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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Pavan Bhatraju MD, PGY-II October 11, 2011. 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 Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Pavan Bhatraju MD, PGY-II October 11, 2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 38 y/o M Firefighter presented 13 days after the 9/11 World Trade Center attack with 2 days of • myalgias • fever • dry cough • pleuritic chest pain • progressive dyspnea with minimal exertion

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Usual state of good health when he arrived at the World Trade Center terrorist attack 20 minutes after the first tower collapsed • Worked 16 hr days and did not use respiratory protection for 10 of 13 days

  4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 11 days PTA he developed a productive cough with blackish sputum that self-resolved in one day • 2 days PTA he developed, cough, fever, myalgias, anterior pleuritic chest discomfort, and dyspnea on exertion with less than one block

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical and • None • Surgical History • None • Social History: • Smoking – 5 pack year history, stopped 20 years ago • Family History: • Non-contributory • Allergies: • None • Medications: • none

  6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: muscular adult male, diaphoretic, in moderate distress • Vital Signs: • T:38.6 BP:130/90 HR:120 RR:35 • O2 sat: 90% on room air • Pulmonary: accessory muscle use, bibasilar decreased breath sounds • Remainder of Physical Exam was Normal.

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: • WBC – 22,600 cells/mm3, • Differential (N = 91%, L = 3% M = 5% E = 1%) • Remainder of CBC was within normal limits • Basic Metabolic panel and Hepatic Panel: • Within normal limits • Arterial Blood Gas on Room Air: • pH 7.46 • paO2 53 mmHg • paCO2 32 mmHg • HC03 23 mEq/L • O2 sat 89%

  8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray and CT Scan: • Patchy ground glass opacifications • Thickening of respiratory airways • Bilateral pleural effusions.

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Lung Injury • Dust Induced • Infection Related • Bioterrorism induced Pneumonia (Anthrax)

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • He was admitted to the MICU and treated with • oxygen • levofloxacin • methylprednisolone • Bronchoalveolar Lavage - 730,000 cells/ml (normal <250,000 cells/ml) • Differential E = 70%, M = 18%, L = 8% N = 4% • Total IgE was 58 ng/ml (normal <180 ng/ml) • BAL fluid IgE was 0.4 ng/ml

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  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 9: • Clinically improved with repeat CT showing near complete resolution. • He was discharged with 3 weeks of corticosteroid therapy • Pulmonary Function Tests: • FEV1 = 2.6 L (71%) • FVC = 3.8 L (86%) • FEV1/FVC = 68% • DLCO = 23.1 ml/mmHg/min (77%) • His oxygen saturation at rest (94%) dropped to 87% after a brisk walk of 150 ft.

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Post-Discharge Worked as a firefighter for the next 3 years Developed increasing dyspnea and irritant sensitivity Repeat PFTs showed worsening airflow obstruction with a bronchodilator response Received disability retirement for reactive airways disease

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Acute Eosinophilic Pneumonia • Subsequent onset of reactive airways disease

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