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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. James Araujo, PGY2 September 29, 2010. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette James Araujo, PGY2 September 29, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint 59 year old woman referred to Oncology clinic with a diffuse skin rash for one year

  3. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness One year prior to referral, the patient was started on topical medications for her rash which did not improve A skin biopsy at an outside clinic revealed lichenified dermatitis, consistent with cutaneous T cell lymphoma

  4. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness On presentation to Oncology clinic, the patient reported severe pruritis, but denied systemic symptoms The original biopsy was reviewed by New York University dermatopathology, confirming the diagnosis of cutaneous T cell lymphoma

  5. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History • Past Medical History • Hypertension • Past Surgical History • Hysterectomy at age 45 • Social History • Born in Trinidad • Denies tobacco, alcohol, or drug use • Family History • Lung cancer, diabetes, hypertension • No family history of lymphoma • Allergies • No known drug allergies • Medications • Atenolol 25 mg orally once daily • Multivitamin once daily

  6. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Exam • General Well-developed, in no acute distress • Vital Signs T 98.2 F, BP 158/80, HR 95, RR 16, O2 sat 99% • Skin Extensive hyperpigmented plaques covering 90% of body and desquamation over the shoulders and back • Remainder of physical exam was normal

  7. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings • Complete Blood Count: WBC 6,700 (Differential: 73% segmented neutrophils; 17% lymphocytes; 8% monocytes) Hemoglobin 13.1 Hematocrit 38.8 Mean Corpuscular Volume 87 Platelet Count 77,000 • Basic Metabolic and Hepatic Panels were normal • LDH was normal

  8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies • Peripheral blood smear revealed no evidence of Sézary cells • Molecular studies identified a rearranged T cell receptor gene • Human T lymphocyte virus I (HTLV-I) antibodies were negative

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies • Positron Emission Tomography – Computed Tomography demonstrated bilateral axillary, cervical, and inguinal lymphadenopathy, without central lymphadenopathy

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Interim History • One month after her initial clinic visit, the patient began treatment with bexarotene and had a partial clinical response

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Interim History • Two months after her initial clinic visit, the patient had several inpatient admissions for bacterial and fungal sepsis presenting with hypothermia • These septic episodes were thought to be secondary to skin breakdown

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Cutaneous T cell lymphoma, complicated by bacterial and fungal sepsis

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