CASE CONFERENCE Arif Shahzad, M.D. PGYIII Internal Medicine / Pediatrics
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1 CASE CONFERENCE Arif Shahzad, M.D. PGYIII Internal Medicine / Pediatrics
2 Chief Complaint I feel very weak and dizzy
3 History of Present Illness 54 yr man with PMHX DM-II and depression who was in his USOH until~ 1-2 months ago when he presented to ED for generalized weakness, increased urinary frequency, and dryness of mouth. At that time he was found to be hypovolemic and hyperglycemic for which he received IVF and was discharged home with scheduled follow up.
4 HPI continued He then presented in the ED after a few weeks complaining of a stuffy nose and irritated eyes. He was given doxycycline for presumed sinusitis. In addition he was evaluated by ophthalmology and prescribed Moxifloxacin eye drops for presumed conjunctivitis. He subsequently had several ED visits due to his unresolved stuffy nose and irritated eyes. During one of his ED visits he underwent an imaging study of his head which showed evidence of mild sinusitis (according to the patient).
5 HPI continued After about 2-3 weeks he presented to the ED with generalized weakness and fatigue. His laboratory data was abnormal as compared to the previous ED visit one month prior and hence the medicine team was consulted to evaluate the patient.
6 Past Medical History DMII 4 visits in the past 2 months for presumed sinusitis, irritated eyes Depression for which he was admitted to MHERE a month ago for a period of 4 days
7 More Past Medical History Medications Metformin 500mg po BID Insulin glargine 100 units QHS Citalopram 20mg po qd Acetaminophen/Butalbital/Caffeine 325/50/40 po q4 prn HA Hydroxyzine 50mg po qd NKDA Surg Hx Denied Fam Hx Parents have DMII, denied any autoimmune diseases
8 Social History Denied any tobacco, ETOH or illicit drug use Previously homeless (4 months ago) but now lives with his brother in NOLA Unemployed. Used to work in the graveyard TST was negative according to patient ( date unknown)
9 Review of Systems Decreased energy Poor appetite + night sweats X 2 months 30 lbs unintentional weight loss X 2 months due to depression Temporal headaches X2 months, no thunderclap headaches no neck pain, No easy bruising /no h/o soft tissue infections/edema
10 Review of systems Denied- Any vision changes/ diplopia/ photophobia Any dysphagia/ drooling/ tinnitus/epistaxis Any chest pain/no palpitations/no syncope No dyspnea/productive cough other than early morning dry cough / orthopnea/ paroxysmal nocturnal dyspnea No abdominal pain/ N/V/D no melena/ hematochezia No dysuria/flank pain/ hematuria/penile discharge
11 Physical Exam VS: BP: 152/87 P: 77 R:14 T: % RA #: BMI:25 Gen: A&Ox4, quiet, NAD, actively vomiting during interview HEENT: NCAT, PERRLA, left eye hemorrhage, EOMIs, patent nares, tongue ring, no exudate in OP, no LAD, no facial rash; trachea midline: JVP: 6cm H20 at 45 degrees No TTP over the sinuses, intact nasal septum Chest: good effort, normal AP diameter, symmetric rise, no rales, rhonchi or wheezing; CV: S1, S2 present; no murmurs/rubs/gallops; PMI nondisplaced Abdomen: nondistended, normoactive BS, nontender, no organomegaly
12 Physical Exam, continued EXT: 2+ distal pulses, mild non pitting LE edema Neuro:, no facial asymmetry; no gross sensory or motor deficits; ambulatory without ataxia; reflexes +2/4 (achilles, patellar, brachioradialis, biceps); normal sensation in the bottom of his feet Skin: no rashes, no tattoos, no petechia
13 LABS N 22L 7M 1E 0B GFR 11 HIV neg Lactic acid 1.7 CK 34 PT37.7 INR 1 PTT37.7 7/11 HGA1c
14 Urine studies UA: S.G protein 150 glucose 50 ketones 0 Blood 250 WBCs, 3-5 sq epis 2-20 RBCs 100, cast 0 LE/nitrite neg UA microscopy- Dysmorphic RBCs no casts Microalbumin/CR 819, TP/CR Urine eosinophils present Urine NA 90 Urine CR 61 FENA 6.8% Urine cultures drawn
15 Chest X-ray
16
17
18 Hospital Course Days 1-2 Patient admitted to medicine service Started on Normal Saline Transfused 2 units PRBC for anemia Nephrology consulted for acute renal failure
19 Renal Ultrasound Right kidney: 12.9cm X 5.4cm X 6.7 cm Left kidney 14.2cm X 5.4X 5.4cm cm Normal renal echogenicity, no hydronephrosis and no masses
20 ASO 25 C3 144, C4 78 Uric acid 7.5 CPK 34 IPTH 169 Calcium 7.6 Additional labs ordered - SPEP/ UPEP CANCA PANCA RF RPR ANA
21 Retic count 1.6% Iron 42 transferrin 168 TIBC 218 Iron sat 19 Ferritin 630 B Folate 4.3 Acute Hepatitis - Negative Urine Culture contaminant > 3 organisms RF<20 RPR Negative ANA Negative
22 Hospital Course Day 3 Pt did not respond to IVF therefore Renal Biopsy planned 8/9/2011 Psychiatry consulted for depression- Tapered citalopram and started olanzapine 5mg po q8
23 Hospital day 4-7 Renal Biopsy (day 5) IVF discontinued SPEP/UPEP- Normal
24 C-ANCA positive Hospital day 7
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28 Hospital Course Day 7 Prednisone 60mg po qd cyclophosphamide po (2mg/kg/day) plasmapheresis initiated (8/11-8/17 ) Day Atovaquone for PCP prophylaxis Cyclophosphamide changed to 0.5g/m2 IV/month due to nausea Completed 7 days of plasmapheresis
29
30 Hospital Course Day nd round Plasmapheresis X 8 days 8/24-9/2 patient developed - Pancytopenia-Heme/Onc consulted Bone marrow suppression secondary to cyclophophamide & renal disease
31 Hospital day #24 Rheumatology consulted for further recommendations
32 Recommended to continue Cyclophosphamide and Prednisone. Ordered additional labs ESR CRP, PR3- ordered and pending Also ordered CT Head and Chest If pt did not improve with treatment Rituximab to be considered
33 LABS ESR-1 CRP-0.62 PR3-Negative
34
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38 CT Chest without contrast
39 Hospital Course Day Creatinine improved
40 Follow Up- F/u with Nephrology in 2 days, Rheumatology 8 days, L Medicine 2months Nephrology 2 days 6 days GFR15 GFR13
41 Follow Up- With Rheumatology- 8 days 9.6 Mg 2.1, phos GFR
42 Additional follow up PR3 Positive CRP<0.5 ESR 4 Vitamin D-O UA: S.G protein 75 glucose 50 ketones 0 Blood 50 WBCs 3-5 sq epis 2-20 RBCs cast 0-2 LE/nitrite neg
43 Hospital course 2 nd admit Day 1-3 Nephrology was consulted Hemodialysis initiated Cyclophosphamide was renally dosed Prednisone 60mg po qd Atovaquone was continued
44 Hospital day #7 Rituximab was initiated given poor response to initial treatment Cyclophosphamide,Prednisone and Atovaquone were continued
45 Creatinine improved Rituximab
46 Follow up Currently on Hemodialysis thrice weekly Has close follow up with Rheumatology Plan is to get repeat labs and decision about treatment with Rituximab vs Cyclophosphamide will be made depending on the results Taper prednisone over the next 3-6 mths
47 FINAL DIAGNOSIS WEGNER S GRANULOMATOSIS
48
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