Department of Medicine Grand Rounds Clinical Vignette

Ilana Bragin January 14 th , 2009 NYU Langone Medical Center Internal Medicine Residency Program

Chief Complaint

The patient is a 61 year old Caucasian male who presented with 2 weeks of increasing edema and decreased urine output.

History of Present Illness

Approximately one year prior to presentation, the patient presented with new onset ascites.

Work-up at that time included a diagnostic paracentesis, which revealed atypical cells. Subsequent CT scan showed a 6 cm mass at the pancreatic tail and 3 cm omental caking. Core biopsy showed moderately differentiated adenocarcinoma consistent with pacreaticoviliary cancer.

History of Present Illness

He was enrolled in a clinical trial and started on Gemcitabine (Gemzar), Bevacizumab (Avastin), and Erlotinib (Tarceva). He was also started on aldactone for his ascites.

A follow up CT scan showed some improvement in the size of the mass and the amount of ascites. Six months later, routine labs revealed an increased creatinine of 2.2 from his baseline of 1. The aldactone was discontinued.

One week later, he presented to clinic with increased edema (legs, hands, face), fatigue, and decreased urine output. His creatinine at that time was 2.6.

Chemotherapy was held.

Additional History

Past Medical History: – Hypothyroidism – Benign Prostatic Hypertrophy – Coronary Artery Disease Past Surgical History: – Coronary Artery Bypass Grafting, 4 years ago Social History: – No toxic habits Family History: – Non-contributory Medications: – Atorvastatin 20 mg at night – Aspirin 81 mg daily – Levothyroxine 125 mcg daily – Famotidine 20 mg twice daily – Darbepoetin alfa 200 mcg weekly – Gemcitabine, Bevacizumab, Erlotinib (HELD)

Physical Exam

Gen: sitting comfortably, no acute distress Vital Signs: T 98, HR 80, BP 160/90, RR 16 Extremities: 3+ pitting edema bilaterally

The remainder of the physical exam was normal

Laboratory

CBC: WBC- 2 Hgb-10.2 Platelets-13 – MCV 99, Differential: 44% Neut, 38% Lymph, 16% Monos – Smear: occasional schistocytes Basic Metabolic: BUN 44 Creatinine 2.6 –

Remainder of values were within normal limits

Liver Function Panel: AST-152 ALT-106 Albumin 2.7

–

Remainder of values were within normal limits

Coagulation Panel: INR-1.02 PTT-28.9

Fibrinogen-595 D-dimer-734 Fibrin Degradation Products >5 LDH 1951 Urinalysis: large blood, 3+ protein, 11-25 RBCs

Differential Diagnosis

Obstruction secondary to mass Thrombotic Thrombocytopenic Purpura (TTP) Acute Tubular Necrosis (ATN) secondary to chemotherapy regimen or infection Glomerulonephritis Nephrotic syndrome Renal artery thrombosis

Hospital Course

A renal ultrasound was done: – Kidneys normal in size, echotexture and parenchymal thickness. No solid mass, hydronephrosis, shadowing calculi or perinephric abnormality.

A renal MRI: – Patent renal veins Renal Biopsy: – changes of thrombotic microangiopathy consistent with TTP

Final Diagnosis

Renal Thrombotic Microangiopathy consistent with Thrombotic Thrombocytopenic Purpura (TTP)