June 2013 Critical Care Case of the Month: Scratch Where It Itches

Robert A. Raschke, M.D.

Banner Good Samaritan Medical Center

Phoenix Arizona

History of Present Illness

The patient is a 64 year old man who had suffered a non-orthostatic syncopal episode at home, shortly after the onset of lightheadedness.  The patient was transported to an outlying hospital where he was described to be confused, wheezing, and in respiratory distress.  He was said to be hypotensive (but no blood pressures were recorded in the transfer medical record). He was resuscitated with intravenous saline and underwent endotracheal intubation.

Past Medical History

On arrival at our hospital, further history revealed that the patient had a truncal rash for more than 20 years.  He had two previous syncopal episodes associated with delirium, hypotension and respiratory failure.  None of these episodes had any clear precipitating event.  After the first event, two years previously, a cardiac evaluation resulted in coronary artery bypass surgery. He also had a history of type 2 diabetes mellitus and was taking glipizide and metformin. There was a history of glaucoma and he was receiving timolol.

Physical Exam

Vital Signs: blood pressure 111/60 mm Hg, RR 16 breaths/min, HR 72 beats/min, temperature 37.5° C. 

HEENT: epistaxis and an oral endotracheal tube. The ETT tube had bloody pulmonary secretions.

Heart and lung: examination was unrevealing. 

Skin: venous and arterial puncture sites were oozing blood.  An erythematous and tan maculopapular rash covered his trunk (shown in figure 1).

Figure 1. Tan maculopapular rash on patient’s back (Panel A) and abdomen (Panel B)

Laboratory

Glucose 50 mg/dL (normal 70-100 mg/dL).

Activated partial thromboplastin time (aPTT) > 200 sec (normal < 30 seconds), prothrombin time (PT) > 120 secs (normal <30 seconds), and a fibrinogen of 39 mg/dL (normal 200-400 mg/dL), D-dimer 2.1 mcg/mL (normal <0.5 mcg/mL), haptoglobin <10 mg/dL (normal 41 - 165 mg/dL),  LDH 508 U/L (normal 140-280 U/L), hemoglobin 9 gms/dL (normal 13-17 gms/dL), platelet count 274,000 cells/mcL (normal 150,000-450,000 cells/mcL).

Which of the following is (are) true?

1. The glucose of 50 is just below the normal range and does not need treatment
2. The patient’s elevated D-dimer is diagnostic of a pulmonary embolism
3. The patients abnormal coagulation panel is most consistent with a history of taking anticoagulants
4. The coagulation panel is consistent with disseminated intravascular coagulation
5. All of the above

Reference as: Raschke RA. June 2013 critical care case of the month: scratch where it itches. Southwest J Pulm Crit Care. 2013;6(6):255-62. PDF

May 2013 Critical Care Case of the Month: Not an Air-Filled Sac

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 66 year old woman presented to outside hospital with hematemesis and hematochezia. She was intubated for airway control and received 4 units of packed red blood cells. She was transferred to the Mayo Clinic Arizona due to an inability to control her upper gastrointestinal bleeding. During her transfer she required vasopressors.

PMH

She has a history of hepatitis C with cirrhosis and esophageal varices. In addition, she was diagnosed with a B-cell lymphoma 3 months prior to admission and had received 3 cycles of rituximab, cyclophosphamide, hydroxydaunorubicin (doxorubicin), Oncovin® (vincristine) and prednisone (R-CHOP).  

Physical Examination

She was intubated and receiving oxygen at a FiO2 of 0.4.

Vital signs: P 100 beats/min; B/P 113/78 mm Hg; Afebrile; R 20 breaths/min; SpO2 99%

Chest: clear to auscultation.

Laboratory

Her hemoglobin was 9.3 g/dL and her hematocrit was 29%.

Radiology

Her admission chest x-ray is shown in Figure 1.

Figure 1. Admission portable chest-x-ray.

Which of the following should be done initially?

1. Bronchoscopy with bronchoalveolar lavage
2. Endoscopy
3. Administer octreotide to control hypotension
4. Administer 2 units of packed red blood cells to stay ahead of the bleeding
5. All of the above

Reference as: Wesselius LJ. May 2013 critical care case of the month: not an air-filled sac. Southwest J Pulm Crit Care. 2013;6(5):209-17. PDF

April 2013 Critical Care Case of the Month: Too Many Diagnoses

Elijah Poulos, MD

David M. Baratz, MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

History of Present Illness

A 71 year old diabetic woman was admitted for 6-8 weeks of progressive dyspnea, non-productive cough, orthopnea, generalized edema and intermittent fevers. She has a history of living-related donor renal transplant from her husband in 1999 and was diagnosed with locally advanced pancreatic adenocarcinoma in October 2012. She was treated with insulin for diabetes; the immunosuppressants tacrolimus, mycophenolate and low-dose prednisone for her renal transplant; and weekly gemcitabine beginning in 11/2012 for her pancreatic cancer. Her course was complicated by left lower extremity deep venous thrombosis in January 2013 and she was treated with full dose enoxaparin at 1 mg/kg BID. She was tolerating her chemotherapy poorly with a myriad of complaints including fatigue, skin ulcerations, poor appetite, weakness, dysphagia, malaise, nausea and intermittent chest pains. Her most recent chemotherapy was held because of pancytopenia. She was admitted to our hospital in early March 2013 with the above symptoms.

Physical Examination

Vital signs: Temp 98.8°F, BP 125/65 mm Hg, HR 84 beats/min, RR 18/min, O2 saturation 85% on room air.

General: She was an obese woman in no distress but with conversational dyspnea

Neck: Jugular venous distention could not be appreciated secondary to obesity.

Lungs: Bibasilar rales

Heart: regular rhythm with distant heart sounds, but no murmur or gallop.

Lungs: Bibasilar rales

Abdomen: Soft and non-tender without palpable organomegaly or masses.

Ext: 2+ bilateral lower extremity pitting edema to above the knees.

Radiography

Her chest x-ray was interpreted as showing cardiomegaly with radiographic sequelae of pulmonary venous hypertension (Figure 1).

Figure 1. Admission PA (Panel A) and lateral (Panel B) chest radiography.

A thoracic CT scan was performed and was interpreted as showing vague diffuse bilateral groundglass opacities (Figure 2).

  

Figure 2. Movies of axial thoracic CT (upper panel) and  coronal thoracic CT (lower panel).  

Which of the following is a cause of ground glass opacities?

1. Pulmonary edema
2. Pneumonia
3. Hypersensitivity pneumonitis
4. Drug reaction
5. All of the above

Reference as: Poulos E, Baratz DM. April 2013 critical care case of the month: too many diagnoses. Southwest J Pulm Crit Care. 2013;6(4):161-7. PDF

March 2013 Critical Care Case of the Month: Beware the Escargot

Allen R. Thomas, MD

Suresh Uppalapu, MD

Phoenix VA Medical Center

Phoenix, Arizona

History of Present Illness

A 29 year old woman presented to the Phoenix VA Medical Center with complaints of headache and diffuse generalized weakness most pronounced in the lower extremities. She also noted recent fecal and urinary incontinence, abdominal pain, back pain, numbness in the feet and a non pruritic skin rash on the trunk. Onset of symptoms was about 2 weeks prior to her presentation.  Since her symptoms began she had seen in multiple local emergency departments for these same complaints as they worsened and was discharged home in each case with suspected viral syndrome.

PMH, SH, FH

She had no allergies and her past medical history was only significant for post- traumatic stress disorder. She has had no major surgery in her life so far and her family history was not contributory to her current presentation. She smokes marijuana for recreational purposes and drinks alcohol socially. She was not taking any medications on regular basis.

She had been in the military until six months prior to her presentation and her service included tours in Alaska and Hawaii.  She had recently returned from Fiji.  During her stay in Fiji, she reported eating snails and other uncooked food as well as drinking unpurified water

Physical Exam

Vital signs on presentation- T 98.4°C, P 102 beats/min, R 18 breaths/min, BP150/78 mm Hg  O2 sat 97% on room air

She was awake, alert, and oriented. She had mild nuchal rigidity and left ptosis. Lungs were clear and her cardiac exam was normal. Abdominal exam showed diffuse tenderness to palpation with hypoactive bowel sounds. Strength was 5/5 in the upper extremities, 4/5 on the right lower extremity, and 3/5 left lower extremity.  Sensation was Intact throughout.  Deep tendon reflexes were 1+.  Exam was thought to be somewhat limited due to poor effort.

Laboratory findings

White blood cell count was 12,400 mm³ with 75% neutrophils and 8% eosinophils.

Hemoglobin- 13.8 mg/dl; Hematocrit-41%; Platelet count was 317,000/mm³

Complete metabolic profile was normal.

CPK was elevated at 696 IU/Liter.

Radiology 

Chest x-ray showed some blunting of the left costophrenic angle with clear lung fields.

Which of the following are appropriate?

1. Observation. She probably has a viral syndrome.
2. Head CT scan
3. Cerebral angiogram
4. Nerve conduction studies
5. Liver ultrasound

Reference as: Thomas AR, Uppalapu S. March 2013 critical care case of the month: beware the escargot. Southwest J Pulm Crit Care. 2013;6(3):103-111. PDF

February 2013 Critical Care Case of the Month: Thoracentesis Through the Looking Glass

Clement U. Singarajah MD

Jay E. Blum

Allen R. Thomas MD

Henry Luedy MD

Elijah Poulos MD

Tonya Whiting DO

Phoenix VA Medical Center

Phoenix, AZ

History of Present Illness

A 62 year old man was recently diagnosed with Stage 4 squamous cell left lung cancer with metastases to the pleura, brain and mediastinum. He also had known chronic obstructive pulmonary disease (COPD) with a FEV1 = 1.96 L and a known left side pleural effusion (see Figure 1).

Figure 1. Baseline chest radiograph showing left pleural effusion (red arrow).

He was seen as an outpatient for symptomatic shortness of breath and underwent real time ultrasound guided left sided thoracentesis removing 500 ml of straw-colored fluid. The procedure was uneventful except that near the end, the patient started to cough.  He denied any symptoms post procedure apart from some minor puncture site pain. A routine post procedure chest x-ray was performed (Figure 2).

Figure 2. Post-thoracentesis x-ray (Panel A) and its negative image (Panel B).

What new abnormality is identified on the post-procedure chest x-ray?

1. Left pneumothorax
2. Right pneumothorax
3. Lung “sliding” on the left
4. New pneumonia in the left upper lobe
5. Left hilar retraction

Reference as: Singarajah CU, Blum JE, Thomas AR, Luedy H, Poulos E, Whiting T. February 2013 critical care case of the month: thoracentesis through the looking glass. Southwest J Pulm Crit Care. 2013;6(2):63-74. PDF