NYU Medical Grand Rounds Clinical Vignette

Lisa Parikh, MD

PGY 2

5/8/2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 65 year old man who presents with a cough x 1 week.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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

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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•ECG: atrial fibrillation, ventricular rate 118, left atrial dilitation, left ventricular hypertrophy

•Chest X-Ray: no acute cardiopulmonary disease

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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

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

• Final diagnosis: Co-infection with Lyme disease and babesiosis

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS