NYU Medical Grand Rounds Clinical Vignette Rachel Solomon, PGY-3 March 13, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

43 year old Chinese male with fever, chills, and cough for two weeks; admitted with new diagnosis of acute myelogenous leukemia on CBC with 33% blasts, Auer rods, hemoglobin 5.8 and platelets of 62,000. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2 weeks prior to admission: private MD with fever, chills, cough also increased weakness / fatigue x 1 mo treated for pneumonia Day of admission to Bellevue Hospital Center: admitted to Oncology service with new dx: AML HD #2: initiation of chemotherapy with cytarabine, idarubicin HD#8: T104°F, HR126, BP116/69, RR26, SaO2 mid-80%RA Acutely ill-appearing with cough, hemoptysis, and diffuse rales on auscultation. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Studies CBC: WBC 0.9, 83% neutrophils: ANC 747 hemoglobin 6.7mg/dl, platelets 14,000 ABG: pH 7.48, CO2 27, O2 55, HCO3 20, SpO2 90% Chest X-Ray: dense perihilar consolidation in right upper lung field focal airspace opacity in left upper lung field Urinalysis: no protein, glucose, blood Blood Cultures: 4/4 bottles, Klebsiella Pneumoniae U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Chest X-ray: HD #1 and HD#8 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Working Diagnosis: Neutropenic Fever and Multi-focal Pneumonia MICU Day 1: Intubated, pressors Antibiotics: vancomycin, imipenem, amikacin Chemotherapy held Lung-protective ventilation for likely ARDS MICU Day #6: pressors discontinued, extubated Continued fevers: caspofungin HD #19: CT chest, ill-defined diffuse densities suggest aspergillosis Started on amphotericin Fever curve downtrended Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

CT Chest – HD #19 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

HD #35: discharged to home to complete course of oral voriconazole Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Neutropenic Sepsis Klebsiella bacteremia complicated by ARDS and presumed aspergillosis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS