November 2019 Case of the Month

MSGERC Case of the Month
Title: A Bold Mold Takes Hold
Submitted by: Emily M. Eichenberger, Jennifer L. Saullo, John R. Perfect, Danielle Brander, Julia M. Messina   Institution: Duke University Medical Center
Email: Emily.Eichenberger@duke.edu
Date Submitted: 9/30/2019

History: 
62-year-old man with newly diagnosed chronic lymphocytic leukemia (CLL) on Ibrutinib therapy for 1 month prior to presentation with fevers, aphasia and a new brain lesion.
He was doing well on the therapy for approximately 3 weeks until he developed a sore throat, and neck swelling. He was seen by an otolaryngologist who described a left peritonsillar abscess . An aspiration of the left peritonsillar abscess was attempted to alleviate the swelling, but no purulence was aspirated. He was instructed to take amoxicillin-clavulanate for 10 days.  
While nearing the end of the antibiotic therapy, the patient began to have intermittent fevers and progressive word finding difficulty. His symptoms progressed to confusion and profound expressive aphasia. He was subsequently admitted to the hospital...

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October 2019 Case of the Month

DrFungus.Org Case of the Month 

Title: Unilateral vision loss in a previously healthy patient
Submitted by: Sarah Tran MD, Luke Chang MD
Institution: Medical College of Georgia/Augusta University
Email: satran@augusta.edu
Date Submitted: 09/27/2019

History of Present Illness: 
A 30 year-old man presented to the emergency department with 3 weeks of progressive right eye pain and redness, accompanied by blurred and darkened vision in the affected eye. He denied any preceding trauma to the eye, fever, headache, or facial pain. He otherwise felt systemically well. He was initially diagnosed with uveitis and prescribed prednisolone and cyclopentolate eye drops by an outside provider. However, he felt that his symptoms were not improving and presented to a different ophthalmology office for a second opinion. At that time, he was found to have significant anterior chamber inflammatory reaction, vitreous haze, and a fluffy white lesion overlying the peripheral retina of the right eye. After discussing these findings with the patient, he admitted to intravenous (IV) drug use, raising...

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September 2019 Case of the Month

Centrifugal Fungus: Black Mold Emerges from the Tube Submitted by: Robert Rolfe Jr, Becky Smith, Jacob Klapper, John Perfect, Julia Messina Institution: Duke University History: A 67 year-old man originally from Colombia with end-stage interstitial lung disease was admitted to Duke University Medical Center (DUMC) for bilateral orthotopic lung transplant (BOLT). His BOLT surgery was complicated by hemorrhage requiring multiple units of red blood cells, plasma, platelets, and cryoprecipitate. Post-operatively, his chest was left open, and he was placed on veno-venous extracorporeal membrane oxygenation (ECMO). Per hospital protocol, the patient was placed on inhaled amphotericin B lipid complex prophylaxis as well as prophylactic intravenous (IV) fluconazole with plans to continue through index hospitalization. However, as he had worsening liver function, his fluconazole was switched to micafungin on post-operative day two. On this same day, the patient was taken back to the operating room (OR) for right middle and lingula lobectomies, and his chest remained open. On post-operative day five, he underwent tracheostomy. On...

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June 2019 Case of the Month

Title: Fever of Unknown Etiology and Pancytopenia in a Solid Organ Transplant Recipient. Submitted by: Amy Spallone, MD, Laila Woc-Colburn, MD Institution: Baylor College of Medicine Email: amy.spallone@bcm.edu Date Submitted: April 2019   History: 34 y/o Hispanic male was admitted for worsening pancytopenia over the past two weeks. His past medical history was significant for alcoholic cirrhosis leading to orthotopic liver transplantation in August 2017. Two weeks prior to this presentation he was admitted for fevers without any associated complaints. He underwent an extensive infectious disease work up, which revealed he was Rhinovirus positive on respiratory viral panel. Patient was treated with supportive care at the time. On his current admission, patient states that he was been having persistent and daily fevers since his last hospitalization. Medications: Prednisone 17.5mg daily and tacrolimus 1mg BID. His mycophenolic acid was stopped a few days prior to admission due to a downward trend of his white blood cell count. Social History: He lives in Houston, TX with his family. He...

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January 2019 Case of the Month

Worsening Pneumonia, Intubation and ARDS Submitted by: Shiwei Zhou, M.D., & John Mills, M.D., University of Michigan History:  A 78yo woman was admitted for ARDS in the setting of right sided pneumonia. About 3 weeks ago she developed fevers, chills, and a nonproductive cough. Chest X-ray at an urgent care showed a right lower lobe infiltrate, and she was started on PO Levofloxacin but worsened over the next 3 days.  She was then admitted to an outside hospital and started on IV Ceftriaxone and Azithromycin, but continued to worsen over the next week with increasing oxygen requirements and was intubated prior to transfer to our hospital, where she was started on Vancomycin, Piperacillin-Tazobactam, and Azithromycin. Per family, she had no chest pain, abdominal pain, joint symptoms, or skin rashes; no other sick contacts.  PMH:Hypertension, type 2 diabetes, obesity, atrial fibrillation SH: Patient lives in Marquette, Michigan (Upper Peninsula) in a suburban area. No outdoor recreation activities. No travel to other parts of the US or outside...

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