there’s always a first time - ucsf medical education10/26/2015 2 ground rules for cps exercise...
TRANSCRIPT
10/26/2015
1
There’s Always a First TimeA Clinical Problem Solving Case
Gurpreet Dhaliwal, MD
Professor of Medicine University of California, San Francisco
10/26/2015
2
Ground Rules for CPS Exercise
Goop has never heard these cases Not a trivial undertaking
Goal is to make the thought process of a master clinician transparent It’s not magic
You don’t have to “know everything”
“Getting it right” is cool, but relatively unimportant in the grand scheme
Enjoy – this is the fun part of medicine
10/26/2015
3
Ockham’s Razor vs. Hickam’s Dictum
“Entities must not be multiplied beyond necessity.”
-- William of Ockham
“Patients can have as many diseases as they damn well please.” -- John Hickam
History A 73-year-old man with a history of COPD and a
mechanical MVR/porcine AVR (on coumadin) was admitted to an outside hospital for several acute episodes of dyspnea over the prior month.
He denied cough, CP, palpitations, orthopnea, or fever. He did endorse mild abdominal distension.
He had no prior history of PE, pneumonia, or heart failure. He had never been hospitalized for COPD. His valve surgery was 5 years earlier. He claimed to be taking his coumadin. No travel history documented.
10/26/2015
4
ED Assessment and Exam The patient was noted to be wheezing and in mild
respiratory distress
Afebrile, RR 20, O2 97% RA, BP 85/57, which responded to fluids
Initial ABG: 7.46/42/63 (RA)
WBC 9.7, diff normal
CXR unremarkable
A CT scan was neg for PE and volume overload; it showed only mild bibasilar atelectasis
ED Management
The patient was treated for a COPD exacerbation
He received a steroid burst, duonebs, and azithromycin
He improved over the first 6-12 hours but was admitted for further treatment and observation
10/26/2015
5
What do you think is going on?
1. Sounds like a routine case of COPD exacerbation. Is Bob trying to fool Goop by giving him a bread and butter VA case?
2. Must have something to do with the valves
3. I remember one of my profs from med school saying something like, “All that wheezes isn’t asthma,” but I can’t remember what it is
4. Did he say “no travel history documented”?
5. Did he also say “the patient claimed to be taking his coumadin”?
Goop’s Initial Thoughts
10/26/2015
6
Hospital Course The patient’s abdominal distension (a mild complaint on
admission, not confirmed on exam) worsened over the first 2-3 days of hospitalization
A KUB on hospital day 4 showed dilated bowel loops consistent with ileus
An abdominal CT was obtained: no evidence of ileus or bowel abnormalities (his symptoms had improved)
On hospital day 6, his breathing took a marked turn for the worse – with severe dyspnea and tachypnea
A diagnosis of respiratory failure was made
The patient was taken to the ICU and intubated
Now I’m worried about…
1. Bowel ischemia
2. Churg-Strauss vasculitis
3. Inflammatory bowel disease
4. Lupus
5. Sepsis and ARDS
6. A hypercoagulable state and in-situ thromboses
7. That Donald Trump could really be our next president
10/26/2015
7
ICU Course Repeat CXR unchanged from admission
TTE showed no evidence of heart failure, valvulardysfunction, or vegetations
Antibiotics were broadened to vanco and tigecycline
Blood cultures from the time of the deterioration grew enterococcus faecalis
Vanco was changed to linezolid
UA was negative
PICC line felt likeliest source of bacteremia and d/ced
Aggressive COPD rx led to improvement, extubated on hospital day 14
10/26/2015
8
Post-Intubation Course
The patient complained, for the first time, of back pain and lower extremity weakness
On further questioning, he noted that he had had progressive leg weakness for several weeks
Spinal imaging showed a T5-6 burst fracture with retropulsion and mild central canal narrowing, along with soft tissue fullness around the spine, c/w necrotic mass or abscess
10/26/2015
9
10/26/2015
10
Wow, that’s not good. Now I’m worried about…
1. Syphilis
2. Tuberculosis
3. Lymphoma
4. Cocci
5. Endocarditis
6. MRSA
7. Sorry, I’m still worried about Donald Trump
10/26/2015
11
Post-Intubation Course
Cocci serum titers sent and returned weakly positive Started on fluconazole
Soon, cocci immunodiffusion and comp fix returned negative, so fluconazole d/c’ed
Patient transferred from community hospital to UCSF neurosurgery service
10/26/2015
12
Past Medical History (obtained at UCSF admission)
COPD (no prior PFTs, hospitalizations) HTN Bioprosthetic AVR & Mechanical MVR (both placed 2
yrs earlier) Knee osteoarthritis, treated with NSAIDs, injections Hypothyroidism
SH: Originally from Guatemala, with frequent trips back. Single, lives with son. 20 pack year tobacco hx, quit in 1992. 2 cans of beer/wk. No elicits. Used to work in a warehouse; now retired.
FH: Son with pulmonary TB rxed for at least 6 months (more than 20 years ago). No other history of cardiac, pulmonary, infectious, rheum, heme, bone disorders.
NKDA
Home Meds:CoumadinCarvedilolLisinoprilFurosemide Simvastatin Levothyroxine OmeprazoleVitamin D
Meds on transfer: Fluconazole Budesonide nebs Furosemide Aspart insulin SSLevothyroxineFamotidineDocusateSennaPolyethylene glycolFerrous sulfate
10/26/2015
13
Physical Exam After TransferVITALS: 36.9 °C, 98, 159/43, 20, 95 % RA GENERAL: Deeply sedated.
HEENT: NC/AT. Neck supple. No JVD.
CVR: RRR. Mechanical second heart sound. No m/r/g.
PULM: Clear to ascultation bilaterally.
ABD: Soft, non-tender. Distended and tympanitic.
MSK: No edema. Warm distally.
NEURO:
After lightening sedation, the patient was A+O x 2.
PERRL, EOMI.
5/5 strength in face and BUE with no pronator drift. No movement in LE’s.Absent rectal tone.
Nl sensation to light touch and pain in bilat UEs. Sensory level at T3~T4.
0+ reflexes in patella/ankles bilaterally; UE reflexes normal.
Labs
WBC: 16.6Hgb: 13.1Plt: 411
Na: 129K: 4.4Cl: 95CO2: 25BUN: 7Cr: 0.5Glucose 126Ca: 9.2PTT 37.4, INR 1.9
CRP 112
ABG: 7.44/41/382 (60% FiO2) Lactate 0.8
Blood, urine cultures sent
EKG: LVH with repolarization abnormality
10/26/2015
14
CXR at time of transfer
Low lung volumes. RLL patchy consolidation. Diffuse indistinct pulmonary vascularity.
Studies
KUB: Nonspecific bowel gas pattern.
TTE:1. Normal ventricular size and EF. 2. Severe concentric LVH. Paradoxical septal motion. 3. Mod LAE. Nl right atrium.4. Mechanical mitral prosthesis normal. Bioprosthetic
aortic valve normal.5. Mitral prosthesis precludes the accurate
evaluation of diastolic function.6. PASP estimated 12-16 mmHg.7. No pericardial effusion.
10/26/2015
15
MRI Spine – T2
MRI Spine – T2
Vertebral collapse at T5, 50% height loss at T6. Retropulsionat T5 leading to canal stenosis. Abnormal cord signal T7 on up, with moderate cord compression at T5-6. Pre-syrinx (fluid filled cavity within cord) formation.
10/26/2015
16
Neurosurgery Management While the neurosurgeons felt there was little hope for LE
recovery, the pre-syrinx formation risked moving upwards, potentially compromising UE function Recommended decompressive laminectomy
A few days after transfer, pt had posterior spinal fusion Finding: epidural phlegmon,T5 fracture with cord infarct,
spinal stenosis—fused. Fluid from phlegmon, tissue from ligament sent for culture
and path
Path: hypercellular, esp. plasma cells, but not clonal C/w chronic inflammation
Micro: gram stain, culture, AFB, special stains all negative
Post-op LabsDay 30 (2 days post-neurosurgery) labs:
WBC 16.9, with 6.51K eos (39%)
Looking back:
Admission to outside hospital: WBC 9.7, 194 eos (2%)
Day 16: 270 eos (3%)
Day 26: (day prior to transfer, 2 days pre-op) 3.6K eos (40%)
(This bump in eos was not previously recognized)
10/26/2015
17
Huh. Eos. Wow. Now…
1. Could this be a really nasty case of asthma?
2. Could this be whatever they call Wegener’s now?
3. Can TB do this?
4. Can cocci do this?
5. Could this all be a worm?
6. Could this be another sign of thromboembolism?
7. Pulmonary infiltrates and eos… I think that’s a syndrome
8. Gotta be from one of his drugs
Goop’s Riff on the Eos
10/26/2015
18
Hospital Course Because eos developed in-house, suspicion for drug
reaction Antibiotics changed to aztreonam, dapto
Stool O&P and strongyloides antibody sent, along with IgE, ANCA, SPEP, UPEP
Cosyntropin test sent to r/o adrenal insufficiency
Eos continued to rise, peaking at 9.8K
Patient continued to have episodes of respiratory distress and wheezing
A chest CT was performed to further assess lungs and eosinophilia
10/26/2015
19
Low lung volumes; diffuse ground glass opacities, some ill defined nodules.
10/26/2015
20
Bronchoscopy
Differential: 88% monos, 5% lymphs and 7% eos
Gram stain & culture: Mod mixed gram positive flora
CMV culture: positive
Pneumocystis: negative
KOH stain and fungal culture: negative
No strongyloides on parasite wet mount
AFB smears: negative
Respiratory virus panel PCR and Ag testing: negative
10/26/2015
21
Recurrent respiratory distress
On hospital day 40, the patient woke from a nap with severe respiratory distress Exam, Diffuse expiratory wheezing, RR 20 30
92% on 2L 87% on 2L
ABG 7.30/58/107
CXR unchanged
Continuous nebs, tx to ICU for bipap, trial of diuresis
VBG 7.32/53
A diagnostic test returned
10/26/2015
22
Goop, Time to Take a Shot
Gurpreet Dhaliwal, is that your… final
answer?
10/26/2015
23
A diagnostic test returned… Strongyloides antibody: 3.76, 4.94 on repeat
Stool O&P: Strongyloides stercoralis rhabditiformlarvae
ANCA neg
SPEP, UPEP unremarkable
HIV neg
Cort stim 6 15
Treatment The diagnosis of strongyloides hyperinfection was
made, involving lungs, GI tract, and possibly vertebrae
Started treatment with ivermectin, 15 mg/d
Steroids weaned and then held
Patient placed on bipap along with COPD meds
Over next few days, rapid improvement in respiratory condition
Discharged back to outside hospital for PT for paraplegia, with markedly improved pulmonary status
10/26/2015
24
Final Diagnosis
Strongyloides stercoralis hyperinfection with
Pulmonary infiltrates and recurrent wheezing
Eosinophilia
Gram-negative bacteremia
Spinal osteomyelitis with cord compression
Strongyloides vs. enterococcus faecalis
Special thanks to Kara Bischoff for preparing the case
Ddx of Profound Eosinophilia
ID: Parasitic infections, certain fungi (cocci, ABPA), infestations (scabies)
Allergic or atopic diseases
Heme-Malignant: hypereosinophic syndromes, some leukemias & lymphomas, other tumors (particularly lung, bladder), systemic mastocytosis
Immunologic: HyperIgE syndrome, GVH disease
Endocrine: hypoadrenalism
Other: radiation, atheroembolic, sarcoid
10/26/2015
25
Doesn’t anybody take histories
anymore?
DDx of Eosinophilic Lung Diseases
Primary
Simple pulmonary eosinophilia
Chronic eosinophilicpneumonia
Acute eosinophilic pneumonia
Churg-Strauss vasculitis
Idiopathic hypereosinophilicsyndrome
ABPA
Bronchocentricgranulomatosis
Secondary Drug-induced
Parasite-induced
Fungal-induced
Diseases Assoc w/ Eos
Asthma
Ideopathic pulmonary fibrosis
Sarcoidosis
Hypersensitivity pneumonitis
Malignancy
Langerhans cell granulomatosis
Cryptogenic organizing pneumonia
10/26/2015
26
Strongyloides HyperinfectionSyndrome
Parasite endemic in tropical, subtropical regions Including SE United States
Normal life cycle: skin->lungs->GI tract
Autoinfection cycle: may lay dormant for decades, or cause indolent disease w/ GI symptoms and eosinophilia
With immunosuppression, massive growth in disease burden, disseminated disease Lungs, GI tract (enteric bacteremia), skin, CNS No cases of strongyloides osteomyelitis reported, but
there is one case of entercoccus faecalis involving CNS in setting of hyperinfection
Rhabditiform larvae of strongyloidesfound in stool specimen
10/26/2015
27
There’s Always a First TimeA Clinical Problem Solving Case
Gurpreet Dhaliwal, MD
Professor of Medicine University of California, San Francisco
10/26/2015
28