Monday, July 27, 2009

Sick I

No more of that outpatient nonsense; this week, we have three sick patients.

A 60 year old man with a history of treatment refractory multiple myeloma just received an allogeneic bone marrow transplant from an HLA matched donor 3 weeks ago. Prior to bone marrow transplant, he received high dose cyclophosphamide and total body radiation. Post-transplant, the patient is on cyclosporine and prednisone. Since you know the literature, you know this is not the ideal approach to multiple myeloma; there is a 20% early mortality and 30-50% overall mortality; UpToDate does not recommend myeloablative transplants for myeloma outside a clinical trial setting.

Alas, the harm has been done. The transplant team is calling you to admit the patient to the intensive care unit. The patient has been febrile to 41 C for two days. He complained of chest pain and dyspnea. He had one episode of hemoptysis. He was cultured and started on broad spectrum antibiotics and amphotericin B. The antibiotics have not helped. Here is the CXR:

Lower extremity Dopplers are negative for DVT. Here is a slice of the CT chest with the "arrow sign."

Challenge: The cultures are cooking. The transplant team wants to know if you have a diagnosis, and more importantly - a proposed treatment.

Both images shown under fair use.


Alex said...

pcp? cmv?

Craig Chen said...

Sick I

This is invasive pulmonary aspergillosis. Risk factors include prolonged severe neutropenia, glucocorticoid therapy, hematopoietic stem cell transplant, solid organ transplant, AIDS, and chronic granulomatous disease. CT shows nodules surrounded by ground-glass appearance, known as the "halo sign." Voriconazole is the treatment of choice.

Sources: UpToDate;;