1. LSU Internal Medicine Case Conference “What the Bullae!" 10/02/2012
Jay Mansfield, MD
PGY I
Internal Medicine

2. “Worsening shortness of breath” x several months
Chief Complaint
“Worsening shortness of breath” x several months

3. HPI
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.

4. HPI 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.

5. Past History Past Medical History: Surgical History: As above plus
Hypothyroidism
Surgical History:
Hysterectomy
ICD (2010)
Left SFA stents (3 weeks prior)

6. Past History Allergies: Home Medications:
Penicillin/Sulfa  swelling and rash
Home Medications:
Aspirin 81 mg Daily
Clopidogrel 75 mg Daily
Simvastatin 40 mg QHS
Carvedilol mg BID
Lantus 10 Units QHS
NovoLog 5 Units BID
Levothyroxine 50 mcg Daily
Ondansetron 4 mg PO q8hrs prn nausea

7. Past History Family History Social History: NC
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

8. Past History Health Maintenance: Review of Systems
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

9. Vital Signs & Physical Exam

10. Vital Signs Temp 99° F Pulse 93 RR 20 BP 131/57 Pulse Ox 97% on RA
Weight 77 kg
Height cm
BMI

11. Physical Exam I General: HEENT: Neck: Cardiovascular:
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.

12. Physical Exam II Pulmonary: Abdomen: Extremity:
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.

13. Physical Exam III Skin: Neurologic:
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

14. Laboratory Data
Day of Admission

15. Admit Laboratory Data I
WBC 12.4 ( )
Hgb 12.4
Hct 39.7
PLT 161
MCV 74.8 (80-100)
RDW 17.8 ( )
Seg 80%
Bands 13%
Lymphs 1%
Monos 5%
Basophils 1%

16. Admit Laboratory Data II
Na 136
K 4.5
Cl 104
Bicarbonate (24-32)
BUN (7-25)
Creatinine ( )
GFR 38 (>60)
Glucose 239 (65-99)
Ca 9.78 Mg
Phos 3.4

17. Admit Laboratory Data III
Total Protein 6.8
Albumin ( )
Total Bilirubin (<1.3)
AST
Alkaline Phosphatase 114
ALT
BNP (<100)
TSH
Free T

18. EKG
Day of Admission

20. EKG 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

21. Chest X-Ray
Day of Admission

24. CXR “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.”

25. Hospital Day 1

26. Initial Management Patient was admitted to Medicine
IV furosemide 40mg q12 hours initiated with strict I/O’s
Home medications continued

27. 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

28. Vital Signs Temp 97° F (96-99.9 ° F) Pulse 98 RR 20 BP 123/63
Pulse Ox 96% on 3L NC

29. Physical Exam I General: HEENT: Cardiovascular: Pulmonary: Abdomen:
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

30. Physical Exam II Extremity: Skin:
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.

31. Laboratory Data I Day #3 WBC 2.6 (4.5-11.0) Hgb 13.8 Hct 43.6
PLT ( )
MCV (80-100)
RDW ( )
Seg 52%
Bands 13%
Lymphs 17%
Monos 16%
Basophils 1%

32. Laboratory Data II Day #3
Na 137
K 3.7
Cl 104
Bicarbonate (24-32)
BUN 29
Creatinine ( )
GFR (>60)
Glucose (65-99)
Ca++ 7.99.66
Mg++ 1.5
Phos 3.4
Blood cultures pending
ABG 7.45/40/235/28/100% on 100% NRB

33. Laboratory Data III Day #3
Total Protein ( )
Albumin ( )
Total Bilirubin (<1.3)
AST
Alkaline Phosphatase 58
ALT
INR ( )
PT (9-12.7)
PTT (24-37)
Lactic Acid

34. 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

35. Hospital Course: Day #3 Transfer Antibiotic Medications: Ciprofloxacin
Vancomycin
Clindamycin
Tigecycline

36. 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

37. 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

38. Hemorrhagic Bullae Suprapubic

39. Anterior Thigh Right Lower Extremity

40. Medial Right Lower Extremity

41. Lateral Right Lower Extremity

42. Right Upper Extremity

43. 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

44. Laboratory Data I Morning Day #4
WBC ( )
Hgb 12.9
Hct 40.1
PLT 111 ( )
Seg 71%
Bands 8%
Lymphs 13%
Monos 8%
Basophils 0%

45. Laboratory Data II Morning Day #4
Na 139
K 4.4
Cl 101
Bicarbonate
BUN 31 (7-25)
Creatinine 1.55 ( )
GFR 40 (>60)
Glucose 92
Anion Gap 18 (<10)
Ca++ 7.49.32
Mg++ 1.4
Phos 4.5

46. Laboratory Data III Day #3
Total Protein (6-8)
Albumin ( )
Total Bilirubin (<1.4)
AST (<45)
Alkaline Phosphatase 44
ALT
BNP 3923 (<100)
Lactic Acid 4.2 ( )

47. 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

48. Hospital Course: Day #4
X-Ray of Right Lower Extremity revealed extensive edema, no subcutaneous emphysema

49. Significant Laboratory Data Day #4
Lactic Acid 1.6  4.2  10.4
Bicarbonate  25  12  6
Creatinine 1.24  1.55  1.95  2.41
WBC 2.6  2.7  10.1  14.3
Bandemia 13% 27% 8%  35%
Platelets 110  131  111  97  49
INR 2  3.9
PT  43.1
CK 608
CRP 16.9
Troponin 1.88

50. Cont…..
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

51. Microbiology and Pathology Results

52. 7/9/12: Right upper thigh, punch biopsy

56. 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

57. Streptococcal Toxic Shock Syndrome
Final Diagnosis
Streptococcal Toxic Shock Syndrome

58. Thanks For Your Attention!