Memorial ICU
UCI/LBM Joint Conference
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Chief Complaint
• “Sore throat, fever”
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HPI
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62 yo M
Sore throat, fever x 3 days
One day of vomiting, diarrhea
Preceded by a week and a half of clear
rhinorrhea prior to onset of fever
• Presented to LBMC for worsening of symptoms
• Onset of symptoms was while traveling in Salt
Lake City, Utah for a business trip with his wife.
They are in retail.
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HPI (Con’t)
• While in Salt Lake City, he states that there were
local fires and proposed that this may have
contributed to his symptoms.
• The patient also endorses odynophagia, chills,
nausea, and shortness of breath when lying flat
• Denies sick contacts, chest pain, abdominal
pain, weight changes, cough, vision changes, ear
pain, urinary symptoms.
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Review of Systems
• CONSTITUTIONAL: No weight loss, endorsed fever, chills, and
fatigue
• HEENT: No vision changes
• SKIN: No rash or itching
• CV: No CP or palpitations
• RESP: No cough or sputum, endorsed shortness of breath with
lying down
• GI: endorsed N/V/D
• GU: No dysuria, frequency or urgency
• NEURO: No HA, dizziness, syncope
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PMHx/PSHx
• GERD - PRN H2 blocker only
• Knee arthroscopy – remote
• Takes no other medications
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Social History
• Lives in Mount Shasta and visiting family in
SoCal
• Married
• Sexual activity: Monogamous
• Pets: Dogs
• Worked: Self employed, retail
• Tobacco: None
• Alcohol: Occasional (2 beers a month)
• Illicit: Denies IVDU and all other illicit drugs
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Physical Examination 1 of 2
• Vitals: T 38.1 , BP 71/43, P 111, RR 34, O2 98%
on RA
• Gen: Mild discomfort, A&Ox 4
• HEENT: NCAT, anicteric, PERRLA, EOMI,
moist oral mucosa . Dentition unremarkable.
Mild tonsillar erythema with white exudates on
left tonsil. No bulging of posterior pharynx
• Neck: Supple, trachea midline. Nontender to
palpation. No LAD.
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Physical Examination 2 of 2
• CV: Tachycardic but regular, no M/R/G. PMI
non displaced, no JVD or peripheral edema
• Chest: Tachypneic, CTAB, no W/R/R
• Abd: Soft, non distended, non tender,, normal
BS, no hepatosplenomegaly or palpable masses
• Neuro: Awake, alert, oriented x3, speech intact,
no focal deficits, patient moving all extremities,
CN 2-12 intact bilaterally
• Ext: No cyanosis, clubbing or edema
• Skin: No rashes, pallor, splinter hemorrhages,
Janeway lesions or Osler nodes
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Initial Labs 1 of 2
• Sodium 136, potassium 4.0, chloride 103, bicarb
18, BUN 40, creatinine 2.10, glucose 182,
calcium 8.8, Anion Gap 15
• total protein 7.4, albumin 4.0, alk phos 48, total
bilirubin 1.3, AST 24, and ALT 15
• White blood cell count 17.4 (33% Neutrophils,
6% Lymphocytes, 45% Monocytes, 4%
Eosinophils, 11% Bands), hemoglobin 13.3, and
platelets 131
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Initial Labs 2 of 2
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Lactic acid 5.57.4
CRP 25.8
Cortisol >75
TSH 0.485
ABG: 7.37/26/69/15/-10.0/20%
UA: pH 5.0, SG 1.027, Positive for Bilirubin,
Glucose 150, WBC 8, Protein 100
• CXR: No acute pulmonary disease
• Blood, urine, throat, cultures pending
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ER Course
•Patient was aggressively fluid resuscitated. In the
ED, he received 6.5L of NS boluses.
•Despite fluids, his SBP remained in the 70s-80s
and he was started on Levophed.
•He was also empirically started on doxycycline,
flagyl, and vancomycin.
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Initial Assessment
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Septic Shock
Monocytosis – differential on next slide
AKI
Anion Gap Metabolic Acidosis 2/2 lactic acidosis
Thrombocytopenia
Pharyngitis
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Monocytosis DDx
• Infectious:
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EBV
CMV
Subacute Bacterial Endocarditis
Erlichiosis/anaplasmosis
Rocky Mountain Spotted Fever
Brucellosis
Syphilis
• Autoimmune: SLE, IBD, etc
• Myeloproliferative: Hodkin’s and certain
leukemias
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Initial management
• Early Goal Directed therapy
• Empiric Antibiotics with Unasyn, Vancomycin,
Doxycycline – concern for tonsillar pathology
• Blood, urine, sputum cultures
• Throat cultures
• Rickettsia, EBV, CMV serologies
• RPR, HIV, ANA, procalcitonin
• CT neck with IV contrast to r/o peritonsillar
abscess once stable
• Peripheral blood smear
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Next day labs
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Blood, urine, throat, sputum Cx: Prelim negative
Respiratory viral panel PCR: Neg
EBV: marked elevation of IgG. IgM normal.
Smear review shows increased promonocytes
(19%) and rare myeloblasts. This is a finding
highly suspicious for acute leukemia
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Hospital Course
• Continued to endorse SOB and was tachypneic
with respiratory rates in 50s
• CXR unchanged
• Patient intubated
• Increasing pressor requirement with addition
of vasopressin and dobutamine
• ABG 7.12/28/88/9 on FiO2 35%, given 2 amps
bicarb and started on bicarb drip
• Worsening creatinine to >3 with decreasing
urine output
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Hospital Course
• Infectious Disease consulted
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Meropenam, vancomycin, doxycycline and
acyclovir (concern for possible EBV reactivation)
• Heme/Onc consulted
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Reviewed smear with pathology, very likely AML
Bone marrow biopsy showed 24% myeloblasts,
18% monoblasts and promonocytes – supportive
of AML, suggestive of myelomonocytic leukemia
Cytogenetic studies pending
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Final Diagnosis
• Septic shock with unknown source - likely
pharyngeal/tonsillar given symptoms and
tonsillar exudate
▫ Less likely a zebra as monocytosis reflects
leukemia immunodeficient state
▫ Considering strep pharyngitis with development
of Lemierre’s syndrome in the setting of AML
• CT scan for further evaluation pending…