August 2015 Critical Care Case of the Month: A Diagnostic Branch of Medicine

William T. Love, MD

Karen L. Swanson, DO

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

 History of Present Illness

A 66-year-old man had undergone an orthotopic heart transplantation on March 28th, 2015 due to end-stage cardiomyopathy. During a recent hospitalization from 6/26-7/2 a transbronchial lung biopsy was suggestive of  subacute rejection. He was treated with:

• Plasmapheresis x 3
• Intravenous immunoglobulin (IVIG)
• 500 mg Solu-Medrol daily
• Tacrolimus held as supra-therapeutic level of 16.2
• Mycophenolate decreased to 500mg BID
• Prednisone at 10mg BID on discharge

On July 3rd he began having cough productive of clear sputum, nausea, vomiting, and headache. Subsequently he had body aches, subjective fever, chills, night sweats, and a poor appetite with a 4 kg weight loss over the last week. There was also a history of several falls after “losing his balance".

Past Medical History

There was also a history of type 2 diabetes mellitus, chronic kidney disease, coronary artery disease with coronary artery bypass grafting in 2000.

Physical Examination

• Vital signs: T-37.1, HR-100, BP-130/88, RR-22, 96% RA
• Heart: regular rate & rhythm. 2/6 Systolic Murmur
• Lungs: clear to auscultation bilaterally

Laboratory

• Hemoglobin 9.7, WBC 6.3, creatinine 2.2, mildly elevated AST/ALT
• Lumbar Puncture– Protein 58 mg/dL, Glucose 46 mg/dL, 47 Nucleated cells

Radiography

A chest x-ray was performed (Figure 1).

Figure 1. Admission PA of the chest.

Based on the chest x-ray and lumbar puncture, which of the following are true? (Click on the correct answer to proceed to the second of four panels)

1. The chest x-ray and lumbar puncture findings in this clinical situation suggest cancer metastatic to the lung and brain
2. The chest x-ray and lumbar puncture findings in this clinical setting suggest an infection involving the lung and brain
3. The clinical findings suggest granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis)
4. The clinical findings are suggestive of acute rejection
5. The clinical findings are suggestive of tuberculosis

Reference as: Love WT, Swanson KL. August 2015 critical care case of the month: a diagnostic branch of medicine. Southwest J Pulm Crit Care. 2015;11(2):59-65. doi: http://dx.doi.org/10.13175/swjpcc100-15 PDF