CPC Case for December 11, 2003

Discussant: Dr. Carew
Case presented by: Dr. Wadsworth

CC

Dyspnea
HPI

41 year old African-American male with no significant past medical history presents to the ED c/o marked dyspnea.  

His history began approximately 2 weeks prior to admission when he had gradually developed dyspnea, fatigue, and subjective fever and chills.

He had visited ED’s on 3 separate occasions in the two weeks prior to admission.  

On the most recent visit (3 days PTA), a CT angiogram was performed for suspicion of PE, and diffuse alveolar infiltrates in the lower lobes were found without evidence of PE.  He was discharged from that ED with Azithromycin.  Over the past 3 days, he noted worsening of his symptoms.  Due to a respiratory rate of 40 and oxygen saturation of 91% on a 100% non-rebreather, he was intubated in the ED.

PMH

None per the patient and the patient’s friend who accompanied him.
MEDICATIONS Azithromycin, Chlorpheniramine/Hydrocodone, Beclomethasone nasal inhaler

SH

 No tobacco, alcohol, or drug use reported.  He is married with two children.  He is self-employed as a construction worker with a history of various jobs dealing with ceramics, fiberglass, and installation of flooring.  Last travel was 3 years ago to Puerto Rico.  No history of TB exposure.
ALLERGIES None known to patient.
FH

Notable for Diabetes Mellitus.

ROS

Positive for subjective fevers, chills, cough productive of clear sputum, night sweats, fatigue, and malaise.  Negative for hemoptysis, chest pain, rash, neck stiffness, headache, nausea/vomiting, dysuria, loose stools, or bright red blood per rectum.

PHYSICAL EXAM:

General: Well-nourished, well-developed African-American male in respiratory distress

Vital Signs: Tmax 103.6, Pulse 120-130 and regular, RR 30-40, BP 143/89.

HEENT: Anicteric sclera, no conjunctival petechiae, no nasal or ear drainage

Neck: supple, no JVD or lymphadenopathy present

Lungs: Inspiratory rales heard bilaterally, mostly in the bases.  There is dullness to percussion in the left posterior lung field.

Heart: Tachycardic, without murmurs, rubs, or gallops.

Abdomen: Soft, nontender, nondistended.  No masses or organomegaly.  Bowel sounds  normal

Extremities: No edema present.  Pulses were normal and symmetric.

Skin: No rashes or petechia.

Neurological: Alert and oriented x 4, anxious, no deficits were noted.


LABS:
WBC
15.8
HGB
 12.5
HCT
 36
PLT
 289K
RBC
 4.19
RDW
 12.5
MCV
85.9
MCH
30  
Diff:
 88.1% polys, 5.1 % lymphs, 4.5 % monos, 2.2 % eos,

Na
140
K
 4.0
Cl
 104
CO2
 28
Glucose
 93
BUN
 9
Creatinine
 0.9
Ca
8.1
Mg
 1.9
Phos
 4.3
 
 
 
 
Alk Phos
 90
AST
69
ALT
35
TP
6.3
Alb
 2.5
Total Bili
1.9
Globulins
 3.8

UA: 1.032/6.0/clear/yellow/ (-) nitrite/ (-) leukocyte/100 protein/rare bacteria/ 3 WBC
ABG: 7.42/39.6/61 FIO2 was 100% on Non-rebreather mask
CXR: Bilateral alveolar infiltrates predominantly in the bases (worse than last study).       
Legionella IgG (Blood) negative, Histoplasma Ag negative      
HOSPITAL COURSE
DAY 1 Admited and started on Levofloxicin, Piperacillin/Tazobactam, and vancomycin
DAY 2

Fevers continue.  ID consult changes Levo to Moxifloxicin.  Vanc D/C’ed.
Pip/Tazo eventually changed to Ceftriaxone and Fluconazole added for oral thrush.

DAY 4 - 6

Blood/Sputum cultures negative. Ceftriaxone changed back to Pip/Taz.
Now requiring pressure-control ventilation.
Hypersensitivity panels sent and IV  Solumedrol started.  Norepinephrine intermittently required for hypotension
DAY 7 - 12

Increase in LFT’s (AST 219, ALT 134).  
Antibiotics changed to Moxifloxacin and Clindamycin and LFT’s decrease.  Fevers continue to 101 range.
DAY 13 - 16

Right pneumothorax secondary to barotrauma – chest tube placed
Doxycycline started for “potential unusual organisms”.  Moxi stopped.  Steroids continue.
X-ray of sinuses negative.

DAY 17 - 22 Convalescent titers for Legionella, Hanta, CMV sent.  All Antibiotics stopped.  New right and later new left pneumothorax requiring 2 new chest tubes
DAY 23 - 24 Clinical deterioration with persistent air-leak from chest tubes.  Difficult oxygenation.  “Quick-look” bronchoscopy done which revealed only minimal secretions.
DAY 25 Patient becoming increasingly bradycardic and hypotensive with pulse in the 40’s and systolic bp <70.  Patients rhythm eventually degenerated into pulseless electrical activity and patient expired.


FURTHER SPECIAL LABS DONE:

Fungal serology : Negative for Aspergillus, Blastomyces, Coccidiodes, and Histoplasma

Q Fever Ab negative

CMV IgM and IgG negative

Central Line cath tip culture negative
 
An autopsy was performed and a diagnosis was made.