NYU Medicine Grand Rounds Clinical Vignette Ben Milgrom, PGY-2 11/13/13 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

NYU Medicine Grand Rounds Clinical Vignette

Ben Milgrom, PGY-2

11/13/13

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

Chief Complaint

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

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

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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Acute liver failure

• Differential diagnosis is acute viral hepatitis, reactivation hepatitis in setting of steroid use, versus toxic medication effect from previous azithromycin use

Working or Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

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

Hospital Course

• Disseminated HSV-1 infection leading to fulminant hepatic failure

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Systems Error

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Systems Error

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS