NYU Medical Grand Rounds Clinical Vignette

Han Na Kim PGY-3 February 7, 2012

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Chief Complaint

• The patient is a 43-year-old Chinese man who presents with fatigue and weakness for 3 weeks.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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) PTT: within normal limits Fibrinogen: 443 (152-427) Uric Acid: 6.8 (3.6-7.7)

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Working Diagnosis

• The working diagnosis at this time was acute myeloid leukemia.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 thought to be from pneumonia and possible phlebitis.

ºF • He was started on broad spectrum antibiotics with vancomycin/cefepime and blood cultures later grew out gram negative rods.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Imaging Study

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.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS