1. NYU Medicine Grand Rounds Clinical Vignette
Ben Milgrom, PGY-2
11/13/13
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint
Mr. C is a 64 year old man with a history of COPD who presented with 1 week history of gnawing epigastric pain
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

3. History of Present Illness
The patient has been admitted multiple times over the previous year for COPD exacerbations.
Most recent admission was 3 weeks prior to the current admission.
At that time, he was treated with nebulizers, steroids, and antibiotics with improvement in his respiratory status
He was discharged with prescriptions for a prednisone taper, fluticasone/salmeterol and albuterol inhalers, and azithromycin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

4. History of Present Illness
Following discharge, the patient’s respiratory status improved to baseline
The patient reports an episode of unprotected sex 2 weeks ago (1 week following hospital discharge)
Shortly thereafter, he developed a nontender ulcerated lesion on the glans penis
He then developed a maculopapular rash across his chest and abdomen
Skin lesions were asymptomatic so the patient did not seek medical care
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

5. History of Present Illness
One week prior to admission, he developed gnawing epigastric pain which had become progressively more severe.
Pain was described as constant, nonradiating, and not associated with food.
He also had numerous watery bowel movements daily, without blood or melena
He denied nausea or vomiting, change in skin or eye color, change in medications other than the prescribed azithromycin and prednisone.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

6. Additional History Past Medical History: Past Surgical History:
COPD (GOLD stage III)
Hypertension
Past Surgical History:
Hemorrhoidectomy
Social History:
30 pack year smoking history quit 6 years ago
Denies alcohol or illicit drug use
Immigrated from Ghana 40 years ago, has not left NYC in 5 years
Works as a musician
Lives with alone in an apartment in Manhattan
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

7. Additional History Family History: No known family medical history
Allergies:
No known drug allergies
Medications:
15 day prednisone course and 5 day azithromycin course recently completed
Fluticasone/salmeterol inhaler BID
Amlodipine 10 mg PO daily
Albuterol inhaler PRN dyspnea
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

8. Physical Examination
General: African American man resting in no distress
Vital Signs: Temperature F, blood pressure 95/65, heart rate 105, RR 16, 98% O2 saturation on room air
Maculopapular eruption on face, neck, torso, abdomen, and arms
Hepatomegaly 5 cm below costal margin, tenderness in epigastrium with guarding, no rebound, abdomen soft
Ulcerated lesion on glans penis without discharge
Remainder of physical exam was within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

9. Laboratory Findings CBC: Platelets 30 Basic Metabolic panel:
Remainder of CBC was within normal limits
Basic Metabolic panel:
Sodium 130, Potassium 5.7, Chloride 98, CO2 24, BUN 40, Creatinine 1.7
Hepatic panel:
AST 11,126, ALT 7, 840, Alkaline Phosphatase 239, Total Bilirubin 2.0, Direct Bilirubin 1.3, Total Protein 5.4, Albumin 2.8
Lipase 175 (< 66), INR 2.9, salicylates/acetaminophen/ethanol levels negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

10. Other Studies ECG: Sinus tachycardia
Chest X-Ray: No infiltrate or effusion
CT Abdomen/Pelvis w/o contrast: Low attenuation of the liver which may be due to fatty infiltration versus edema/inflammation
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

11. Working or Differential Diagnosis
Acute liver failure
Differential diagnosis is acute viral hepatitis, reactivation hepatitis in setting of steroid use, versus toxic medication effect from previous azithromycin use
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

12. Hospital Course Hospital Day 1: Hospital Day 2:
Sepsis alert was called and patient received IV normal saline, vancomycin and piperacillin/tazobactam
N-Acteylcysteine IV was given
Hospital Day 2:
Tzanck smear performed on skin lesion which was positive
Viral hepatitis serologies were negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

13. Hospital Course Hospital Day 3: Hospital Day 4:
Papular lesions developed into vesicles
Viral culture of penile lesion confirmed HSV-1
HIV, CMV, VZV serologies negative
Hospital Day 4:
Synthetic liver function continue to worsen, total bilirubin > 30, INR 5.0
Transplant surgery confirmed patient would not be a candidate given disseminated HSV infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

14. Hospital Course Hospital Day 5-8:
Clinical status continued to deteriorate
Patient developed respiratory distress requiring intubation and mechanical ventilation
Chest CT showed multifocal infiltrates concerning for pneumonia versus ARDS
Hypotension developed requiring vasopressor support
Renal failure developed requiring hemodialysis

15. Hospital Course Hospital Day 9-14
The patient’s condition failed to improve despite aggressive measures
Goals of care discussion held with family
Decision made to refer to hospice

16. Final Diagnosis
Disseminated HSV-1 infection leading to fulminant hepatic failure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

17. Systems Error
On review of records from previous hospital discharge, an error was found in the discharge medications:
Prednisone comes in 50 mg and 10 mg tabs
The patient was meant to be prescribed 10mg tabs with directions to take 5 tabs daily
Instead, the patient was prescribed 50 mg tabs, and was instructed to take 5 tabs
The patient therefore took prednisone 250mg daily instead of 50mg daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS

18. Systems Error
The patient received an inappropriately high steroid dose leading to disseminated HSV-1
The error was not caught by pharmacist, nurse, or discharging physician
This systems error at discharge contributed to the patient’s demise
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS