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Memorial ICU


Title: PowerPoint Presentation Author: Priya Noor Last modified by: UCI_Employee Created Date: 10/6/2013 4:14:35 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Memorial ICU

Memorial ICU
  • UCI/LBM Joint Conference

Chief Complaint
  • Sore throat, fever

  • 62 yo M
  • Sore throat, fever x 3 days
  • One day of vomiting, diarrhea
  • Preceded by a week and a half of clear rhinorrhea
    prior to onset of fever
  • Presented to LBMC for worsening of symptoms
  • Onset of symptoms was while traveling in Salt
    Lake City, Utah for a business trip with his
    wife. They are in retail.

HPI (Cont)
  • While in Salt Lake City, he states that there
    were local fires and proposed that this may have
    contributed to his symptoms.
  • The patient also endorses odynophagia, chills,
    nausea, and shortness of breath when lying flat
  • Denies sick contacts, chest pain, abdominal pain,
    weight changes, cough, vision changes, ear pain,
    urinary symptoms.

Review of Systems
  • CONSTITUTIONAL  No weight loss, endorsed fever,
    chills, and fatigue
  • HEENT  No vision changes
  • SKIN  No rash or itching
  • CV  No CP or palpitations
  • RESP  No cough or sputum, endorsed shortness of
    breath with lying down
  • GI  endorsed N/V/D
  • GU  No dysuria, frequency or urgency
  • NEURO  No HA, dizziness, syncope

  • GERD - PRN H2 blocker only
  • Knee arthroscopy remote
  • Takes no other medications

Social History
  • Lives in Mount Shasta and visiting family in
  • Married
  • Sexual activity Monogamous
  • Pets Dogs
  • Worked Self employed, retail
  • Tobacco None
  • Alcohol Occasional (2 beers a month)
  • Illicit Denies IVDU and all other illicit drugs

Physical Examination 1 of 2
  • Vitals T 38.1 , BP 71/43, P 111, RR 34, O2 98
    on RA
  • Gen Mild discomfort, AOx 4
  • HEENT NCAT, anicteric, PERRLA, EOMI, moist oral
    mucosa . Dentition unremarkable. Mild tonsillar
    erythema with white exudates on left tonsil. No
    bulging of posterior pharynx
  • Neck Supple, trachea midline. Nontender to
    palpation. No LAD.

Physical Examination 2 of 2
  • CV Tachycardic but regular, no M/R/G. PMI non
    displaced, no JVD or peripheral edema
  • Chest Tachypneic, CTAB, no W/R/R
  • Abd Soft, non distended, non tender,, normal BS,
    no hepatosplenomegaly or palpable masses
  • Neuro Awake, alert, oriented x3, speech intact,
    no focal deficits, patient moving all
    extremities, CN 2-12 intact bilaterally
  • Ext No cyanosis, clubbing or edema
  • Skin No rashes, pallor, splinter hemorrhages,
    Janeway lesions or Osler nodes

Initial Labs 1 of 2
  • Sodium 136, potassium 4.0, chloride 103, bicarb
    18, BUN 40, creatinine 2.10, glucose 182, calcium
    8.8, Anion Gap 15
  • total protein 7.4, albumin 4.0, alk phos 48,
    total bilirubin 1.3, AST 24, and ALT 15
  • White blood cell count 17.4 (33 Neutrophils, 6
    Lymphocytes, 45 Monocytes, 4 Eosinophils, 11
    Bands), hemoglobin 13.3, and platelets 131

Initial Labs 2 of 2
  • Lactic acid 5.5?7.4
  • CRP 25.8
  • Cortisol gt75
  • TSH 0.485
  • ABG 7.37/26/69/15/-10.0/20
  • UA pH 5.0, SG 1.027, Positive for Bilirubin,
    Glucose 150, WBC 8, Protein 100
  • CXR No acute pulmonary disease
  • Blood, urine, throat, cultures pending

ER Course
  • Patient was aggressively fluid resuscitated. In
    the ED, he received 6.5L of NS boluses.
  • Despite fluids, his SBP remained in the 70s-80s
    and he was started on Levophed.
  • He was also empirically started on doxycycline,
    flagyl, and vancomycin.

Initial Assessment
  • Septic Shock
  • Monocytosis differential on next slide
  • AKI
  • Anion Gap Metabolic Acidosis 2/2 lactic acidosis
  • Thrombocytopenia
  • Pharyngitis

Monocytosis DDx
  • Infectious
  • EBV
  • CMV
  • Subacute Bacterial Endocarditis
  • Erlichiosis/anaplasmosis
  • Rocky Mountain Spotted Fever
  • Brucellosis
  • Syphilis
  • Autoimmune SLE, IBD, etc
  • Myeloproliferative Hodkins and certain

Initial management
  • Early Goal Directed therapy
  • Empiric Antibiotics with Unasyn, Vancomycin,
    Doxycycline concern for tonsillar pathology
  • Blood, urine, sputum cultures
  • Throat cultures
  • Rickettsia, EBV, CMV serologies
  • RPR, HIV, ANA, procalcitonin
  • CT neck with IV contrast to r/o peritonsillar
    abscess once stable
  • Peripheral blood smear

Next day labs
  • Blood, urine, throat, sputum Cx Prelim negative
  • Respiratory viral panel PCR Neg
  • EBV marked elevation of IgG. IgM normal.
  • Smear review shows increased promonocytes (19)
    and rare myeloblasts. This is a finding highly
    suspicious for acute leukemia

Hospital Course
  • Continued to endorse SOB and was tachypneic with
    respiratory rates in 50s
  • CXR unchanged
  • Patient intubated
  • Increasing pressor requirement with addition of
    vasopressin and dobutamine
  • ABG 7.12/28/88/9 on FiO2 35, given 2 amps bicarb
    and started on bicarb drip
  • Worsening creatinine to gt3 with decreasing urine

Hospital Course
  • Infectious Disease consulted
  • Meropenam, vancomycin, doxycycline and acyclovir
    (concern for possible EBV reactivation)
  • Heme/Onc consulted
  • Reviewed smear with pathology, very likely AML
  • Bone marrow biopsy showed 24 myeloblasts, 18
    monoblasts and promonocytes supportive of AML,
    suggestive of myelomonocytic leukemia
  • Cytogenetic studies pending

Final Diagnosis
  • Septic shock with unknown source - likely
    pharyngeal/tonsillar given symptoms and tonsillar
  • Less likely a zebra as monocytosis reflects
    leukemia immunodeficient state
  • Considering strep pharyngitis with development of
    Lemierres syndrome in the setting of AML
  • CT scan for further evaluation pending