Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
LSU Internal Medicine Case Conference “What the Bullae!" 10/02/2012 Jay Mansfield, MD PGY I Internal Medicine “Worsening shortness of breath” x several months 76 year-old African American woman with significant past medical history of ischemic cardiomyopathy s/p AICD (last EF <20% in 12/2011), hypertension, hyperlipidemia, CKD stage III, peripheral vascular disease s/p left SFA stent (3 weeks prior) with left foot ischemic toes and multiple ulcers presented to the ED complaining of progressively worsening shortness of breath and fatigue over the past several months. The patient started developing bilateral lower extremity edema and claudication. She also developed orthopnea – having to sleep upright in a chair. She had previously been able to ambulate about 1½ blocks easily but now can only walk a few steps before becoming short of breath. She denied any chest pain, nausea, vomiting, fever or chills. The patient is not able to recall all her medications and reports that she has not been adherent with her medications. Past Medical History: As above plus Hypothyroidism Surgical History: Hysterectomy ICD (2010) Left SFA stents (3 weeks prior) Allergies: Penicillin/Sulfa swelling and rash Home Medications: Aspirin 81 mg Daily Clopidogrel 75 mg Daily Simvastatin 40 mg QHS Carvedilol 3.125 mg BID Lantus 10 Units QHS NovoLog 5 Units BID Levothyroxine 50 mcg Daily Ondansetron 4 mg PO q8hrs prn nausea Family History NC Social History: History of tobacco use >20 years previously with 5-pack year history No ETOH, no illicit drugs Lives alone Has three daughters who live close and visit frequently Health Maintenance: PCP at LSU Medicine Clinic (Dr. Lacour) Up-to-date on Influenza and Tdap Unknown Pneumovax Mammogram WNL (1/2012) No colonoscopy Review of Systems Negative except per HPI Temp Pulse RR BP Pulse Ox Weight Height BMI 99° F 93 20 131/57 97% on RA 77 kg 124 cm 50 General: AAOx3, no acute distress HEENT: NCAT, PERRL, EOMI, clear oropharynx Neck: Supple. No Carotid bruits. JVP 12 cm H2O Cardiovascular: Regular rate and rhythm. No murmurs or rubs. Pulmonary: CTA bilaterally, no wheezes/rhonchi/crackles Abdomen: Nondistended, bowel sounds present, soft , non tender, obese Extremity: Dorsalis pedis and Posterior tibial pulses not palpable. 2+femoral and radial pulses bilaterally. 2+ pitting edema bilaterally in lower extremities to lower back. 1+pitting edema in LUE. No palpable cords. Skin: No rashs, no bruises. Left foot bandaged with multiple ischemic toes and wounds with purple stained skin from gentian violet preparation Neurologic: Face symmetric, tongue and uvula midline. Hearing grossly intact. Muscle strength 5/5 x 4 Decreased sensation to pain and light touch over lower extremities especially feet bilaterally Day of Admission WBC Hgb Hct PLT MCV RDW Seg Bands Lymphs Monos Basophils 12.4 12.4 39.7 161 74.8 17.8 80% 13% 1% 5% 1% (4.5-11.0) (80-100) (11.5-14.5) Na K Cl Bicarbonate BUN Creatinine GFR Glucose Ca++ Mg++ Phos 136 4.5 104 21 (24-32) 30 (7-25) 1.60 (0.5-1.10) 38 (>60) 239 (65-99) 8.99.78 1.9 3.4 Total Protein Albumin Total Bilirubin AST Alkaline Phosphatase ALT BNP TSH Free T4 6.8 2.9 2.5 34 114 14 (3.4-5.0) (<1.3) 3928 (<100) 4.52 0.77 EKG Day of Admission First degree A-V block Cannot rule out anterior myocardial infarction, age undetermined Low QRS voltage in limb leads No significant change from previous tracing Chest X-Ray Day of Admission “Dual lead pacemaker again noted. The cardiomediastinal silhouette is stable with calcifications of the aortic knob and four-chamber cardiac enlargement. Bronchovascular marking pattern is unchanged. There is no evidence of pulmonary edema. The lungs are clear. There is no focal airspace consolidation, pleural effusion, or evidence of pneumothorax. Again noted is osteopenia and thoracic kyphosis.” Patient was admitted to Medicine IV furosemide 40mg q12 hours initiated with strict I/O’s Home medications continued Hospital Day #3 Patient was noted by Primary Care team to have developed multiple hemorrhagic bullae on her right lower extremity She was also noted to have altered mental status Medical ICU, General Surgery and Infectious Disease services were consulted Labs, cultures, and ABG were obtained Patient was placed on NRB Patient was empirically started on Vancomycin, Clindamycin, and Ciprofloxacin Temp Pulse RR BP Pulse Ox 97° F (96-99.9 ° F) 98 20 123/63 96% on 3L NC General: Awake, lethargic, no acute distress HEENT: NCAT, PERRL, EOMI, clear oropharynx Cardiovascular: Regular rate and rhythm. No murmurs or rubs. Pulmonary: CTA bilaterally, diffuse expiratory wheezes present; no crackles, good air movement Abdomen: Nondistended, obese, bowel sounds present, soft , non tender Extremity: 2+ Radial pulses bilaterally. PT and DPs not palpable secondary to edema. 2+ pitting edema LE bilaterally to upper thighs. Left foot dressed in clean bandage. Multiple ischemic toes on Left foot. Skin: Multiple hemorrhagic bullae to anterior and medial aspect of RLE measuring 4x2cm. Posterior aspect of RLE near popliteal fossa where bullae erupted, weeping serosanguinous fluid with associated erythema and warmth. Laboratory Data I Day #3 WBC Hgb Hct PLT MCV RDW Seg Bands Lymphs Monos Basophils 2.6 13.8 43.6 110 73.7 18.5 52% 13% 17% 16% 1% (4.5-11.0) (130-400) (80-100) (11.5-14.5) Laboratory Data II Day #3 Na K Cl Bicarbonate BUN Creatinine GFR Glucose 137 3.7 104 23 (24-32) 29 1.24 (0.5-1.10) 51 (>60) 38 (65-99) Ca++7.99.66 Mg++ 1.5 Phos 3.4 Blood cultures pending ABG 7.45/40/235/28/100% on 100% NRB Laboratory Data III Day #3 Total Protein Albumin Total Bilirubin AST Alkaline Phosphatase ALT INR PT PTT Lactic Acid 4.8 1.8 2.7 31 58 12 (6.0-8.0) (3.4-5.0) (<1.3) 2.0 (0.9-1.1) 21.7 (9-12.7) 40.3 (24-37) 1.6 Hospital Course: Day #3 Patient was given a total of 2 amps of D50 and some juice. Patient’s mental status returned to baseline. Repeat accucheck was 96. Patient underwent Ultrasound of right lower extremity – no DVT Patient was transferred to MICU for continued monitoring and management Hospital Course: Day #3 Transfer Antibiotic Medications: Ciprofloxacin Vancomycin Clindamycin Tigecycline Hospital Course: Day #3 Patient’s bullae began to desquamate and increase in number: affected anterior thigh area measured 8x4cm, posterior fossa skin involvement measured ~12cm in length Patient had no mucosal involvement New bullae appeared on patient’s suprapubic area with notable erythema and extreme tenderness 4x2cm Right upper extremity became more edematous and extremely tender to touch, no bullae were noted, increased erythema noted in RUE antecubital fossa Hospital Course: Day #3 Dermatology was consulted and performed bedside examination and punch biopsy of one of the bullae on patient’s right lower extremity Hemorrhagic Bullae Suprapubic Anterior Thigh Right Lower Extremity Medial Right Lower Extremity Lateral Right Lower Extremity Right Upper Extremity Hospital Course Morning Day #4 Patient stated she felt better. Patient only complaining of pain in right arm and right hand Oriented to person, place. Confused about exact date. Small bullae noted in RUE antecubital fossa measuring 0.5x0.5cm Other bullae and lesions appeared stable Laboratory Data I Morning Day #4 WBC Hgb Hct PLT Seg 2.7 (4.5-11.0) 12.9 40.1 111 (130-400) 71% Bands 8% Lymphs 13% Monos 8% Basophils 0% Laboratory Data II Morning Day #4 Na K Cl Bicarbonate BUN Creatinine GFR Glucose Anion Gap 139 4.4 101 25 31 1.55 40 92 18 Ca++ Mg++ Phos (7-25) (0.5-1.10) (>60) (<10) 7.49.32 1.4 4.5 Laboratory Data III Day #3 Total Protein Albumin Total Bilirubin AST Alkaline Phosphatase ALT BNP 3923 (<100) Lactic Acid 4.2 (0.3-2.4) 4.2 1.6 3.2 61 44 15 (6-8) (3.4-5.0) (<1.4) (<45) Hospital Course: Day #4 Patient became hypotensive requiring pressor support with total of 2 pressors: Levophed and Vasopressin Patient became more altered and was intubated to protect her airway Patient’s UOP significantly declined despite being on a lasix drip Patient was transfused albumin to help with diuresis Hospital Course: Day #4 X-Ray of Right Lower Extremity revealed extensive edema, no subcutaneous emphysema Significant Laboratory Data Day #4 Lactic Acid Bicarbonate Creatinine WBC Bandemia Platelets INR PT CK CRP Troponin 1.6 4.2 10.4 21 25 12 6 1.24 1.55 1.95 2.41 2.6 2.7 10.1 14.3 13% 27% 8% 35% 110 131 111 97 49 2 3.9 21.7 43.1 608 16.9 1.88 Patient became bradycardic and hypotensive, then became pulseless Patient was resuscitated with chest compressions and epinephrine Patient’s family decided to make the patient DNR if another code were to occur Patient became hypotensive again despite pressor support and died Microbiology and Pathology Results Microbiology and Pathology Results Blood cultures obtained on day of transfer to MICU revealed Group A Streptococcus in two bottles Swab of right thigh lesion grew Group A Streptococcus Repeat blood cultures on day after transfer to MICU had no growth Right upper thigh punch biopsy revealed subepidermal vesicular dermatitis with thrombotic vasculopathy, autolysis, and numerous interstitial bacterial cocci Streptococcal Toxic Shock Syndrome