Inpatient small feedings

1. Inpatient small feedings Daniel J. Brotman, MD, FACP Director, Hospitalist Program, Johns Hopkins Hospital Associate Professor of Medicine

2. Financial disclosures • No relevant disclosures.

3. Case #1 • 34 y/o African American man, generally healthy. Fell of 3rd floor balcony during altercation and hurt R leg.

4. Right tib/fib fracture confirmed

6. Additional imaging (body CT), no evidence of internal bleeding------ Went to OR for repair

7. Gen Med consult post-ORIF

10. Additional history • No prior medical history. • Admits to occasional marijuana, inhaled cocaine. No IV drugs. • + incarceration 2 months prior; reportedly negative PPD at this time. Was told he had abnormal CXR, but no work-up done. • + occ dark sputum, attributed to smoking marijuana. • No fevers, weight loss, malaise

11. Labs • BUN/CR = 25/1.7 • Albumin 3.9, Tot Pro 8.6 • AlkP = 140; AST/ALT 27/26 • WBC 13K, Hct 42, Plts 239

12. Differential diagnosis • TB (no fever/wt loss; but + cough, recent incarceration) • Fungus (?marijuana-related vs endemic) • Cancer (eg, lymphoma, given spleen) • Sarcoid (black race, multi-system)

13. Would you isolate this patient to rule-out TB?

14. Diagnosis intentionally omitted from handout e-mail Dr. Brotman for full slide set: brotman@jhmi.edu

15. Case #2: • 41 y/o African American woman presents to ED with malaise, jaundice, and loose stools. • 5 weeks prior, had undergone frontal craniotomy for a brain mass • Pathology showed adenocarcinoma • Additional imaging negative for primary

18. Additional history • Hepatitis C from prior IV drug use • + Tobacco use • Morbid obesity • Only med: Prophylactic phenytoin (300mg bid) started as seizure prophylaxis following brain surgery

19. Exam: • Fatigued appearing and anxious, but alert and appropriate • HR 120; Temp 99.1F; BP 90/60; RR 18; Sats 97% RA • HEENT: post-op changes; + icterus • No focal findings

20. Labs: AST = 634 ALT = 510 124 26 87 AlkP = 382 113 23 3.7 0.9 Alb = 2.8 Tbili = 7.6 (conj = 6.1) 13.0 11.5 246 INR = 3.6 37.7 PTTr = 1.2 PMN = 52%, L = 18%, M = 7%, E = 23%

21. Fearing the worst… • Adenocarcinoma of unknown primary, now with jaundice • ? Pancreatic cancer • ? Cholangiocarcinoma • Phenytoin held

22. RUQ ultrasound • Liver appears normal • Possible 1.5cm mass in body of pancreas • 3mm common bile duct • Cholelithiasis, with mildly thickened GB wall (5mm), but no pericholecystic fluid

23. Abdominal MRI (hosp day 2) • Not suggestive of cholecystitis • No intrahepatic or extrahepatic ductal dilatation, and normal pancreatic ducts • Supposed pancreatic lesion seen on US was not visualized on MRI

25. Patient’s status, day 2 • Low-grade fever (38.1) • Complains of eye irritation and continued malaise/loose stools • Exam shows conjunctival injection and some new cutaneous erythema

26. Day 2 Labs: AST = 483 ALT = 441 127 21 95 AlkP = 393 113 21 3.6 0.8 Tbili = 8.8 13.0 12.0 246 INR = 5.8 37.7 (No diff) Hepatitis serologies pending

27. Diagnosis intentionally omitted from handout e-mail Dr. Brotman for full slide set: brotman@jhmi.edu

28. Case #3: • 53 y/o orthopedic surgeon from Florida presents for 2nd opinion for FUO • Previously extremely healthy (exercise nut)

29. 6 weeks prior to presentation… • Headache • Dyspnea on exertion • Fevers to 103F with shaking chills, limiting his ability to operate • Aching all over (flu-like) • Presented to outside hospital

30. At outside hospital (6 weeks prior) • WBC 37,000 • Febrile • Diffuse achiness with musculoskeletal pain and abdominal pain • Received piperacillin/tazobactam, vancomycin, and cefepime • RUQ ultrasound showed some fluid • Laparoscopic cholecystectomy • Normal GB

31. Delirium ensued • LP showed >2000 WBCs, mainly PMNs; cultures and cytology negative • Acycolvir and doxycycline empirically added • MRI brain showed meningeal enhancement but no focal lesions • Near-intubation for pulmonary infiltrates thought due to ARDS • ESR > 100

32. HIV Crypto serology Toxo serology West Nile Zoonoses Rickettsia Borrelia Coxiella Ehrlichia Leptospirosis PPD negative TA biopsy Blood cultures TEE ANA, RF (trivially elevated RF) No steroid trial done Negative studies

33. Repeat LP 1 week after 1st LP: • 128 WBC, still with PMN predominance • Discharged feeling partially better (still fatigued and achy, but not delirious) • About a week later, symptoms returned so he came for 2nd opinion.

34. Upon presentation to JHH… • Fatigued, achy, c/o weight loss of 14 lbs in 6 wks. • Meds PRN only (analgesics) • Temp 38.5 • No rash or other focal findings on exam, but hurt to touch over many joints/muscles without obvious inflammation

35. Labs: AST = 41 ALT = 66 130 18 94 AlkP = 120 135 27 4.2 1.0 Alb = 3.1 Tbili = 0.2 8.5 18.0 367 ESR = 122 26.0 PMN = 79%, L = 9%, M = 11%, E = 1%

36. Neg rheum serologies HIV negative RPR negative Periph smear negative except for L shift with toxic granulation Marrow biopsy: hypercellular, increased M:E ratio. No lymphoma Ferritin 338 TIBC 191 Iron 10 (5% sat) LDH = 134 Labs…continued

37. PET-CT: • Diffuse increased bone marrow uptake • Mild R hilar adenopathy • Significant adenopathy gastrohepatic ligament • Anterior abd wall inflammation

40. How likely is cancer? • Biopsy abdominal nodes? • Biopsy hilar nodes?

41. Diagnosis intentionally omitted from handout e-mail Dr. Brotman for full slide set: brotman@jhmi.edu