Department of Medicine Grand Rounds Clinical Vignette

1. Department of Medicine Grand RoundsClinical Vignette Ilana Bragin January 14 th, 2009 NYU Langone Medical Center Internal Medicine Residency Program

2. Chief Complaint The patient is a 61 year old Caucasian male who presented with 2 weeks of increasing edema and decreased urine output.

3. History of Present Illness • Approximately one year prior to presentation, the patient presented with new onset ascites. • Work-up at that time included a diagnostic paracentesis, which revealed atypical cells. • Subsequent CT scan showed a 6 cm mass at the pancreatic tail and 3 cm omental caking. • Core biopsy showed moderately differentiated adenocarcinoma consistent with pacreaticoviliary cancer.

4. History of Present Illness • He was enrolled in a clinical trial and started on Gemcitabine (Gemzar), Bevacizumab (Avastin), and Erlotinib (Tarceva). He was also started on aldactone for his ascites. • A follow up CT scan showed some improvement in the size of the mass and the amount of ascites. • Six months later, routine labs revealed an increased creatinine of 2.2 from his baseline of 1. The aldactone was discontinued. • One week later, he presented to clinic with increased edema (legs, hands, face), fatigue, and decreased urine output. His creatinine at that time was 2.6. • Chemotherapy was held.

5. Additional History • Past Medical History: • Hypothyroidism • Benign Prostatic Hypertrophy • Coronary Artery Disease • Past Surgical History: • Coronary Artery Bypass Grafting, 4 years ago • Social History: • No toxic habits • Family History: • Non-contributory • Medications: • Atorvastatin 20 mg at night • Aspirin 81 mg daily • Levothyroxine 125 mcg daily • Famotidine 20 mg twice daily • Darbepoetinalfa 200 mcg weekly • Gemcitabine, Bevacizumab, Erlotinib (HELD)

6. Physical Exam • Gen: sitting comfortably, no acute distress • Vital Signs: T 98, HR 80, BP 160/90, RR 16 • Extremities: 3+ pitting edema bilaterally The remainder of the physical exam was normal

7. Laboratory • CBC: WBC- 2 Hgb-10.2 Platelets-13 • MCV 99, Differential: 44% Neut, 38% Lymph, 16% Monos • Smear: occasional schistocytes • Basic Metabolic: BUN 44 Creatinine 2.6 • Remainder of values were within normal limits • Liver Function Panel: AST-152 ALT-106 Albumin 2.7 • Remainder of values were within normal limits • Coagulation Panel: INR-1.02 PTT-28.9 • Fibrinogen-595 • D-dimer-734 • Fibrin Degradation Products >5 • LDH 1951 • Urinalysis: large blood, 3+ protein, 11-25 RBCs

8. Differential Diagnosis • Obstruction secondary to mass • Thrombotic Thrombocytopenic Purpura (TTP) • Acute Tubular Necrosis (ATN) secondary to chemotherapy regimen or infection • Glomerulonephritis • Nephrotic syndrome • Renal artery thrombosis

9. Hospital Course • A renal ultrasound was done: • Kidneys normal in size, echotexture and parenchymal thickness. No solid mass, hydronephrosis, shadowing calculi or perinephric abnormality. • A renal MRI: • Patent renal veins • Renal Biopsy: • changes of thrombotic microangiopathy consistent with TTP

10. Final Diagnosis Renal Thrombotic Microangiopathy consistent with Thrombotic Thrombocytopenic Purpura (TTP)