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

January 2013 Critical Care Case of the Month: Different Name, Same Disease...or Is It?

Nathaniel Reyes MD (NReyes@deptofmed.arizona.edu)

Jarrod Mosier MD (JMosier@aemrc.arizona.edu)

University of Arizona- AHSC/Pulmonary

1501 N Campbell Ave.

Tucson, AZ 85724-5030

History of Present Illness

A 50-year-old female who presented with 2-weeks of worsening cough and shortness of breath.  She presented to another hospital 2-weeks prior to presentation complaining of cough productive of yellow sputum and was diagnosed with bronchitis and discharged home with a normal chest x-ray.  Her symptoms persisted and one day prior to admission she experienced one episode of hemoptysis which prompted her presentation to our emergency department.  She denied fever, chills, night sweats, and complained only of dyspnea on exertion.

PMH/SH

Granulomatous polyangitis (GPA) was diagnosed by renal biopsy in 2004. She subsequent developed end-stage renal disease and has been receiving peritoneal dialysis.  She has never required immunosuppresive therapy. There is no history of tobacco use.  She has lived in Arizona for many years.  She is retired but previously worked as an information technology manager. 

Physical Exam

Vital signs were normal except for an O2 saturation of 91% on room air.  Physical exam was significant only for pale sclerae and bilateral dry crackles.

Laboratory Data

Hemoglobin: 5.4 g/dL; Hematocrit: 17%.  BUN: 43 mg/dL; creatinine: 10.7 mg/dL.   

ABG: PaO2 75; PaCO2 39; pH 7.43 on 2L O2.

P-ANCA: Positive

Myeloperoxidase antibody titer: 83 U/mL

C-ANCA/proteinase 3 antibody titer/Anti-GBM antibodies: negative.

Imaging

Chest X-ray showed diffuse areas of consolidation (Figure 1).

Figure 1. PA Chest X-ray

Which of the following is not appropriate in her management?

1. Admit to the intensive care unit.
2. Computerized tomography of the chest.
3. High dose corticosteroids
4. Bronchoscopy
5. Coccidioidomycosis serology

The authors report no conflict of interest.

Reference as: Reyes N, Mosier J. Critical care case of the month: different name, same disease...or is it? Southwest J Pulm Crit Care 2013;6(1):5-11. PDF

December 2012 Critical Care Case of the Month: Sepsis-like Syndrome in a Returning Traveler

Eric Chase, MD

Eric Ong, MD

John Bloom, MD

University of Arizona

Division of Pulmonary and Critical Care Medicine

Tucson, AZ

History of Present Illness

The patient is a 56 year old male with a past medical history that is significant only for well controlled hypertension presenting with acute onset of fever, hematuria, jaundice and fatigue. He had been hospitalized in Mexico for the last 5 days. When he failed to improve his friends chartered an airplane and brought him to the U.S. Prior to his hospitalization in Mexico he had traveled to Sierra Leone related to his work as a geologist.

PMH, SH, FH

Past Medical History: Hypertension, gastroesophageal reflux disease

Past Surgical History: Vasectomy

Medications:  Omeprazole, Lisinopril

Social History:  Works as a geologist with recent travel to Sierra Leone, no history of alcohol abuse, intravenous drug abuse, or HIV

Physical Examination

Vital signs: Temperature 97.5° F, Pulse 87 beats/min, Respiratory Rate 18 breaths/min, Blood Pressure 111/84 mm Hg, and SaO2 89% on room air. 

The patient was initially alert, oriented and appropriate.

His pulmonary examination revealed faint bibasilar rales. 

His abdomen was obese, soft, non-tender and non-distended. 

His skin had obvious jaundice and his sclerae were icteric. 

He later decompensated, became altered and developed significant tachypnea.

Admission Laboratory Studies

Significant initial laboratory studies are as follows:  Hemoglobin 11.5 g/dl, Hematocrit 35%, Platelet Count 25,000/uL, Chloride 115 mMol/L, CO2 17 mMol/L, BUN 35mg/dL, Creatinine 1.6 mg/dL, Albumin 1.5 g/dL, Total Bilirubin 13.2 mg/dL, ALT 38 IU/L, AST 97 IU/L, INR 1.7, Fibrinogen 270 mg/dL, D-Dimer 8.37 ug/ml, Venous Lactate 3.9 mMol/L, Urinalysis: Small Blood, 2 RBCs/HPF, Moderate Bilirubin, Urobilinogen 2.0 mg/dL.                    

As part of the workup for possible hemolysis a peripheral blood smear was obtained (Figure 1).

Figure 1. Peripheral smear of the patient’s blood.

Which of the following is the diagnosis?

1. Malaria
2. Babesosis
3. Ehrlichiosis
4. Relapsing fever
5. American trypanosomiasis (Chagas disease)

Reference as: Chase E, Ong E, Bloom J. December 2012 critical care case of the month: sepsis-like syndrome in a returning traveler. Southwest J Pulm Crit Care 2012;5:279-85. PDF