital Course
• Hospital Day 9-14
– The patient’s condition failed to improve
despite aggressive measures
– Goals of care discussion held with family
– Decision made to refer to hospice
Final Diagnosis
• Disseminated HSV-1 infection leading to
fulminant hepatic failure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Systems Error
• On review of records from previous hospital discharge,
an error was found in the discharge medications:
• Prednisone comes in 50 mg and 10 mg tabs
• The patient was meant to be prescribed 10mg tabs
with directions to take 5 tabs daily
• Instead, the patient was prescribed 50 mg tabs, and
was instructed to take 5 tabs
• The patient therefore took prednisone 250mg daily
instead of 50mg daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Systems Error
• The patient received an inappropriately high steroid dose
leading to disseminated HSV-1
• The error was not caught by pharmacist, nurse, or
discharging physician
• This systems error at discharge contributed to the
patient’s demise
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS