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!