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NYU Medicine Grand Rounds Clinical Vignette

NYU Medicine Grand Rounds Clinical Vignette. James Kim, M.D., PGY-2 February 26, 2014. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medicine Grand Rounds Clinical Vignette

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  1. NYU Medicine Grand Rounds Clinical Vignette James Kim, M.D., PGY-2 February 26, 2014 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 53 year-old woman presents with pain in multiple joints (knees, wrists, shoulders, elbows, ankles) for 2 months and fatigue, shortness of breath and hemoptysis for 1 week

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 1 year prior to current presentation, presented with left sided vision changes – pink spots alternating with darkness. Found to have elevated ESR/CRP and prescribed course of prednisone for optic neuritis • Underwent a temporal artery biopsy, which was non-diagnostic, and the patient’s vision returned to normal after completing prednisone course • 2 months ago, began to develop fluctuating pain in multiple joints accompanied by swelling, mildly relieved by ibuprofen • 1 week ago, began to develop generalized fatigue, shortness of breath, and blood-streaked sputum • Due to worsening symptoms, she presented to the hospital

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Left optic neuritis • Seasonal allergies • Past Surgical History: • None • Social History: • No tobacco, alcohol, illicit drugs • Family History: • No notable family history • Allergies: • Acetaminophen (rash) • Medications: • Ibuprofen as needed

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Pale, no acute distress • Vital Signs: T: 97.8 F BP: 141/81 HR: 102 RR: 18 and O2 sat: 100% 2L nasal cannula • Conjunctival pallor • Heberden nodes on all digits • Trace right knee effusion without warmth, erythema, tenderness • Remainder of physical exam was normal

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: hemoglobin 4.6 g/dL, hematocrit 13.9% • Remainder of CBC was within normal limits • Basic Metabolic panel: within normal limits • Hepatic panel: within normal limits • ESR: 60 mm/hr (0-20) • CRP: 69.9 mg/L (<= 3.0) • C-ANCA: < 6 (<1.0) • P-ANCA: >100 (<1.0) • Urinalysis: 3+ blood, RBC 15-30/hpf (0-4/hpf)

  7. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray: diffuse tiny nodular infiltrates scattered throughout both lungs • Chest CT with contrast: ground glass density in the mid lung fields that becomes more confluent at the bases. Diffuse subcentimeter nodules.

  8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Microscopic Polyangiitis • PolyarteritisNodosa • Churg-Strauss Syndrome

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Started on IV methylprednisolone, and transfused 2 units of packed red blood cells • Diffuse alveolar hemorrhage seen on bronchoscopy. Transbronchial biopsy showing no evidence of vasculitis • Hospital Day 2: • Hematocrit and symptoms improved following transfusion and steroids

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 3: • Hematocrit remained stable, methylprednisolone changed to daily prednisone • Renal biopsy obtained, consistent with ANCA associated, pauci-immune crescentic glomerulonephritis • Hospital Day 4: • Discharged with close follow up

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Microscopic Polyangiitis

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