Transcript LSU Medicine Case Conference

LSU Internal Medicine
Case Conference
“What the Bullae!"
10/02/2012
Jay Mansfield, MD
PGY I
Internal Medicine
“Worsening shortness of breath” x
several months
 76 year-old African American woman with
significant past medical history of ischemic
cardiomyopathy s/p AICD (last EF <20% in 12/2011),
hypertension, hyperlipidemia, CKD stage III,
peripheral vascular disease s/p left SFA stent (3
weeks prior) with left foot ischemic toes and
multiple ulcers presented to the ED complaining of
progressively worsening shortness of breath and
fatigue over the past several months.
 The patient started developing bilateral lower extremity
edema and claudication.
 She also developed orthopnea – having to sleep
upright in a chair.
 She had previously been able to ambulate about 1½
blocks easily but now can only walk a few steps
before becoming short of breath.
 She denied any chest pain, nausea, vomiting, fever
or chills.
 The patient is not able to recall all her medications
and reports that she has not been adherent with her
medications.
 Past Medical History:
 As above plus
 Hypothyroidism
 Surgical History:
 Hysterectomy
 ICD (2010)
 Left SFA stents (3 weeks prior)
 Allergies:
 Penicillin/Sulfa  swelling and rash
 Home Medications:
 Aspirin 81 mg Daily
 Clopidogrel 75 mg Daily
 Simvastatin 40 mg QHS
 Carvedilol 3.125 mg BID
 Lantus 10 Units QHS
 NovoLog 5 Units BID
 Levothyroxine 50 mcg Daily
 Ondansetron 4 mg PO q8hrs prn nausea
 Family History
 NC
 Social History:
 History of tobacco use >20 years previously with 5-pack
year history
 No ETOH, no illicit drugs
 Lives alone
 Has three daughters who live close and visit frequently
 Health Maintenance:
 PCP at LSU Medicine Clinic (Dr. Lacour)
 Up-to-date on Influenza and Tdap
 Unknown Pneumovax
 Mammogram WNL (1/2012)
 No colonoscopy
 Review of Systems
 Negative except per HPI
 Temp
 Pulse
 RR
 BP
 Pulse Ox
 Weight
 Height
 BMI
99° F
93
20
131/57
97% on RA
77 kg
124 cm
50
 General:
 AAOx3, no acute distress
 HEENT:
 NCAT, PERRL, EOMI, clear oropharynx
 Neck:
 Supple. No Carotid bruits. JVP 12 cm H2O
 Cardiovascular:
 Regular rate and rhythm. No murmurs or rubs.
 Pulmonary:
 CTA bilaterally, no wheezes/rhonchi/crackles
 Abdomen:
 Nondistended, bowel sounds present, soft , non tender,
obese
 Extremity:
 Dorsalis pedis and Posterior tibial pulses not palpable.
2+femoral and radial pulses bilaterally. 2+ pitting edema
bilaterally in lower extremities to lower back. 1+pitting
edema in LUE. No palpable cords.
 Skin:
 No rashs, no bruises.
 Left foot bandaged with multiple ischemic toes and
wounds with purple stained skin from gentian violet
preparation
 Neurologic:
 Face symmetric, tongue and uvula midline.
 Hearing grossly intact.
 Muscle strength 5/5 x 4
 Decreased sensation to pain and light touch over
lower extremities especially feet bilaterally
Day of Admission
 WBC
 Hgb
 Hct
 PLT
 MCV
 RDW
 Seg
 Bands
 Lymphs
 Monos
 Basophils
12.4
12.4
39.7
161
74.8
17.8
80%
13%
1%
5%
1%
(4.5-11.0)
(80-100)
(11.5-14.5)
 Na
 K
 Cl
 Bicarbonate
 BUN
 Creatinine
 GFR
 Glucose
 Ca++
 Mg++
 Phos
136
4.5
104
21
(24-32)
30
(7-25)
1.60 (0.5-1.10)
38
(>60)
239
(65-99)
8.99.78
1.9
3.4






Total Protein
Albumin
Total Bilirubin
AST
Alkaline Phosphatase
ALT
 BNP
 TSH
 Free T4
6.8
2.9
2.5
34
114
14
(3.4-5.0)
(<1.3)
3928 (<100)
4.52
0.77
EKG
Day of Admission
 First degree A-V block
 Cannot rule out anterior myocardial infarction,
age undetermined
 Low QRS voltage in limb leads
 No significant change from previous tracing
Chest X-Ray
Day of Admission
 “Dual lead pacemaker again noted.
 The cardiomediastinal silhouette is stable with
calcifications of the aortic knob and four-chamber
cardiac enlargement.
 Bronchovascular marking pattern is unchanged. There
is no evidence of pulmonary edema.
 The lungs are clear. There is no focal airspace
consolidation, pleural effusion, or evidence of
pneumothorax.
 Again noted is osteopenia and thoracic kyphosis.”
 Patient was admitted to Medicine
 IV furosemide 40mg q12 hours initiated with strict
I/O’s
 Home medications continued
Hospital Day #3
 Patient was noted by Primary Care team to have





developed multiple hemorrhagic bullae on her right
lower extremity
She was also noted to have altered mental status
Medical ICU, General Surgery and Infectious Disease
services were consulted
Labs, cultures, and ABG were obtained
Patient was placed on NRB
Patient was empirically started on Vancomycin,
Clindamycin, and Ciprofloxacin
 Temp
 Pulse
 RR
 BP
 Pulse Ox
97° F (96-99.9 ° F)
98
20
123/63
96% on 3L NC
 General:
 Awake, lethargic, no acute distress
 HEENT:
 NCAT, PERRL, EOMI, clear oropharynx
 Cardiovascular:
 Regular rate and rhythm. No murmurs or rubs.
 Pulmonary:
 CTA bilaterally, diffuse expiratory wheezes present; no
crackles, good air movement
 Abdomen:
 Nondistended, obese, bowel sounds present, soft ,
non tender
 Extremity:
 2+ Radial pulses bilaterally. PT and DPs not palpable
secondary to edema. 2+ pitting edema LE bilaterally to
upper thighs. Left foot dressed in clean bandage.
Multiple ischemic toes on Left foot.
 Skin:
 Multiple hemorrhagic bullae to anterior and medial
aspect of RLE measuring 4x2cm. Posterior aspect of
RLE near popliteal fossa where bullae erupted, weeping
serosanguinous fluid with associated erythema and
warmth.
Laboratory Data I Day #3
 WBC
 Hgb
 Hct
 PLT
 MCV
 RDW
 Seg
 Bands
 Lymphs
 Monos
 Basophils
2.6
13.8
43.6
110
73.7
18.5
52%
13%
17%
16%
1%
(4.5-11.0)
(130-400)
(80-100)
(11.5-14.5)
Laboratory Data II Day #3
 Na
 K
 Cl
 Bicarbonate
 BUN
 Creatinine
 GFR
 Glucose
137
3.7
104
23 (24-32)
29
1.24 (0.5-1.10)
51 (>60)
38 (65-99)
 Ca++7.99.66
 Mg++
1.5
 Phos
3.4
 Blood cultures pending
 ABG 7.45/40/235/28/100% on 100% NRB
Laboratory Data III Day #3






Total Protein
Albumin
Total Bilirubin
AST
Alkaline Phosphatase
ALT
 INR
 PT
 PTT
 Lactic Acid
4.8
1.8
2.7
31
58
12
(6.0-8.0)
(3.4-5.0)
(<1.3)
2.0 (0.9-1.1)
21.7 (9-12.7)
40.3 (24-37)
1.6
Hospital Course: Day #3
 Patient was given a total of 2 amps of D50 and some
juice. Patient’s mental status returned to baseline.
Repeat accucheck was 96.
 Patient underwent Ultrasound of right lower extremity
– no DVT
 Patient was transferred to MICU for continued
monitoring and management
Hospital Course: Day #3
 Transfer Antibiotic Medications:
 Ciprofloxacin
 Vancomycin
 Clindamycin
 Tigecycline
Hospital Course: Day #3
 Patient’s bullae began to desquamate and increase in
number: affected anterior thigh area measured 8x4cm,
posterior fossa skin involvement measured ~12cm in
length
 Patient had no mucosal involvement
 New bullae appeared on patient’s suprapubic area with
notable erythema and extreme tenderness 4x2cm
 Right upper extremity became more edematous and
extremely tender to touch, no bullae were noted,
increased erythema noted in RUE antecubital fossa
Hospital Course: Day #3
 Dermatology was consulted and performed bedside
examination and punch biopsy of one of the bullae on
patient’s right lower extremity
Hemorrhagic Bullae Suprapubic
Anterior Thigh Right Lower Extremity
Medial Right Lower Extremity
Lateral Right Lower Extremity
Right Upper Extremity
Hospital Course Morning Day #4
 Patient stated she felt better.
 Patient only complaining of pain in right arm and right
hand
 Oriented to person, place. Confused about exact date.
 Small bullae noted in RUE antecubital fossa
measuring 0.5x0.5cm
 Other bullae and lesions appeared stable
Laboratory Data I Morning Day #4
 WBC
 Hgb
 Hct
 PLT
 Seg




2.7 (4.5-11.0)
12.9
40.1
111
(130-400)
71%
Bands
8%
Lymphs
13%
Monos
8%
Basophils 0%
Laboratory Data II Morning Day #4
 Na
K
 Cl
 Bicarbonate
 BUN
 Creatinine
 GFR
 Glucose
 Anion Gap
139
4.4
101
25
31
1.55
40
92
18
 Ca++
 Mg++
 Phos
(7-25)
(0.5-1.10)
(>60)
(<10)
7.49.32
1.4
4.5
Laboratory Data III Day #3






Total Protein
Albumin
Total Bilirubin
AST
Alkaline Phosphatase
ALT
 BNP
3923 (<100)
 Lactic Acid 4.2 (0.3-2.4)
4.2
1.6
3.2
61
44
15
(6-8)
(3.4-5.0)
(<1.4)
(<45)
Hospital Course: Day #4
 Patient became hypotensive requiring pressor support
with total of 2 pressors: Levophed and Vasopressin
 Patient became more altered and was intubated to
protect her airway
 Patient’s UOP significantly declined despite being on a
lasix drip
 Patient was transfused albumin to help with diuresis
Hospital Course: Day #4
 X-Ray of Right Lower Extremity revealed extensive
edema, no subcutaneous emphysema
Significant Laboratory Data Day #4
 Lactic Acid
 Bicarbonate
 Creatinine
 WBC
 Bandemia
 Platelets
 INR
 PT
 CK
 CRP
 Troponin
1.6  4.2  10.4
21  25  12  6
1.24  1.55  1.95  2.41
2.6  2.7  10.1  14.3
13% 27% 8%  35%
110  131  111  97  49
2  3.9
21.7  43.1
608
16.9
1.88
 Patient became bradycardic and hypotensive, then
became pulseless
 Patient was resuscitated with chest compressions and
epinephrine
 Patient’s family decided to make the patient DNR if
another code were to occur
 Patient became hypotensive again despite pressor
support and died
Microbiology and Pathology Results
Microbiology and Pathology Results
 Blood cultures obtained on day of transfer to MICU
revealed Group A Streptococcus in two bottles
 Swab of right thigh lesion grew Group A Streptococcus
 Repeat blood cultures on day after transfer to MICU
had no growth
 Right upper thigh punch biopsy revealed
subepidermal vesicular dermatitis with thrombotic
vasculopathy, autolysis, and numerous interstitial
bacterial cocci
Streptococcal Toxic Shock Syndrome