1. NYU Medical Grand Rounds Clinical Vignette Benjamin Eckhardt, MD PGY-3 October 6, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 39-year-old man presenting with three days of fever, cough, and shortness of breath. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient reported abrupt onset of subjective fevers, chills and headaches three days prior to admission. He noted his cough to be progressively worsening with minimal sputum production. On the day of admission, the patient’s symptoms progressed to include shortness of breath. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: None Past Surgical History: None Social History: From China, came to the United States four years prior to admission Works in a restaurant Denies recent travel or sick contacts Denies toxic habits Family History: noncontributory Allergies: No Known Drug Allergies Denies any Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: Ill-appearing man in moderate respiratory distress Vital Signs: T:103.9 BP:104/49 HR:126 RR:25 O2 Sat: 83% on room air → 97% on 100% non-re-breather Course rhonchi throughout lung fields, no wheezing Cool extremities The remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC: White blood cells 7, 88% Neutrophils Remainder of CBC was within normal limits Hepatic Function Panel: AST: 98, ALT: 64 Remainder of LFTs were within normal limits Basic Metabolic Panel was within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings Lactate Dehydrogenase: 629 (110-225) Influenza A Ag: positive Influenza B Ag: negative Blood cultures and Urine cultures: No Growth U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Admission Chest X-Ray

9. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Cat Scan

10. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Cat Scan

11. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Cat Scan

12. Influenza pneumonia with Acute Respiratory Distress Syndrome Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. The patient’s respiratory status worsened in the emergency room requiring intubation The patient was started broad spectrum anti-microbials, and admitted to the medical intensive care unit. The antimicrobials included: –Oseltamivir 150mg twice daily –Vancomycin 1g twice daily –Piperacillin/tazobactam 4.5g four times daily –Azithromycin 500mg daily Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. The patient remained febrile and dependent on ventilatory support after completing a five day course of oseltamivir and azithromycin Hospital 7: Due to the patient’s persistent fevers he was switched to imipenem and restarted on the anti- virals oseltamivir and rimantidine Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital day 8: Oseltamivir was replaced by intravenous peramiver after being acquired from the Centers for Disease Control Blood cultures, urine cultures, tracheal aspirate cultures, Human Immunodeficiency Virus testing, sputum Acid Fast Bacilli testing and urine legionella antigen were all negative Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Hospital Day 12: A bronchoscopy was performed with negative gram stain, Acid Fast Bacilli, Respiratory Syncytial Virus Polymerase Chain Reaction, bacterial culture and viral culture Hospital Day 15: Antibiotics and antivirals were discontinued for worsening pancytopenia Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Hospital Day 16: Antiobiotics were restarted (cefepime then tigecycline) for neutropenic fever Hospital Day 19-34: The patient’s Hemodynamics improved and vasopressors were weaned off. His fevers abated and his respiratory status improved allowing for capping of his tracheostomy. Additionally the patient’s blood counts improved and the patient was discharged home on hospital day 34. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

18. Influenza pneumonia complicated by acute respiratory distress syndrome Pancytopenia likely secondary to infection versus medication effect. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS