Low Platelets, High Aspirations - aaem.org
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Low Platelets, High Aspirations Scott T Bickel DO, Casey Collier MD AMITA Resurrection Medical Center Emergency Medicine Residency Fig 1-2: CT Abd/pelvis, coronal and axial views. _________________________HPI: ________________________ 55-yo male with pancreatic cancer presents with fatigue and generalized weakness since his last chemo, 1 week prior. He also reports gradually increasing RUQ pain. His oncologist sent him to the ED due to recent lab draw that showed a “Hgb of 7.2 and platelets of 11”. Not on anti- coagulation. He denies chest pain, syncope, nausea or vomiting, diarrhea, fever, flank pain or dysuria. Denies any recent bloody or black/tarry stools. ______________________Physical Exam:___________________ _ Vitals: BP 80/53, BP 117, RR 20, T 36.4, SPO2 97% • Cachectic, toxic/pale/jaundiced, icteric sclera, dry mucous membranes • Tachycardic but regular, intact peripheral perfusion • RUQ tenderness with firmness, no rebound, guarding, or distention • Fully alert, neurologically intact, lungs clear _______________ ________Labs/CXR:_____________________ • WBC 0.2, Hgb 7.2, Hct 22.0, Platelets 13k • Na 129, K 3.9, Cl 95, CO2 24, BUN 38, Cr 1.15, Glu 116, Lactate 2.7 • Total protein 6.0, Albumin 2.3, AST 28, ALT 21, ALP 191, T. bili 3.6, D. bili 2.26 • Lipase < 3, UA unremarkable • CXR: Elevated right hemidiaphragm with prominent air below. The possibility of free intraperitoneal air is raised. _____________ ______Answers:___________________ #1 Hepatic abscess #2 DDx includes pyogenic vs amebic hepatic abscess, liver neoplasm or mets, necrotic tumor, benign cyst, hepatic hydatid cyst, perinephric abscess, bilioma, acute cholangitis, cholecystitis #3 Most causes are polymicrobial - mixed enteric and anaerobic species. Streptococci should prompt further evaluation for metastatic infections at other sites. ___________________Discussion: _________________ • CT demonstrated a very large fluid collection with air-fluid level, consistent with liver abscess. A biliary ductal stent with air is noted. • Patient was given Ceftriaxone and Flagyl in the ED. Admitted to ICU with ID and IR consults. IR requested 2 units of platelets and 2 units of FFP to reverse thrombocytopenia/coagulopathy prior to intervention. • IR later drained approximately 3.9 L of foul-smelling pus. • Cultures grew Strep. constellatus and Citrobacter freundii. Fungal and AFB smears were negative. • Patient was treated with IV ertapenem x 4 weeks. Course was complicated by E.coli sepsis and C. diff but was ultimately discharged home. • Risk factors include pancreatic disease (as in this patient), immuno-compromised state, diabetes, liver/biliary/colorectal CA, liver transplant, and PPI use. __________Take Home Points:_________ 1.Pyogenic liver abscesses are typically caused by intra- abdominal pathogens via portal circulation, hematogenous spread (Strep and Staph), or from nearby biliary infections. 2.Management: perc. drainage and broad antibiotic coverage with IV Zosyn or 3 rd -gen Cephalosporin plus Flagyl. 3.Thrombocytopenia <50k should be corrected prior to major procedures. Correction of INR to <1.5 is NOT routinely needed unless concomitant warfarin use). AAEM 26th Annual Scientific Assembly April 19-23rd 2020. Sheraton Phoenix Downtown – Phoenix, AZ. Poster #XX The presenter, investigators, and institution have no conflict of interest to disclose regarding this presentation. Correspondence to: Shu B. Chan, MD, MS, FACEP Research Director EM Residency Program AMITA Resurrection Medical Center, Chicago Illinois [email protected] _______________________Questions:_______________ _______ #1 What is the diagnosis based on the photo? #2 What is your differential diagnosis? #3 What are the most common causes of this diagnosis?
Transcript of Low Platelets, High Aspirations - aaem.org
Low Platelets, High AspirationsScott T Bickel DO, Casey Collier MD
AMITA Resurrection Medical CenterEmergency Medicine Residency
Fig 1-2: CT Abd/pelvis, coronal
and axial views.
_________________________HPI: ________________________
55-yo male with pancreatic cancer presents with fatigue and generalized
weakness since his last chemo, 1 week prior. He also reports gradually
increasing RUQ pain. His oncologist sent him to the ED due to recent lab
draw that showed a “Hgb of 7.2 and platelets of 11”. Not on anti-
coagulation. He denies chest pain, syncope, nausea or vomiting, diarrhea,
fever, flank pain or dysuria. Denies any recent bloody or black/tarry stools.
______________________Physical Exam:____________________
Vitals: BP 80/53, BP 117, RR 20, T 36.4, SPO2 97%• Cachectic, toxic/pale/jaundiced, icteric sclera, dry mucous membranes
• Tachycardic but regular, intact peripheral perfusion
• RUQ tenderness with firmness, no rebound, guarding, or distention
• Fully alert, neurologically intact, lungs clear
_______________________Labs/CXR:_____________________
• WBC 0.2, Hgb 7.2, Hct 22.0, Platelets 13k
• Na 129, K 3.9, Cl 95, CO2 24, BUN 38, Cr 1.15, Glu 116, Lactate 2.7
• Total protein 6.0, Albumin 2.3, AST 28, ALT 21, ALP 191, T. bili 3.6, D. bili 2.26
• Lipase < 3, UA unremarkable
• CXR: Elevated right hemidiaphragm with prominent air below. The possibility of
free intraperitoneal air is raised.
___________________Answers:___________________
#1 Hepatic abscess
#2 DDx includes pyogenic vs amebic hepatic abscess, liver
neoplasm or mets, necrotic tumor, benign cyst, hepatic hydatid
cyst, perinephric abscess, bilioma, acute cholangitis, cholecystitis
#3 Most causes are polymicrobial - mixed enteric and anaerobic
species. Streptococci should prompt further evaluation for
metastatic infections at other sites.
___________________Discussion:_________________
• CT demonstrated a very large fluid collection with air-fluid
level, consistent with liver abscess. A biliary ductal stent with
air is noted.
• Patient was given Ceftriaxone and Flagyl in the ED.
Admitted to ICU with ID and IR consults. IR requested 2
units of platelets and 2 units of FFP to reverse
thrombocytopenia/coagulopathy prior to intervention.
• IR later drained approximately 3.9 L of foul-smelling pus.
• Cultures grew Strep. constellatus and Citrobacter freundii.
Fungal and AFB smears were negative.
• Patient was treated with IV ertapenem x 4 weeks. Course was
complicated by E.coli sepsis and C. diff but was ultimately
discharged home.
• Risk factors include pancreatic disease (as in this patient),
immuno-compromised state, diabetes, liver/biliary/colorectal
CA, liver transplant, and PPI use.
__________Take Home Points:_________1.Pyogenic liver abscesses are typically caused by intra-
abdominal pathogens via portal circulation,
hematogenous spread (Strep and Staph), or from
nearby biliary infections.
2.Management: perc. drainage and broad antibiotic
coverage with IV Zosyn or 3rd-gen Cephalosporin plus
Flagyl.
3.Thrombocytopenia <50k should be corrected prior to
major procedures. Correction of INR to <1.5 is NOT
routinely needed unless concomitant warfarin use).AAEM 26th Annual Scientific Assembly April 19-23rd 2020. Sheraton Phoenix Downtown – Phoenix, AZ. Poster #XX
The presenter, investigators, and institution have no conflict of interest to disclose regarding this presentation. Correspondence to: Shu B. Chan, MD,
MS, FACEP Research Director EM Residency Program AMITA Resurrection Medical Center, Chicago Illinois [email protected]
_______________________Questions:______________________#1 What is the diagnosis based on the photo?
#2 What is your differential diagnosis?
#3 What are the most common causes of this diagnosis?
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