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NYU Medicine Grand Rounds Clinical Vignette

NYU Medicine Grand Rounds Clinical Vignette. Ben Milgrom, PGY-2 11/13/13. 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 Ben Milgrom, PGY-2 11/13/13 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Mr. C is a 64 year old man with a history of COPD who presented with 1 week history of gnawing epigastric pain

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient has been admitted multiple times over the previous year for COPD exacerbations. • Most recent admission was 3 weeks prior to the current admission. • At that time, he was treated with nebulizers, steroids, and antibiotics with improvement in his respiratory status • He was discharged with prescriptions for a prednisone taper, fluticasone/salmeterol and albuterol inhalers, and azithromycin

  4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Following discharge, the patient’s respiratory status improved to baseline • The patient reports an episode of unprotected sex 2 weeks ago (1 week following hospital discharge) • Shortly thereafter, he developed a nontender ulcerated lesion on the glans penis • He then developed a maculopapular rash across his chest and abdomen • Skin lesions were asymptomatic so the patient did not seek medical care

  5. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • One week prior to admission, he developed gnawing epigastric pain which had become progressively more severe. • Pain was described as constant, nonradiating, and not associated with food. • He also had numerous watery bowel movements daily, without blood or melena • He denied nausea or vomiting, change in skin or eye color, change in medications other than the prescribed azithromycin and prednisone.

  6. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • COPD (GOLD stage III) • Hypertension • Past Surgical History: • Hemorrhoidectomy • Social History: • 30 pack year smoking history quit 6 years ago • Denies alcohol or illicit drug use • Immigrated from Ghana 40 years ago, has not left NYC in 5 years • Works as a musician • Lives with alone in an apartment in Manhattan

  7. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Family History: • No known family medical history • Allergies: • No known drug allergies • Medications: • 15 day prednisone course and 5 day azithromycin course recently completed • Fluticasone/salmeterol inhaler BID • Amlodipine 10 mg PO daily • Albuterol inhaler PRN dyspnea

  8. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: African American man resting in no distress • Vital Signs: Temperature 101.5 F, blood pressure 95/65, heart rate 105, RR 16, 98% O2 saturation on room air • Maculopapular eruption on face, neck, torso, abdomen, and arms • Hepatomegaly 5 cm below costal margin, tenderness in epigastrium with guarding, no rebound, abdomen soft • Ulcerated lesion on glans penis without discharge • Remainder of physical exam was within normal limits

  9. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: Platelets 30 • Remainder of CBC was within normal limits • Basic Metabolic panel: • Sodium 130, Potassium 5.7, Chloride 98, CO2 24, BUN 40, Creatinine 1.7 • Hepatic panel: • AST 11,126, ALT 7, 840, Alkaline Phosphatase 239, Total Bilirubin 2.0, Direct Bilirubin 1.3, Total Protein 5.4, Albumin 2.8 • Lipase 175 (< 66), INR 2.9, salicylates/acetaminophen/ethanol levels negative

  10. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: Sinus tachycardia • Chest X-Ray: No infiltrate or effusion • CT Abdomen/Pelvis w/o contrast: Low attenuation of the liver which may be due to fatty infiltration versus edema/inflammation

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Acute liver failure • Differential diagnosis is acute viral hepatitis, reactivation hepatitis in setting of steroid use, versus toxic medication effect from previous azithromycin use

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Sepsis alert was called and patient received IV normal saline, vancomycin and piperacillin/tazobactam • N-Acteylcysteine IV was given • Hospital Day 2: • Tzanck smear performed on skin lesion which was positive • Viral hepatitis serologies were negative

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 3: • Papular lesions developed into vesicles • Viral culture of penile lesion confirmed HSV-1 • HIV, CMV, VZV serologies negative • Hospital Day 4: • Synthetic liver function continue to worsen, total bilirubin > 30, INR 5.0 • Transplant surgery confirmed patient would not be a candidate given disseminated HSV infection

  14. Hospital Course • Hospital Day 5-8: • Clinical status continued to deteriorate • Patient developed respiratory distress requiring intubation and mechanical ventilation • Chest CT showed multifocal infiltrates concerning for pneumonia versus ARDS • Hypotension developed requiring vasopressor support • Renal failure developed requiring hemodialysis

  15. Hospital Course • Hospital Day 9-14 • The patient’s condition failed to improve despite aggressive measures • Goals of care discussion held with family • Decision made to refer to hospice

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Disseminated HSV-1 infection leading to fulminant hepatic failure

  17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Systems Error • On review of records from previous hospital discharge, an error was found in the discharge medications: • Prednisone comes in 50 mg and 10 mg tabs • The patient was meant to be prescribed 10mg tabs with directions to take 5 tabs daily • Instead, the patient was prescribed 50 mg tabs, and was instructed to take 5 tabs • The patient therefore took prednisone 250mg daily instead of 50mg daily

  18. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Systems Error • The patient received an inappropriately high steroid dose leading to disseminated HSV-1 • The error was not caught by pharmacist, nurse, or discharging physician • This systems error at discharge contributed to the patient’s demise

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