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 […]

Progressive visual field loss, confusion, headache for 2 months Authors: Peter G. Pappas, 64 yo black male with recent onset of progressive visual loss on R visual field, confusion and headache. Symptoms have progressed over 2 months Until then the patient was in his usual state of health, no recent hospitalizations, procedures or history of trauma. Otherwise the patient denies fever, seizures, paresthesias, paresis, vertigo, or falls. Has a history of Evans Syndrome for which he takes low dose prednisone daily (10-20 mg/d) PMH: HTN Evan’s Syndrome Meds: Prednisone, Lisinopril, albuterol, HCTZ Social: From Birmingham, AL, no travel hx, no […]

Authors: Melony Chakrabarty MD and Archana Maniar MD UC-Davis Medical Center A 70yr old Hispanic male with presents with history of disseminated coccidioidomycosis diagnosed in 2004 with progression of disease in 2016 with basilar meningitis requiring ventriculoperitoneal shunt. He has been on Voriconazole 200mg BID since June 2016, and has had therapeutic Voriconazole levels since 8/2016 (ranging 2.6 – 5.1). Admitted February 2018 for acute on chronic weakness occurring after a fall 2-3 months ago where he lost coordination and tripped over a table. Noted joint pain over L shoulder, L elbow and 2nd and 3rd L metacarpals. He describes […]

AML with persistent rash History: 23 yo woman with relapsed AML was recently admitted for re-induction chemotherapy. She became profoundly neutropenic and was managed with empiric antibacterial and antifungal therapy with micafungin. Despite persistent neutropenia, she remained stable afebrile on most days. On day 35 days following admission, she developed worsening fever and her regimen was changed from vancomycin, zosyn, and micafungin to empiric treatment with cefepime, daptomycin, and voriconazole. On Day 36, she developed worsening fever and a progressive palpable, painless, erythematous rash with lesions ranging from 1-2 cms. She remained febrile the on Day 37, with the development […]

History: A 79 y/o male with a history of acute myeloid leukemia on palliative chemotherapy (azacytadine) with persistent neutropenia (ANC < 100 over 12 weeks on prophylactic levofloxacin and voriconazole) presents with increasing pain over the right lower extremity. He states a raised “red” lesion developed over the last 2-3 weeks after he “bumped” against a park bench, and this area has progressively increased in size and pain. He additionally states the area of redness, swelling and pain has continued to increase as well. He sought care at an urgent care center and was prescribed a course of oral cephalexin for presumed cellulitis. Following this, his symptoms continued to worsen and he sought care within a nearby emergency room. He states since last seen the area of concern had formed a blister. He was started empirically on broad spectrum antibiotics with cefepime 2gm IV q8hr and vancomycin 1gm IV q12 and transferred to a tertiary care center. His review of systems was pertinent for subjective fever and chills, a scant dry cough, and shortness of breath with any exertion, but he denies all other review of systems.

History: 62 y/o man with cirrhosis, presented to the emergency department with the chief complaint of fatigue, dizziness, weight loss, and a tongue lesion. Over the preceding 6 months he states he has had progression of his current symptoms and sought care only after the development of a tongue lesion he noticed 3 weeks prior. He states this lesion is moderately painful particularly while eating or drinking. He has not noticed any discharge from this lesion and it has slowly enlarged. During this time frame he has lost over 80 lbs and he additionally complains of mild shortness of breath and a scant, dry cough. He denies fever, chills or sweats. He has no headache or vision changes. He denies chest pain or palpitations, and has no abdominal pain, diarrhea, constipation, joint pain, or skin rashes.

History: 35yr old male with a past medical history of hemophilia A and IgA nephropathy complicated by end stage renal disease on peritoneal dialysis status post failed deceased donor kidney transplant presented to the emergency room with diffuse and sharp abdominal pain. The patient was in his usual state of health until three days prior to admission when he developed abdominal pain surrounding his peritoneal dialysis catheter site. His pain progressed in severity and was associated with significant nausea and “cloudy” catheter effluent. He states he has had chronic pruritus surrounding the catheter site and frequently attempts to scratch this area.