Jay Mansfield, MD PGY I Internal Medicine. “Worsening shortness of breath” x several months.
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Transcript of Jay Mansfield, MD PGY I Internal Medicine. “Worsening shortness of breath” x several months.
LSU Internal Medicine Case Conference“What the Bullae!"10/02/2012
Jay Mansfield, MDPGY IInternal Medicine
“Worsening shortness of breath” x several months
Chief Complaint
76 year-old African American woman with significant past medical history of ischemic cardiomyopathy s/p AICD (last EF <20% in 12/2011), hypertension, hyperlipidemia, CKD stage III, peripheral vascular disease s/p left SFA stent (3 weeks prior) with left foot ischemic toes and multiple ulcers presented to the ED complaining of progressively worsening shortness of breath and fatigue over the past several months. The patient started developing bilateral lower
extremity edema and claudication.
HPI
She also developed orthopnea – having to sleep upright in a chair.
She had previously been able to ambulate about 1½ blocks easily but now can only walk a few steps before becoming short of breath.
She denied any chest pain, nausea, vomiting, fever or chills.
The patient is not able to recall all her medications and reports that she has not been adherent with her medications.
HPI
Past Medical History:As above plusHypothyroidism
Surgical History:HysterectomyICD (2010)Left SFA stents (3 weeks prior)
Past History
Allergies:Penicillin/Sulfa swelling and rash
Home Medications:Aspirin 81 mg DailyClopidogrel 75 mg DailySimvastatin 40 mg QHSCarvedilol 3.125 mg BIDLantus 10 Units QHSNovoLog 5 Units BIDLevothyroxine 50 mcg DailyOndansetron 4 mg PO q8hrs prn nausea
Past History
Family HistoryNC
Social History:History of tobacco use >20 years previously
with 5-pack year historyNo ETOH, no illicit drugsLives aloneHas three daughters who live close and visit
frequently
Past History
Health Maintenance:PCP at LSU Medicine Clinic (Dr. Lacour)Up-to-date on Influenza and Tdap Unknown Pneumovax Mammogram WNL (1/2012)No colonoscopy
Review of SystemsNegative except per HPI
Past History
Vital Signs & Physical Exam
Temp 99° FPulse 93RR 20BP 131/57Pulse Ox 97% on RAWeight 77 kgHeight 124 cmBMI 50
Vital Signs
General:AAOx3, no acute distress
HEENT: NCAT, PERRL, EOMI, clear oropharynx
Neck: Supple. No Carotid bruits. JVP 12 cm H2O
Cardiovascular: Regular rate and rhythm. No murmurs or
rubs.
Physical Exam I
Pulmonary: CTA bilaterally, no wheezes/rhonchi/crackles
Abdomen: Nondistended, bowel sounds present, soft ,
non tender, obese Extremity:
Dorsalis pedis and Posterior tibial pulses not palpable. 2+femoral and radial pulses bilaterally. 2+ pitting edema bilaterally in lower extremities to lower back. 1+pitting edema in LUE. No palpable cords.
Physical Exam II
Skin:No rashs, no bruises.Left foot bandaged with multiple ischemic toes
and wounds with purple stained skin from gentian violet preparation
Neurologic: Face symmetric, tongue and uvula midline.Hearing grossly intact.Muscle strength 5/5 x 4Decreased sensation to pain and light touch
over lower extremities especially feet bilaterally
Physical Exam III
Laboratory DataDay of Admission
Admit Laboratory Data IWBC 12.4 (4.5-11.0)Hgb 12.4Hct 39.7PLT 161MCV 74.8 (80-100)RDW 17.8 (11.5-14.5)
Seg 80%Bands 13%Lymphs 1%Monos 5%Basophils 1%
Admit Laboratory Data IINa 136K 4.5Cl 104Bicarbonate 21 (24-32)BUN 30 (7-25)
Creatinine 1.60 (0.5-1.10)
GFR 38 (>60)Glucose 239 (65-99)Ca++ 8.99.78Mg++ 1.9Phos 3.4
Admit Laboratory Data IIITotal Protein 6.8 Albumin 2.9 (3.4-5.0)Total Bilirubin 2.5 (<1.3)AST 34 Alkaline Phosphatase 114ALT 14
BNP 3928(<100)TSH 4.52Free T4 0.77
Day of Admission
EKG
First degree A-V blockCannot rule out anterior myocardial
infarction, age undeterminedLow QRS voltage in limb leadsNo significant change from previous
tracing
EKG
Day of Admission
Chest X-Ray
“Dual lead pacemaker again noted. The cardiomediastinal silhouette is stable
with calcifications of the aortic knob and four-chamber cardiac enlargement.
Bronchovascular marking pattern is unchanged. There is no evidence of pulmonary edema.
The lungs are clear. There is no focal airspace consolidation, pleural effusion, or evidence of pneumothorax.
Again noted is osteopenia and thoracic kyphosis.”
CXR
Hospital Day 1
Patient was admitted to MedicineIV furosemide 40mg q12 hours initiated with
strict I/O’sHome medications continued
Initial Management
Patient was noted by Primary Care team to have developed multiple hemorrhagic bullae on her right lower extremity
She was also noted to have altered mental status
Medical ICU, General Surgery and Infectious Disease services were consulted
Labs, cultures, and ABG were obtainedPatient was placed on NRBPatient was empirically started on
Vancomycin, Clindamycin, and Ciprofloxacin
Hospital Day #3
Temp 97° F (96-99.9 ° F)Pulse 98RR 20BP 123/63Pulse Ox 96% on 3L NC
Vital Signs
General:Awake, lethargic, no acute distress
HEENT: NCAT, PERRL, EOMI, clear oropharynx
Cardiovascular: Regular rate and rhythm. No murmurs or
rubs.Pulmonary:
CTA bilaterally, diffuse expiratory wheezes present; no crackles, good air movement
Abdomen: Nondistended, obese, bowel sounds present,
soft , non tender
Physical Exam I
Extremity: 2+ Radial pulses bilaterally. PT and DPs not
palpable secondary to edema. 2+ pitting edema LE bilaterally to upper thighs. Left foot dressed in clean bandage. Multiple ischemic toes on Left foot.
Skin:Multiple hemorrhagic bullae to anterior and
medial aspect of RLE measuring 4x2cm. Posterior aspect of RLE near popliteal fossa where bullae erupted, weeping serosanguinous fluid with associated erythema and warmth.
Physical Exam II
WBC 2.6 (4.5-11.0)Hgb 13.8Hct 43.6PLT 110 (130-400)MCV 73.7 (80-100)RDW 18.5 (11.5-14.5)
Seg 52%Bands 13%Lymphs 17%Monos 16%Basophils 1%
Laboratory Data I Day #3
Na 137K 3.7Cl 104Bicarbonate 23 (24-
32) BUN 29Creatinine 1.24 (0.5-
1.10)GFR 51
(>60)Glucose 38 (65-
99)
Ca++ 7.99.66Mg++ 1.5Phos 3.4Blood cultures pending
Laboratory Data II Day #3
ABG 7.45/40/235/28/100% on 100% NRB
Total Protein 4.8 (6.0-8.0)Albumin 1.8 (3.4-5.0)Total Bilirubin 2.7 (<1.3)AST 31 Alkaline Phosphatase 58ALT 12
INR 2.0 (0.9-1.1)PT 21.7 (9-12.7)PTT 40.3 (24-37)Lactic Acid 1.6
Laboratory Data III Day #3
Patient was given a total of 2 amps of D50 and some juice. Patient’s mental status returned to baseline. Repeat accucheck was 96.
Patient underwent Ultrasound of right lower extremity – no DVT
Patient was transferred to MICU for continued monitoring and management
Hospital Course: Day #3
Transfer Antibiotic Medications:CiprofloxacinVancomycinClindamycinTigecycline
Hospital Course: Day #3
Patient’s bullae began to desquamate and increase in number: affected anterior thigh area measured 8x4cm, posterior fossa skin involvement measured ~12cm in length
Patient had no mucosal involvementNew bullae appeared on patient’s suprapubic
area with notable erythema and extreme tenderness 4x2cm
Right upper extremity became more edematous and extremely tender to touch, no bullae were noted, increased erythema noted in RUE antecubital fossa
Hospital Course: Day #3
Hospital Course: Day #3Dermatology was consulted and performed
bedside examination and punch biopsy of one of the bullae on patient’s right lower extremity
Hemorrhagic Bullae Suprapubic
Anterior Thigh Right Lower Extremity
Medial Right Lower Extremity
Lateral Right Lower Extremity
Right Upper Extremity
Hospital Course Morning Day #4Patient stated she felt better. Patient only complaining of pain in right arm
and right handOriented to person, place. Confused about
exact date.Small bullae noted in RUE antecubital fossa
measuring 0.5x0.5cmOther bullae and lesions appeared stable
WBC 2.7 (4.5-11.0)Hgb 12.9Hct 40.1PLT 111 (130-400)
Seg 71%Bands 8%Lymphs 13%Monos 8%Basophils 0%
Laboratory Data I Morning Day #4
Na 139K 4.4Cl 101Bicarbonate 25BUN 31 (7-25)Creatinine 1.55 (0.5-
1.10) GFR 40 (>60)Glucose 92Anion Gap 18 (<10)
Ca++ 7.49.32Mg++ 1.4Phos4.5
Laboratory Data II Morning Day #4
Total Protein 4.2 (6-8)Albumin 1.6 (3.4-5.0)Total Bilirubin 3.2 (<1.4)AST 61 (<45)Alkaline Phosphatase 44ALT 15
BNP 3923(<100)Lactic Acid 4.2 (0.3-2.4)
Laboratory Data III Day #3
Patient became hypotensive requiring pressor support with total of 2 pressors: Levophed and Vasopressin
Patient became more altered and was intubated to protect her airway
Patient’s UOP significantly declined despite being on a lasix drip
Patient was transfused albumin to help with diuresis
Hospital Course: Day #4
X-Ray of Right Lower Extremity revealed extensive edema, no subcutaneous emphysema
Hospital Course: Day #4
Lactic Acid 1.6 4.2 10.4Bicarbonate 21 25 12 6Creatinine 1.24 1.55 1.95 2.41WBC 2.6 2.7 10.1 14.3Bandemia 13% 27% 8%
35%Platelets 110 131 111 97 49INR 2 3.9PT 21.7 43.1CK 608CRP 16.9Troponin 1.88
Significant Laboratory Data Day #4
Patient became bradycardic and hypotensive, then became pulseless
Patient was resuscitated with chest compressions and epinephrine
Patient’s family decided to make the patient DNR if another code were to occur
Patient became hypotensive again despite pressor support and died
Cont…..
Microbiology and Pathology Results
7/9/12: Right upper thigh, punch biopsy
Blood cultures obtained on day of transfer to MICU revealed Group A Streptococcus in two bottles
Swab of right thigh lesion grew Group A Streptococcus
Repeat blood cultures on day after transfer to MICU had no growth
Right upper thigh punch biopsy revealed subepidermal vesicular dermatitis with thrombotic vasculopathy, autolysis, and numerous interstitial bacterial cocci
Microbiology and Pathology Results
Streptococcal Toxic Shock Syndrome
Final Diagnosis
Thanks For Your Attention!