NYU Medical Grand Rounds Clinical Vignette

Lindsay Innes, MD PGY2 September 20, 2011

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Chief Complaint

• The patient is a 58 year old man with a medical history significant for acute myelogenous leukemia (AML) complaining of one week of tooth and throat pain, rigors beginning the evening prior to admission, and fever of 101 ° F on the day of presentation.

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History of Present Illness

• Diagnosed with AML 9 months prior to presentation (trisomy 10), underwent 7:3 induction chemotherapy with rituximab, cyclophosphamide and dexamethasone and day 28 bone marrow biopsy showed complete remission

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History of Present Illness

• Over the following 3 months, treated at Bellevue Hospital with 3 cycles high-dose cytarabine (HiDAC). • His course was complicated by multiple episodes of neutropenic sepsis requiring hospitalization.

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History of Present Illness

• Repeat bone marrow biopsy in June 2011 showed persistent disease. • The patient was subsequently treated with 5 cycles of decitabine in the 4 months prior to admission with the last cycle 3 days prior to admission • Repeat bone marrow biopsy in September showed persistent disease.

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History of Present Illness

• The patient was last admitted again early September for neutropenic fever and multifocal pneumonia. He improved with empiric antifungal treatment and was discharged with an 8 week course of voriconazole.

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History of Present Illness

• The patient had returned to his usual state of health although complaining of persistent throat and tooth pain since the time of his last discharge.

• The night prior to admission, the patient developed rigors, and the following morning, his wife measured his temperature as 101 ° F. • He came to oncology clinic and was referred to the emergency department.

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Additional History

• Past Medical/Surgical History: • Hypertension • Stroke in 2003 without residual deficits • Atrial fibrillation • Social History: • Non-smoker, rare alcohol use • Originally from the Phillipines, he moved to New York in October 2010 after his diagnosis of AML to seek medical care. He lives with his wife. He had been a lawyer in the Phillipines.

• Family History: • Per report, he had a niece and first cousin with leukemia

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Additional History

• No known drug allergies • Medications: • digoxin 0.125mg daily • tamsulosin 0.4mg daily • furosemide 20mg daily • aspirin 81mg daily • nexium 40mg daily • simvastatin 20mg at night • metoprolol 200mg daily • acyclovir 400mg daily • voriconazole 200mg twice daily (8 week course) • oxycodone 5mg as needed every 4 hours

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Physical Examination

• General: the patient appeared ill although in no acute distress • Vital Signs: list T: 98.6

° F BP: 119/76 HR: 104 RR: 16 and O2 sat: 100% on room air • Exam was significant for irregularly irregular heart rate and bibasilar rales on lung auscultation. A left internal jugular central venous catheter was in place.

• Remainder of Physical Exam was normal

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Laboratory Findings

• CBC: WBC 0.9, Absolute neutrophil count 18, Hemoglobin 8, Hematocrit 22.6, Platelets 109 • Basic Metabolic panel: Sodium 127, Magnesium 1.2

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Remainder of basic was within normal limits

• Hepatic panel: within normal limits • Urinalysis was negative for signs of current infection

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Other Studies

• Chest X-Ray: significant for resolving multifocal pneumonia

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Working Diagnosis

• Neutropenic fever of unknown etiology, including, but not limited to the following sources: – Central line-associated infection – Oropharyngeal infection – Persistent pulmonary infection

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Hospital Course

• Hospital Day 1: – Treatment with a course of vancomycin and cefepime was initiated and the patient was continued on voriconazole and acyclovir – He continued to have fever to 101 ° F

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Hospital Course

• Hospital Day 2: – The patient was evaluated by oral and maxillofacial surgery and the etiology of his systemic illness was determined not to be related to a dental or oropharyngeal infection – He defervesced and remained afebrile

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Hospital Course

• The patient remains afebrile and is clinically improving but remains neutropenic. All cultures are negative to date.

• He is awaiting evaluation for possible allogeneic stem cell transplant. Discussion of re-induction of chemotherapy is also ongoing.

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Final Diagnosis

• Neutropenic fever in the setting of treatment refractory AML

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