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CPC Case for February 22, 2004

Discussant: Dr. Sherron Helms
Case presented by: Dr. Robert Kamali

CC

“ I can’t breathe”
HPI

JR is a 48-year-old Hispanic male who had presented to Dallas county health center with symptoms of fever, sweats, cough, SOB, weight loss and fatigue for several weeks. He was diagnosed with TB and started on 3 drug standard regimen. He stated that his dyspnea continued from the time of initiation of the 3 drug regimen but began to progressively worsen about 2 weeks prior to admission. He stopped going to work at this time secondary to the dyspnea. On the day of admission he complained of diffuse, pleuritic chest pain and an acute exacerbation of his SOB. He denied hemoptysis, nausea, vomiting, chest pressure, palpitations, and any HIV risk factors.
PMH negative
MEDICATIONS Rifampin, Isoniazid, Ethambutol, and pyridoxine

SH

 Most of his family live in Mexico. He has a smoking history of 1.5 packs per day for 30 years. He works in construction. He had recently traveled to Mexico and returned approximately one week prior to admission
ALLERGIES  
FH

negative
ROS

 
PHYSICAL EXAM:

Vital Signs: T: 98.6, P: 125, BP: 135/96, RR: 40, oxygen sat 75% on room air

General: WN/WD Hispanic male in bed on 100% non re-breather in moderate distress

HEENT: NC/AT, EOMI, PERRL, oropharynx clear, no conjunctival icterus

Neck: Supple, without any lymphadenopathy

Resp: Diffuse rhonchi and coarse breath sounds heard throughout

Cardiovascular: Tachycardic and regular with no murmurs appreciated

Abdomen: Soft, NT/ND, normoactive bowel sounds, no organomegaly appreciated

Extremities: No cyanosis, clubbing or edema
LABS:
Na
 
K
  
Cl
  
HCO3
  
Glucose
  
BUN
  
Creatinine
  
Ca
 
Mg
  
Phos
 
 
 
Alk Phos
 115
AST
75
ALT
76
TP
 
Alb
  
Total Bili
0.6
Globulins
  
Hepatitis serologies
 negative  
HIV
 nonreactive  
     
   
 
Trop I
2.4 (normal < 0.1)
    
D-dimer
 > 1,050 units                    
WBC
14.1  
Hgb
 17.1  
Hct
 50  
Plts
 154,000  
 
   
Coag:
 PTT 27.7— INR 1.3
ABG:
 pH 7.41, pCO2 42, pO2 81 on 100% non re-breather
UA: 1.030, pH 6.5, 300 protein, large blood, 246 RBC/hpf
All bacterial Cx's negative
EKG: sinus tachycardia.
Imaging
CXR:
diffuse interstitial and alveolar infiltrates bilaterally, much more marked on the right than the left with a greater density in the right upper lung area
CT angiogram:
Extensive bilateral pulmonary emboli, nodular infiltrates in both lungs with coalescence in the right, upper lobe, right pleural effusion, lytic spine lesions, mediastinal and hilar adenopathy.
Echo:
 Normal LV systolic function, RV systolic function moderately reduced, increased RVSP
Hospital Course He rapidly progressed to hypoxemic respiratory failure and was intubated. He also became hypotensive requiring pressor support. His TB meds were continued. Doppler demonstrated a right-sided deep venous thrombosis of the popliteal vein. He received LMWH for his DVT and PE. During the 1st 10 days of his hospital stay, his respiratory status worsened. He required pressure-control ventilation with high FIO2’s. This continued intermittently until the end of his hospital stay. On the 2nd day of his hospitalization, he underwent bronchoscopy because of persistent difficulty with ventilation. The bronchial washings and sputum did not demonstrate AFB or malignant cells. TB-cultures were negative. He also had a thoracentesis and cytology exam found malignant cells C/W poorly differentiated carcinoma. He was unable to be weaned from the ventilator. He ultimately had worsening respiratory status, coma and death on 23rd day of his hospital stay.
  An autopsy was performed and a diagnosis was made.