Case of the Month 11 - Presentation

The academic year is coming to a close but there is always time for a thought-provoking case, no? Try your hand at the following patient presentation to join the COtM hall of champions:

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The patient is a 69 year-old woman with past medical history of HTN and HLD presenting with L eye discharge, fevers/chills, and vomiting for one day. The eye discharge is yellowish and starting to become more heavy. She vomited x 6, nonbilious/nonbloody emesis. She reports no diarrhea, sick contacts, recent travel, other URI symptoms, headache/neck pain, or abdominal pain. There is no contact lens use, eye pain,or recent trauma.

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PMH: As above

PSH: none

Meds: Amlodipine 5mg, atorvastatin 20mg qhs

All: NKDA

SH: No smoking, EtOH, or drug use

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ROS: No other complaints aside what is listed above

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Physical exam:
Vitals: 138/71 , 113, 99.3 18 95%
HEENT: Injected left eye with profuse mucopurulent drainage, PERRL at 4mm, no photophobia, no proptosis, no pain with eye movements
CV: S1S2, regular, grade 3/6 systolic murmur in aortic space
Chest: CTA b/l, no w/r/r
Abd: Soft, nt, BS present, no murphy’s sign, no RLQ tenderness
Ext: No edema

Neuro: A&O x 3, no focal deficits
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Labs reviewed and normal aside from the following abnormalities:

CBC – Plt 89, wbc 4.96 with 86% neutrophils

CMP – Na 135, Cl 95, Co2 22, BUN / Cr 25
Trop – 0.134 –> 0.360

EKG: Sinus @ 112 bpm, no acute ST-T abnormality
CXR: No acute process noted

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Ophthalmology was consulted given the profuse mucopurulent drainage and found

endophthalmitis of the L eye. Intra-vitreal antibiotics were administered and eye drops prescribed. Patient was recommended to be admitted for continued intra-vitreal injections.

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Upon reexamining the patient after her ophthalmology exam, she complained of a “funny feeling” in her right arm. She was noted to have new RUE weakness with an otherwise normal neuro exam.

A stroke code is called and CT head is obtained:

L frontal lobe parenchymal hemorrhage with vasogenic edema and subarachnoid hemorrhage. No mass effect or midline shift. No other lesions or bleeding noted.

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Know what’s going on? If you’ve got your thoughts going, try answering the following questions:

1) What is your differential diagnosis?

2) What further tests/studies would you perform at this time?

3) What medications/therapies would you order at this time?

Bio
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James Hassel

4th Year EM-IM Resident at SUNY Downstate/Kings County Hospital

Latest posts by James Hassel (see all)

Case Of the Month 11 – Answer - June 28, 2016
Case of the Month 11 – Presentation - June 5, 2016
Case Of the Month 10 – Answer - May 12, 2016

1 Comment

selby/tepler · June 7, 2016 at 8:09 pm

ddx
septic picture with physical exam findings of new murmur, and endophtholmatis and now brain bleed, labs sig for thrombocytopenia, left shift without high wbc, troponemea and pre-renal bun/ cr ratio.

Most likely is infectious etiology IE endocarditis with septic emboli, pt only meets 1 minor duke criteria at this point and doesn’t directly explain thrombocytopenia though there is some possibility of assoc MAHA, DIC and shearing at the valve site in prosthetic valve.

Other things to consider with multiple vascular phenomenon (brain, cardiac, eye) are TTP, vasculits and as always: syphilis

at this point work up should include blood cultures, echo (tte follow by tee), RPR and a peripheral smear for schistocytes, if that comes back negative, consider rheum w/u with ana, c-anca/-p-anca

immediate rx should focus on source control with vanco and optimizing BP, fluid status and (she did also have a stroke)
as a side note the pt should be placed on tele and consider serial EKG/ trop monitoring as b/c though MI is not the most likely cause, a pt with risk factors for CAD can develop MI in the setting of acute illness.