NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Lisa Parikh, MD PGY 2 5/8/2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint • 65 year old man who presents with a cough x 1 week. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

3. History of Present Illness • He was in his usual state of good health until 4 weeks ago when he traveled to Shelter Island in New York. • Noted erythema on his right arm thought to be from a bug bite, and when evaluated by a physician, was treated with a 10 day course of cefalexin with resolution of the rash. • In the following days, he then developed dry cough and intermittent fevers, as high as 102F. • Went to PMD the day prior to admission and was given a prescription for moxifloxacin 400mg daily. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

4. History of Present Illness • On the morning of admission, patient rose from bed, felt dizzy, and lost consciousness for 1 minute. He was diaphoretic and dizzy when he awoke. • Wife took him to his PMDs office where his blood pressure was 90/60 with heart rate in the 130s. An EKG showed atrial fibrillation with rapid ventricular response. • He was sent to the ER at Tisch hospital for evaluation. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

5. Additional History • Past Medical History: • HTN • HLD • Rheumatoid Arthritis • Gout • Past Surgical History: • None • Social History: • Former smoker,quit 35 yrs ago • No children at home • Has pet cat x 1 year • No recent travel • Family History: • None • Allergies: • No Known Drug Allergies • Medications: • lisinopril 5 mg daily • aspirin 81 mg daily • ezetimibe/simvastatin 10mg/20mg daily • allopurinol 300mg daily • moxifloxacin 400 mg daily UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

6. Physical Examination • Well-nourished, well-developed man resting comfortably in bed • Vital Signs: • T:100.2 F, BP:119/73, HR:114, • RR:20 and SaO2: 99% room air • Cardiovascular: irregularly irregular, 2/6 systolic murmur at left lower sternal border and apex • Pulmonary: decreased breath sounds at bases bilaterally • The remainder of the physical exam was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

7. Laboratory Findings • CBC: hemoglobin 13.1 • Basic Metabolic panel: Sodium 130 • Hepatic panel: total bilirubin 1.5, AST 69 • Troponin: <.02 • The remainder of the CBC, BMP and hepatic panels were within normal limits. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

8. Other Studies • ECG: atrial fibrillation, ventricular rate 118, left atrial dilitation, left ventricular hypertrophy • Chest X-Ray: no acute cardiopulmonary disease UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

9. Differential Diagnosis • Infection triggered atrial fibrillation • Differential diagnosis of infection: upper respiratory tract infection versus pneumonia caused by viral or bacterial origin; tick-borne illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

10. Hospital Course • Hospital Days 1-3 • Started on diltiazem 90mg q6hr for rate control • Initially, moxifloxacin was continued, but changed to ceftriaxone and azithromycin on hospital day 2. • The patient continued to be febrile. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

11. Hospital Course • Hospital Day 4 • Blood parasites positive for babesia with 1.0% parasitemia • Ceftriaxone was discontinued • Azithromycin 1g daily continued • Atovaquone 750mg was initiated • Chest CT showed a right upper lobe 4mm nodule, mild upper lobe predominant centrilobular emphysema, areas of non-segmental atelectasis involving both lower lobes • Hospital Day 5 • Patient discharged home to complete 7 days of azithromycin and atovaquone

12. Outpatient Follow-Up • Day 1 after discharge • Lyme Ab total blood: 5.4 (normal <0.91) • Lyme IgM Ab titer: 5.59 (normal <0.91) • Lyme western blot IgM: positive

13. Final Diagnosis • Final diagnosis: Co-infection with Lyme disease and babesiosis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS