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MEDICAL GRANDROUNDS

MEDICAL GRANDROUNDS . July 3, 2008 Abigail Cruz-Zaraspe M.D. OBJECTIVES. To present a case of bacteremia in aplastic anemia To discuss salmonella nontyphi bacteremia and myositis manifestations, diagnosis and treatment To discuss briefly the treatment of aplastic anemia. IDENTIFYING DATA.

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MEDICAL GRANDROUNDS

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  1. MEDICAL GRANDROUNDS July 3, 2008 Abigail Cruz-Zaraspe M.D.

  2. OBJECTIVES • To present a case of bacteremia in aplastic anemia • To discuss salmonella nontyphi bacteremia and myositis manifestations, diagnosis and treatment • To discuss briefly the treatment of aplastic anemia

  3. IDENTIFYING DATA • A.R. • 42/M • Married • Real-estate broker

  4. CHIEF COMPLAINT • Right thigh pain

  5. HISTORY OF PRESENT ILLNESS • 5 weeks PTA Easy fatigability, SOB, (+) melena, (+) abdominal pain, (+)palpitations • 4 weeks PTA sought consult, CBC Pancytopenia admitted for the first time for transfusion

  6. HISTORY OF PRESENT ILLNESS • First admission blood transfusions BMA-hypocellular BM Dx: Aplastic anemia treatment options were discussed (discharged-platelet ct 44k)

  7. HISTORY OF PRESENT ILLNESS • 3 weeks PTA intermittent fever (390C),body malaise, nose bleeding Consult: WBC 1860, PLT 10k Tx: Co-amoxyclav 625mg TID x7d, tranexamic acid 500mg TID GCSF 300mcg

  8. HISTORY OF PRESENT ILLNESS • 3 weeks PTA generalized petechial rashes & gum bleeding and was admitted • 2nd admission CBC- pancytopenia Tx: blood & PC transfusions

  9. CBC on SECOND ADMISSION

  10. HISTORY OF PRESENT ILLNESS • 2nd admission Initially given Cefepime 1gm Q12

  11. HISTORY OF PRESENT ILLNESS • 2nd admission + right thigh & hip pain 5/10 (dull, aching constant) +direct tenderness no swelling no limitation in ROM no paresthesia

  12. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

  13. NEUROPATHY • Severe intractable pain • Unusual burning, tingling or shock-like quality • Triggered by light touch • Sensory deficit on area of pain

  14. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

  15. COMPARTMENT SYNDROME • Pain • Parasthesia • Pulselessness • Pallor • pressure

  16. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

  17. HISTORY OF PRESENT ILLNESS • 2nd admission Pelvis and Right hip xray: no pathologic finding

  18. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

  19. HISTORY OF PRESENT ILLNESS • 2nd admission Blood CS: Salmonella enteritidis Grp C Sensitive: Ceftriaxone Chloramphenicol Ciprofloxacin shifted to Ciprofloxacin 500mg/tab, 1 tab BID

  20. HISTORY OF PRESENT ILLNESS • 2nd admission Dx: Aplastic anemia Salmonella nontyphi bacteremia Advised treatment w/ Anti-thymocyte globulin / cyclosporine

  21. HISTORY OF PRESENT ILLNESS • 2nd admission THM: Ciprofloxacin 500mg/tab, 1 tab BID to complete 7 days Prednisone 30mg BID, Tranexamic acid & Omeprazole

  22. HISTORY OF PRESENT ILLNESS • Since discharge episodes of fever & progression R hip & thigh pain on movement & palpation unable to stand admitted 3rd time

  23. (-) headache (-) loss of consciousness (-) cough or colds (-) weight loss (-) chest pain (-) dyspnea (-) palpitations (-) abdominal pain (-) nausea or vomiting (-) LBM/ constipation (+) melena (-) hematochezia (-) dysuria (-) hematuria REVIEW OF SYSTEMS

  24. PAST MEDICAL HISTORY • Non-hypertensive • Non-diabetic • No known allergies

  25. FAMILY HISTORY • No hypertension • No diabetes • No asthma • No blood dyscrasias • No cancer

  26. PERSONAL AND SOCIAL HISTORY • Previous smoker, stopped in late ‘90s • Occasional beer drinker • Lived near an electroplating factory • Previously worked as a cashier in a gasoline station • Real estate broker

  27. PHYSICAL EXAMINATION • General: conscious, coherent, bed-bound • Vital signs: BP 130/80, HR = 103 bpm, reg, RR = 22/min, T = 390C • HEENT: Pale conjunctivae, icteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy

  28. PHYSICAL EXAMINATION • Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, tachycardic with regular rhythm, no murmurs

  29. PHYSICAL EXAMINATION • Abdomen: Flabby, normoactive bowel sounds, soft, non-tender, no hepatomegaly no splenomegaly

  30. PHYSICAL EXAMINATION • Extremities: (+) erythema and hyperemia, right thigh extending to mid-leg area No discharge, no open wounds no sensory deficit Left leg was grossly normal pulses: full and equal

  31. SALIENT FEATURES • 42/M • Known case of aplastic anemia • Known case of non-typhi salmonella bacteremia • Treated with ciprofloxacin 500mg BID x 1 week • Still febrile • Right thigh and hip pain • Erythema and swelling of right lower extremity

  32. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

  33. AVASCULAR NECROSIS • results from infarction of bone trabeculae and marrow cells • equal frequency in the femoral and humeral heads • The femoral heads more commonly undergo progressive joint destruction as a result of chronic weight bearing. The changes are best detected by MRI

  34. AVASCULAR NECROSIS • Most studies have found that the risk is low (< 3 percent) in patients treated with doses of prednisone less than 15 to 20 mg/day • In one series, the prednisone dose in the highest month of therapy exceeded 40 mg/day in 93 percent, and 20 mg/day in 100 percent of patients with osteonecrosis.

  35. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

  36. 150 patients with aplastic anemia treated at Clinical Hematology Branch of the National Heart, Lung and Blood Institute (NHLBI) between 1978 and 1990 • Infection was documented in 47% of cases • respiratory tract (32 percent) • soft tissues (24 percent) • blood (22 percent) • gastrointestinal tract (17 percent) • urinary tract (6 percent).

  37. IMPRESSION • Aplastic anemia • Salmonella non-typhi bacteremia with secondary myositis • r/o Avascular necrosis, osteomyelitis

  38. COURSE IN THE WARDS • On admission • CBC, PT, PTT, UA, CXR, crea, BUN, K, Na were requested. He was placed on a neutropenic diet. • He was started on Piperacillin-tazobactam 4.5mg/IV x 1dose then 2.25mg q8 hours

  39. LABS APRIL 12, 2008 CXR- normal

  40. Piperacillin-tazobactam Febrile

  41. COURSE IN THE WARDS • 2nd hospital day • + severe leg pain, unrelieved by Tramadol. • referred to Orthopedic service • Impression: t/c pathologic fracture vs. avascular necrosis, R hip; aplastic anemia. • Tx: Ketorolac and Morphine.

  42. COURSE IN THE WARDS • 2nd hospital day • Pelvic MRI was requested • Myositis with fasciitis involving the right gluteal and right thigh muscle and the right obturator internus muscle. • Avascular necrosis of the right femoral head considered

  43. COURSE IN THE WARDS • 2nd hospital day • still with fever and leg pain • Blood CS: • Salmonella Enteritidis Group C • sensitive to Ceftriaxone and Ciprofloxacin • resistant to Co-trimoxazole and Ampicillin.

  44. COURSE IN THE WARDS • 5th HD • referred to Infectious Disease service. • Impression: Salmonella nontyphi bacteremia with secondary myositis. • Tx: shift Piperacillin-tazobactam to Ciprofloxacin 500mg/tab 2x a day & ceftriaxone 2g/IV OD

  45. CP & CT PT Febrile

  46. COURSE IN THE WARDS • 11th HD • patient was still febrile (Tmax400C) • endovascular Salmonella was considered • Ceftriaxone was discontinued • Piperacilin-Tazobactam was resumed & increased to 4.5 IV Q8 • dexamethasone 4mg/tab 12 hrs

  47. CP+CT CP PT CT dexa Febrile

  48. COURSE IN THE WARDS • 13th HD • Afebrile • pain decreased • Dexamethasone was tapered to 4mg/tab bid.

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