MEDICAL GRANDROUNDS

1. MEDICAL GRANDROUNDS July 3, 2008 Abigail Cruz-Zaraspe M.D.

2. OBJECTIVES • To present a case of bacteremia in aplastic anemia • To discuss salmonella nontyphi bacteremia and myositis manifestations, diagnosis and treatment • To discuss briefly the treatment of aplastic anemia

5. IDENTIFYING DATA • A.R. • 42/M • Married • Real-estate broker

6. CHIEF COMPLAINT • Right thigh pain

7. HISTORY OF PRESENT ILLNESS • 5 weeks PTA Easy fatigability, SOB, (+) melena, (+) abdominal pain, (+)palpitations • 4 weeks PTA sought consult, CBC Pancytopenia admitted for the first time for transfusion

8. HISTORY OF PRESENT ILLNESS • First admission blood transfusions BMA-hypocellular BM Dx: Aplastic anemia treatment options were discussed (discharged-platelet ct 44k)

9. HISTORY OF PRESENT ILLNESS • 3 weeks PTA intermittent fever (390C),body malaise, nose bleeding Consult: WBC 1860, PLT 10k Tx: Co-amoxyclav 625mg TID x7d, tranexamic acid 500mg TID GCSF 300mcg

10. HISTORY OF PRESENT ILLNESS • 3 weeks PTA generalized petechial rashes & gum bleeding and was admitted • 2nd admission CBC- pancytopenia Tx: blood & PC transfusions

11. CBC on SECOND ADMISSION

12. HISTORY OF PRESENT ILLNESS • 2nd admission Initially given Cefepime 1gm Q12

13. HISTORY OF PRESENT ILLNESS • 2nd admission + right thigh & hip pain 5/10 (dull, aching constant) +direct tenderness no swelling no limitation in ROM no paresthesia

14. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

15. NEUROPATHY • Severe intractable pain • Unusual burning, tingling or shock-like quality • Triggered by light touch • Sensory deficit on area of pain

16. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

17. COMPARTMENT SYNDROME • Pain • Parasthesia • Pulselessness • Pallor • pressure

18. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

19. HISTORY OF PRESENT ILLNESS • 2nd admission Pelvis and Right hip xray: no pathologic finding

20. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

21. HISTORY OF PRESENT ILLNESS • 2nd admission Blood CS: Salmonella enteritidis Grp C Sensitive: Ceftriaxone Chloramphenicol Ciprofloxacin shifted to Ciprofloxacin 500mg/tab, 1 tab BID

22. HISTORY OF PRESENT ILLNESS • 2nd admission Dx: Aplastic anemia Salmonella nontyphi bacteremia Advised treatment w/ Anti-thymocyte globulin / cyclosporine

23. HISTORY OF PRESENT ILLNESS • 2nd admission THM: Ciprofloxacin 500mg/tab, 1 tab BID to complete 7 days Prednisone 30mg BID, Tranexamic acid & Omeprazole

24. HISTORY OF PRESENT ILLNESS • Since discharge episodes of fever & progression R hip & thigh pain on movement & palpation unable to stand admitted 3rd time

25. (-) headache (-) loss of consciousness (-) cough or colds (-) weight loss (-) chest pain (-) dyspnea (-) palpitations (-) abdominal pain (-) nausea or vomiting (-) LBM/ constipation (+) melena (-) hematochezia (-) dysuria (-) hematuria REVIEW OF SYSTEMS

26. PAST MEDICAL HISTORY • Non-hypertensive • Non-diabetic • No known allergies

27. FAMILY HISTORY • No hypertension • No diabetes • No asthma • No blood dyscrasias • No cancer

28. PERSONAL AND SOCIAL HISTORY • Previous smoker, stopped in late ‘90s • Occasional beer drinker • Lived near an electroplating factory • Previously worked as a cashier in a gasoline station • Real estate broker

29. PHYSICAL EXAMINATION • General: conscious, coherent, bed-bound • Vital signs: BP 130/80, HR = 103 bpm, reg, RR = 22/min, T = 390C • HEENT: Pale conjunctivae, icteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy

30. PHYSICAL EXAMINATION • Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, tachycardic with regular rhythm, no murmurs

31. PHYSICAL EXAMINATION • Abdomen: Flabby, normoactive bowel sounds, soft, non-tender, no hepatomegaly no splenomegaly

32. PHYSICAL EXAMINATION • Extremities: (+) erythema and hyperemia, right thigh extending to mid-leg area No discharge, no open wounds no sensory deficit Left leg was grossly normal pulses: full and equal

33. SALIENT FEATURES • 42/M • Known case of aplastic anemia • Known case of non-typhi salmonella bacteremia • Treated with ciprofloxacin 500mg BID x 1 week • Still febrile • Right thigh and hip pain • Erythema and swelling of right lower extremity

34. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

35. AVASCULAR NECROSIS • results from infarction of bone trabeculae and marrow cells • equal frequency in the femoral and humeral heads • The femoral heads more commonly undergo progressive joint destruction as a result of chronic weight bearing. The changes are best detected by MRI

36. AVASCULAR NECROSIS • Most studies have found that the risk is low (< 3 percent) in patients treated with doses of prednisone less than 15 to 20 mg/day • In one series, the prednisone dose in the highest month of therapy exceeded 40 mg/day in 93 percent, and 20 mg/day in 100 percent of patients with osteonecrosis.

37. Hip & Thigh pain Compartment syndrome Avascular necrosis neuropathy infection fracture

38. 150 patients with aplastic anemia treated at Clinical Hematology Branch of the National Heart, Lung and Blood Institute (NHLBI) between 1978 and 1990 • Infection was documented in 47% of cases • respiratory tract (32 percent) • soft tissues (24 percent) • blood (22 percent) • gastrointestinal tract (17 percent) • urinary tract (6 percent).

39. IMPRESSION • Aplastic anemia • Salmonella non-typhi bacteremia with secondary myositis • r/o Avascular necrosis, osteomyelitis

40. COURSE IN THE WARDS • On admission • CBC, PT, PTT, UA, CXR, crea, BUN, K, Na were requested. He was placed on a neutropenic diet. • He was started on Piperacillin-tazobactam 4.5mg/IV x 1dose then 2.25mg q8 hours

41. LABS APRIL 12, 2008 CXR- normal

42. Piperacillin-tazobactam Febrile

43. COURSE IN THE WARDS • 2nd hospital day • + severe leg pain, unrelieved by Tramadol. • referred to Orthopedic service • Impression: t/c pathologic fracture vs. avascular necrosis, R hip; aplastic anemia. • Tx: Ketorolac and Morphine.

44. COURSE IN THE WARDS • 2nd hospital day • Pelvic MRI was requested • Myositis with fasciitis involving the right gluteal and right thigh muscle and the right obturator internus muscle. • Avascular necrosis of the right femoral head considered

45. COURSE IN THE WARDS • 2nd hospital day • still with fever and leg pain • Blood CS: • Salmonella Enteritidis Group C • sensitive to Ceftriaxone and Ciprofloxacin • resistant to Co-trimoxazole and Ampicillin.

46. COURSE IN THE WARDS • 5th HD • referred to Infectious Disease service. • Impression: Salmonella nontyphi bacteremia with secondary myositis. • Tx: shift Piperacillin-tazobactam to Ciprofloxacin 500mg/tab 2x a day & ceftriaxone 2g/IV OD

47. CP & CT PT Febrile

48. COURSE IN THE WARDS • 11th HD • patient was still febrile (Tmax400C) • endovascular Salmonella was considered • Ceftriaxone was discontinued • Piperacilin-Tazobactam was resumed & increased to 4.5 IV Q8 • dexamethasone 4mg/tab 12 hrs

49. CP+CT CP PT CT dexa Febrile

50. COURSE IN THE WARDS • 13th HD • Afebrile • pain decreased • Dexamethasone was tapered to 4mg/tab bid.