January 2015 Critical Care Case of the Month: Who's Your Momma?

Carlos Hartmann, MD

Layth Al-Jashaami, MD

Timothy T. Kuberski, MD

Department of Medicine

Maricopa Integrated Health Services

Phoenix, AZ USA

History of Present Illness

A 39-year-old Hispanic woman was admitted complaining of shortness of breath and bilateral lower extremity edema. She was felt to be in acute hypoxic respiratory failure.

Past Medical History

• Systemic lupus erythematosus
• Congestive heart failure with an ejection fraction of 40%
• End-stage renal disease on dialysis secondary to lupus nephritis

Medications

• Rituximab 550 mg once a week
• Prednisone 40 mg daily
• Plaquenil 200 mg twice a day

Physical Examination

The patient was tachypneic in obvious respiratory distress. She was afebrile. Crackles at the bases. Heart was tachycardic. There was 3+ bilateral pitting pretibial edema.

Laboratory

CBC: Hemoglobin 7.8 g/dL, WBC 11 X 10⁹ cells per liter, differential: neutrophils 98%, eosinophils 0%, lymphocytes 1%.

Electrolytes: Potassium 5.8 mEq/L, sodium 143 mEq/L, creatinine 3.3 g/dL, BUN 98 mg/dL.

Brain naturetic peptide: 4055 pg/ml.

Imaging

Admission chest x-ray showed cardiomegaly and bilateral interstitial prominence suggestive of congestive heart failure.

Which of the following are appropriate initial management? (Click on the correct answer to proceed to the 2nd of 4 panels)

1. Bronchoscopy with bronchoalveolar lavage
2. Hemodialysis
3. Increased methylprednisolone for a potential lupus "flare"
4. 1 and 3
5. All of the above 

Reference as: Hartmann C, Al-Jashaami L, Kuberski TT. January 2015 critical care case of the month: who's your momma? Southwest J Pulm Crit Care. 2015:10(1):11-15. doi: http://dx.doi.org/10.13175/swjpcc145-14 PDF