CASE CONFERENCE 내분비 대사 내과 R2 박지나

CC : fever & myalgia o/s) 내원 3일전 11816956 김0주 (F/23) Adm 06-1-25 CC : fever & myalgia o/s) 내원 3일전 PI : 특이 병력 없던 환자로 내원 6일전 기도원에서 금식 기도한 후 3일전부터 fever, chilling, skin rash, generalized myalgia , nausea, vomiting, watery diarrhea 있어 local에서 manage 받았으나 증상호전 없어 큰 병원 권유 받아 ER 경유 입원

PMHx) DM(-) HTN(+) Pulmonary Tb (-) Hepatitis(-) OP Hx(-) Allergy(-) PHx) alcohol (-) smoking(-)

Family history

Review of system General fever (+) chill (+) fatigue (+) myalgia (+) Skin rash(+) pigmentation(-) Head & neck headache(+) dizziness(-) neck stiffness(-) neck pain(+) sore throat(+) Eye & ENT visual disturbance(-) hearing loss(-) Breast pain(-) lump(-) discharge(-) Respiatory cough(-) sputum(-) dyspnea(-) Cardiac angina(-) orthopnea(-) palpiation(+) Gastointestinal anorexia (+) nausea(+) vomiting(+) diarrhea(+) constipaition(-) abdominal pain(-) Genitourinary frequency (+) urgency (+) dysuria (-) Musculoskeletal multiple joint pain (+) ; both knee, hand

Physical examination V/S 100/70mmHg –130회/min– 20회/min – 39.5°C G/A Alert consciousness acutely ill-looking appearance Skin petechiae (+) Osler’s node (+) splinter hemorrahages (+) H/N No cervical LN enlargement No neck vein engorgement Thyroid enlargement (+), tenderness (+) neck stiffness(-)

Petechiae

Osler’s nodes

Conjunctival hemorrhage

E/E/N/T Isocoric pupil with PLR (+/+) subconjunctival petechiae (+) Exophthalmosis(-) Chest Regular & rapid heart beat with pansystolic murmur(Gr I-II) Clear breathing sound without crackle Abdomen Hyperactive bowel sound Soft & flat abdomen Tenderness/Rebound tenderness(-/-)

Back & extremities CVA tenderness(-/-) Pretibial pitting edema(-/-) Both hand and knee tenderness(-), redness(-), swelling(-) Neurology facial palsy(-) DTR(+/+) mortor sensory v v 100 100 100 100 v v

Laboratory findings I CBC/DC 6370/mm3 – 12.6 g/dl – 36.7 % - 36k ( seg. 84.7 % ) PT/PTT 14.2S (INR 1.13) / 49C33 Chemistry T/D–bilirubin 1.62 / 0.51 mg/dL AST / ALT 63 / 138 U/L T-protein/albumin 5.3 / 2.7 g/dL Glucose 145 mg/dL BUN / Cr 11/0.8 mg/dL Na/ K /Cl 133 / 3.2 / 100 mmol/L CRP 22.3 mg/dL U/A RBC 2~4 / HPF WBC 0~2 / HPF nitrite (+) protein 100 mg/dL pH 6.5 S.G 1.025

EKG

Chest PA

Brain CT (06-1-26)

Initial assessment Infective endocarditis subcortical hematoma R/o Thyrotoxicosis

Diagnostic plan Blood culture 3쌍 2-D Echocardiography 2. TFT ,TSI,TBII,TG Thyroid scan

TTE ( 06. 1. 26 )

TEE ( 06. 2. 26 )

Brain CT ( 06. 3. 9 )

Laboratory findings II TFT T3 171 (80~200 ng/dL) free T4 10.3 (0.77~1.94 ng/dL) TSH 0.04 (0.3~4.0 μ /mL) TG-Ab <50 (<100 IU/ml ) TG(S) 348 ( <50 ng/ml ) TBII 0.1 (<10 %) TMS 1 (<8 ug/ml) 단백면역 AS0 329() C3 12(88-201) C4 12(15-45) Blood culture ; S. aureus (MSSA), S. viridans(2/19) Urine culture ; S. aureus (MSSA)

<내원 기간동안의 TFT 의 변화> PTU,Propranolol(2/4-2/15)

Clinical course blood culture 3쌍; MSSA , 2-D Echo; vegetation Infective endocarditis 진단, IV antibiotics start 2. Brain CT; Rt occipital lobe ICH F/U brain CT에서 hematoma resolve되고 두통 감소. 3. 1/31 PSVT 발생 IV CCB 사용후 resolved recurrent pulmonary edemaO2 supply및 lasix 투여 4. 2/4 TFT T3 171,FT$10.3,TSH0.04 PTU 300mg q 6hr 및 propranolol 40mg q6hr start

Clinical course 5. 2/15 fever(+) ANC 289PTU stop 6. F/U TFT T3 51, FT41.65, TSH 0.05 ->Euthyroid state, propranolol 40mg q8hr 7. 2/26 F/U 2-D Echo에서 severe MR OP 위해 타병원 transfer됨.

Clinical course(antibiotics) HD 1 2 6 22 ~ vancomycin S. viridans (+)  vancomycin GM cefazolin MSSA infective endocarditis  cefazolin ceftriaxone Cb Hrr. d/t septic emboli  ceftriaxone d/t BBB penitration S. viridans (+) MSSA infective endocarditis MSSA at Urine Cx & blood Cx , Cb Hrr. d/t septic emboli Empirical Tx for infective endocarditis

Final diagnosis 1.Infective endocarditis : MSSA - Sepsis d/t septic emboli - subcortical hematoma - Mitral regurgitation 2.Thyrotoxicosis - d/t subacute thyroiditis ? subclinical hyperthyroidism?