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Department of Medicine Grand Rounds Clinical Vignette

Department of Medicine Grand Rounds Clinical Vignette. Ilana Bragin January 14 th , 2009 NYU Langone Medical Center Internal Medicine Residency Program. Chief Complaint.

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Department of Medicine Grand Rounds Clinical Vignette

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  1. Department of Medicine Grand RoundsClinical Vignette Ilana Bragin January 14 th, 2009 NYU Langone Medical Center Internal Medicine Residency Program

  2. Chief Complaint The patient is a 61 year old Caucasian male who presented with 2 weeks of increasing edema and decreased urine output.

  3. History of Present Illness • Approximately one year prior to presentation, the patient presented with new onset ascites. • Work-up at that time included a diagnostic paracentesis, which revealed atypical cells. • Subsequent CT scan showed a 6 cm mass at the pancreatic tail and 3 cm omental caking. • Core biopsy showed moderately differentiated adenocarcinoma consistent with pacreaticoviliary cancer.

  4. History of Present Illness • He was enrolled in a clinical trial and started on Gemcitabine (Gemzar), Bevacizumab (Avastin), and Erlotinib (Tarceva). He was also started on aldactone for his ascites. • A follow up CT scan showed some improvement in the size of the mass and the amount of ascites. • Six months later, routine labs revealed an increased creatinine of 2.2 from his baseline of 1. The aldactone was discontinued. • One week later, he presented to clinic with increased edema (legs, hands, face), fatigue, and decreased urine output. His creatinine at that time was 2.6. • Chemotherapy was held.

  5. Additional History • Past Medical History: • Hypothyroidism • Benign Prostatic Hypertrophy • Coronary Artery Disease • Past Surgical History: • Coronary Artery Bypass Grafting, 4 years ago • Social History: • No toxic habits • Family History: • Non-contributory • Medications: • Atorvastatin 20 mg at night • Aspirin 81 mg daily • Levothyroxine 125 mcg daily • Famotidine 20 mg twice daily • Darbepoetinalfa 200 mcg weekly • Gemcitabine, Bevacizumab, Erlotinib (HELD)

  6. Physical Exam • Gen: sitting comfortably, no acute distress • Vital Signs: T 98, HR 80, BP 160/90, RR 16 • Extremities: 3+ pitting edema bilaterally The remainder of the physical exam was normal

  7. Laboratory • CBC: WBC- 2 Hgb-10.2 Platelets-13 • MCV 99, Differential: 44% Neut, 38% Lymph, 16% Monos • Smear: occasional schistocytes • Basic Metabolic: BUN 44 Creatinine 2.6 • Remainder of values were within normal limits • Liver Function Panel: AST-152 ALT-106 Albumin 2.7 • Remainder of values were within normal limits • Coagulation Panel: INR-1.02 PTT-28.9 • Fibrinogen-595 • D-dimer-734 • Fibrin Degradation Products >5 • LDH 1951 • Urinalysis: large blood, 3+ protein, 11-25 RBCs

  8. Differential Diagnosis • Obstruction secondary to mass • Thrombotic Thrombocytopenic Purpura (TTP) • Acute Tubular Necrosis (ATN) secondary to chemotherapy regimen or infection • Glomerulonephritis • Nephrotic syndrome • Renal artery thrombosis

  9. Hospital Course • A renal ultrasound was done: • Kidneys normal in size, echotexture and parenchymal thickness. No solid mass, hydronephrosis, shadowing calculi or perinephric abnormality. • A renal MRI: • Patent renal veins • Renal Biopsy: • changes of thrombotic microangiopathy consistent with TTP

  10. Final Diagnosis Renal Thrombotic Microangiopathy consistent with Thrombotic Thrombocytopenic Purpura (TTP)

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