1. NYU Medical Grand Rounds Clinical Vignette Lisa Parikh, MD PGY 2 5/8/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 65 year old man who presents with a cough x 1 week. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. He was in his usual state of good health until 4 weeks ago when he traveled to Shelter Island in New York. Noted erythema on his right arm thought to be from a bug bite, and when evaluated by a physician, was treated with a 10 day course of cefalexin with resolution of the rash. In the following days, he then developed dry cough and intermittent fevers, as high as 102F. Went to PMD the day prior to admission and was given a prescription for moxifloxacin 400mg daily. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. On the morning of admission, patient rose from bed, felt dizzy, and lost consciousness for 1 minute. He was diaphoretic and dizzy when he awoke. Wife took him to his PMDs office where his blood pressure was 90/60 with heart rate in the 130s. An EKG showed atrial fibrillation with rapid ventricular response. He was sent to the ER at Tisch hospital for evaluation. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: HTN HLD Rheumatoid Arthritis Gout Past Surgical History: None Social History: Former smoker,quit 35 yrs ago No children at home Has pet cat x 1 year No recent travel U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Family History: None Allergies: No Known Drug Allergies Medications: lisinopril 5 mg daily aspirin 81 mg daily ezetimibe/simvastatin 10mg/20mg daily allopurinol 300mg daily moxifloxacin 400 mg daily

6. Physical Examination Well-nourished, well-developed man resting comfortably in bed Vital Signs: T:100.2 F, BP:119/73, HR:114, RR:20 and SaO2: 99% room air Cardiovascular: irregularly irregular, 2/6 systolic murmur at left lower sternal border and apex Pulmonary: decreased breath sounds at bases bilaterally The remainder of the physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings CBC: hemoglobin 13.1 Basic Metabolic panel: Sodium 130 Hepatic panel: total bilirubin 1.5, AST 69 Troponin: <.02 The remainder of the CBC, BMP and hepatic panels were within normal limits. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Other Studies ECG: atrial fibrillation, ventricular rate 118, left atrial dilitation, left ventricular hypertrophy Chest X-Ray: no acute cardiopulmonary disease U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Infection triggered atrial fibrillation –Differential diagnosis of infection: upper respiratory tract infection versus pneumonia caused by viral or bacterial origin; tick-borne illness Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Hospital Days 1-3 –Started on diltiazem 90mg q6hr for rate control –Initially, moxifloxacin was continued, but changed to ceftriaxone and azithromycin on hospital day 2. –The patient continued to be febrile. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hospital Course Hospital Day 4 –Blood parasites positive for babesia with 1.0% parasitemia –Ceftriaxone was discontinued –Azithromycin 1g daily continued –Atovaquone 750mg was initiated –Chest CT showed a right upper lobe 4mm nodule, mild upper lobe predominant centrilobular emphysema, areas of non-segmental atelectasis involving both lower lobes Hospital Day 5 –Patient discharged home to complete 7 days of azithromycin and atovaquone

12. Outpatient Follow-Up Day 1 after discharge –Lyme Ab total blood: 5.4 (normal <0.91) –Lyme IgM Ab titer: 5.59 (normal <0.91) –Lyme western blot IgM: positive

13. Final diagnosis: Co-infection with Lyme disease and babesiosis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS