NYU Medical Grand Rounds
Clinical Vignette
Roy Mukku, MD
PGY-2
1/15/13
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• Mrs. W is a 49 year old Chinese woman
who presents with 2 weeks of hemoptysis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Two weeks prior to presentation, the patient began
experiencing a productive cough with flecks of blood in the
sputum.
• During the same time period, the patient also began
experiencing fatigue, dyspnea on exertion and a decreased
exercise tolerance.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient regularly undergoes hemodialysis secondary to
lupus nephritis.
• On the day of admission, she was referred to the ED from
dialysis after being found to have a hemoglobin of 7 g/dL,
down from her baseline of 11 g/dL.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Past Medical History:
• Lupus Nephritis
• Social History:
• Denies tobacco, ethanol, or illicit drug use
• Immigrated from China 20 years prior
• Medications: Methotrexate 7.5 mg PO q weekly,
Iron Sulfate 325 mg PO TID
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Chinese woman, sitting in
stretcher, appears comfortable
•Vital Signs: list T: 98.4 BP: 105/57 HR: 88
RR: 18 and O2 sat: 96% on room air
•III/VI systolic ejection murmur heard
throughout precordium
• Remainder of the physical exam was
normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Complete Blood Count:
• Hemoglobin 7.2 g/dL
• Remainder of CBC was within normal limits
• Basic Metabolic Panel:
• Creatinine 3 mg/dL
• Remainder of basic was within normal limits
• Coagulation panel within normal limits
• Ferritin 1245, Iron 46, TIBC 269
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• ECG: Normal Sinus Rhythm
• Chest X-Ray: bilateral opacification at
bases, new from previous images
• CT Chest: diffuse ground-glass opacities
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Methotrexate Toxicity
• TB
• Diffuse Alveolar Hemorrhage
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Patient was transferred to the MICU for closer
monitoring given concern for diffuse alveolar
hemorrhage
– Patient underwent hemodialysis with concomitant
blood transfusion
– Bronchoscopy was scheduled for the same day
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Signout was given that Rheumatology Consult was
already contacted and was awaiting bronchoscopy
results prior to leaving official recommendations.
– Underwent bronchoscopy, the results of which were
consistent with diffuse alveolar hemorrhage, likely the
effect of a capilleritis secondary to lupus vasculitis.
– Results were discussed on rounds and the decision
was made to start high dose steroids while awaiting
formal recommendations from Rheumatology.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
11
Hospital Course
• Hospital Day 2:
– Patient appeared quite well, yet it was noted on rounds
that Rheumatology had not yet left formal
recommendations
– Housestaff stated that Rheumatology was aware of
patient
– Patient was stable for transfer out of MICU, but
decision was made to hold off on transfer until
recommendations from Rheumatology had been
documented in chart
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
12
Hospital Course
• Hospital Day 2:
– Rheumatology was re-consulted, at which point
consult service was completely unaware of patient
– Rheumatology service subsequently made
recommendations on steroid dose and duration
– Patient did well, and was discharged a few days later
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
13
11
Final Diagnosis
• Diffuse Alveolar Hemorrhage
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS