Southwest Journal of Pulmonary, Critical Care and Sleep

Mily Sheth, MD

Carmen Luraschi, MD

Matthew P. Schreiber, MD, MHS

University of Nevada School of Medicine: Las Vegas

Department of Internal Medicine

Division of Pulmonary/Critical Care

Las Vegas, NV

History of Presenting Illness:

A 23-year-old Ethiopian woman with a known history of systemic lupus erythematosus (SLE) but of unknown duration presented with the chief complains of cough and generalised weakness for 1 week. She had a recent history of travelling to Ethiopia 3 months ago for 3 weeks. She complained of subjective fevers and one episode of blood tinged sputum. She also complained of fatigue and an episode of syncope which prompted her hospitalization.

PMH, SH and FH:

The patient has a past medical history of SLE diagnosed in Ethiopia of which no records were available. She is a student and denied alcohol, smoking or drug abuse. She denied any family history of autoimmune disorders. She did not take any medications at home.

Physical Examination:

Initial admission vital signs were temperature of 100.5 F, heart rate of 130, respiratory rate of 30 and blood pressure of 92/48. Oxygen saturation was 96% on 2 L/min via nasal cannula.

She appeared to be in moderate distress but was speaking in full sentences. Skin examination revealed a malar rash on her face. Her upper and lower extremities had excoriated plaques. Her anterior chest had flat non blanchable, macular rash. CVS examination revealed tachycardia without any murmurs. Respiratory exam was positive for bilaterally diffuse bronchial breath sounds. The remainder of her exam was within normal limits.

Laboratory and Radiology:

CBC: WBC 6.7 million cells/mcL, hemoglobin 7.1 g/dL, hematocrit 20.9, platelet 160,000 cells/mcL

Renal panel: within normal limits.

Troponin 0.01, creatine kinase 457 U/L, lactic acid 1.1 mm/L, HIV non-reactive

Liver function tests: AST 288 U/L, ALT 93 U/L alkaline phosphatase 136 IU/L, total bilirubin 0.9 mg/dL

Radiography:

Her initial chest x-ray is shown in figure 1. It was interpreted as showing diffuse pulmonary infiltrates, right lung greater than left. No pleural effusions. No pneumothorax.

Figure 1. Initial chest x-ray.

In a patient with these characteristics, which other test(s) would you order? (Click on the correct answer to proceed to the second of five panels)

Reference as: Sheth M, Luraschi C, Schreiber MP. February 2015 critical care case of the month: a blood mess. Southwest J Pulm Crit Care. 2015;10(2):63-9. doi: http://dx.doi.org/10.13175/swjpcc148-14 PDF