1. NYU Medical Grand Rounds Clinical Vignette Lindsay Innes, MD PGY2 September 20, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 58 year old man with a medical history significant for acute myelogenous leukemia (AML) complaining of one week of tooth and throat pain, rigors beginning the evening prior to admission, and fever of 101°F on the day of presentation. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Diagnosed with AML 9 months prior to presentation (trisomy 10), underwent 7:3 induction chemotherapy with rituximab, cyclophosphamide and dexamethasone and day 28 bone marrow biopsy showed complete remission History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Over the following 3 months, treated at Bellevue Hospital with 3 cycles high-dose cytarabine (HiDAC). His course was complicated by multiple episodes of neutropenic sepsis requiring hospitalization. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Repeat bone marrow biopsy in June 2011 showed persistent disease. The patient was subsequently treated with 5 cycles of decitabine in the 4 months prior to admission with the last cycle 3 days prior to admission Repeat bone marrow biopsy in September showed persistent disease. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. The patient was last admitted again early September for neutropenic fever and multifocal pneumonia. He improved with empiric antifungal treatment and was discharged with an 8 week course of voriconazole. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. The patient had returned to his usual state of health although complaining of persistent throat and tooth pain since the time of his last discharge. The night prior to admission, the patient developed rigors, and the following morning, his wife measured his temperature as 101°F. He came to oncology clinic and was referred to the emergency department. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Additional History Past Medical/Surgical History: Hypertension Stroke in 2003 without residual deficits Atrial fibrillation Social History: Non-smoker, rare alcohol use Originally from the Phillipines, he moved to New York in October 2010 after his diagnosis of AML to seek medical care. He lives with his wife. He had been a lawyer in the Phillipines. Family History: Per report, he had a niece and first cousin with leukemia U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Additional History No known drug allergies Medications: digoxin 0.125mg daily tamsulosin 0.4mg daily furosemide 20mg daily aspirin 81mg daily nexium 40mg daily simvastatin 20mg at night metoprolol 200mg daily acyclovir 400mg daily voriconazole 200mg twice daily (8 week course) oxycodone 5mg as needed every 4 hours U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Physical Examination General: the patient appeared ill although in no acute distress Vital Signs: list T: 98.6°F BP: 119/76 HR: 104 RR: 16 and O2 sat: 100% on room air Exam was significant for irregularly irregular heart rate and bibasilar rales on lung auscultation. A left internal jugular central venous catheter was in place. Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Laboratory Findings CBC: WBC 0.9, Absolute neutrophil count 18, Hemoglobin 8, Hematocrit 22.6, Platelets 109 Basic Metabolic panel: Sodium 127, Magnesium 1.2 Remainder of basic was within normal limits Hepatic panel: within normal limits Urinalysis was negative for signs of current infection U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Other Studies Chest X-Ray: significant for resolving multifocal pneumonia U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Neutropenic fever of unknown etiology, including, but not limited to the following sources: –Central line-associated infection –Oropharyngeal infection –Persistent pulmonary infection Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Day 1: –Treatment with a course of vancomycin and cefepime was initiated and the patient was continued on voriconazole and acyclovir –He continued to have fever to 101°F Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Day 2: –The patient was evaluated by oral and maxillofacial surgery and the etiology of his systemic illness was determined not to be related to a dental or oropharyngeal infection –He defervesced and remained afebrile Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. The patient remains afebrile and is clinically improving but remains neutropenic. All cultures are negative to date. He is awaiting evaluation for possible allogeneic stem cell transplant. Discussion of re-induction of chemotherapy is also ongoing. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Neutropenic fever in the setting of treatment refractory AML Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS