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Cases from Yale-New Haven Hospital

From the November ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Christopher Sankey, MD, ACP Member, Physician Editor

The Brief Case is a new, quarterly column comprising summaries of real-life inpatient cases. It is written by hospital physicians and edited by Christopher Sankey, MD, ACP Member, a hospitalist at Yale-New Haven Hospital in Connecticut. If you are interested in writing one or more summaries of cases from your hospital, please e-mail us.

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Case 1: Acute EBV infection and HIV antibody cross-reactivity

The patient

A 22-year-old sexually active female college student without chronic medical comorbidity presented with two weeks of fever, sore throat, malaise, and fatigue. She subsequently developed jaundice and sought further evaluation. Upon admission, examination revealed a low-grade temperature of 100.1°F. She was nontoxic-appearing, without rash, oral lesions, or significant lymphadenopathy. She was jaundiced, with scleral and sublingual icterus. No hepatomegaly or splenomegaly was present. Admission testing was significant for the following:

Test Result
Total/direct bilirubin 6.16/4.56 mg/dL
Aspartate aminotransferase/alanine aminotransferase 109/108 U/L
Right upper quadrant ultrasound Nonspecific periportal and pancreatic adenopathy
Atypical lymphocytes/absolute lymphocyte count 60%/16,600 cells/μL
Heterophile antibody (monospot) Positive
EBV viral capsid antigen (VCA) antibody Positive (IgM and IgG)
EBV nuclear antigen (EBNA) antibody Negative (IgG)
HIV-1 and HIV-2 antibody Positive

The diagnosis

This patient's diagnosis is acute infectious mononucleosis. Sore throat and malaise or fatigue are the most commonly encountered symptoms in this clinical syndrome. Marked atypical lymphocytosis is common, the presence of which (in quantity greater than 10%) has a sensitivity of 75% and specificity of 92% for the diagnosis of infectious mononucleosis. Heterophile antibody testing has a specificity of nearly 100%, though case reports of false positives (most notably in acute HIV infection) exist. The Epstein-Barr virus (EBV)-specific antibody pattern is consistent with an acute EBV infection. Cholestatic jaundice is uncommon and is estimated to be present in fewer than 10% cases.

Important entities in the differential diagnosis of a monuncleosis-like syndrome include HIV, cytomegalovirus, human herpesvirus 6, and toxoplasmosis. The positive HIV antibody test was presumed to reflect cross-reactivity in the setting of acute EBV infection, as confirmed by a negative quantitative HIV polymerase chain reaction (PCR) the following day. The patient was reassured that she did not have HIV, was discharged from the hospital, and made a complete recovery.

Pearls

  • The diagnosis of infectious mononucleosis in young adults can regularly be made on the basis of clinical presentation, atypical lymphocytosis, and a positive heterophile antibody test.
  • Acute HIV infection is an important diagnostic alternative, with quantitative HIV PCR as the suggested screening method in appropriate individuals.
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Case 2: Recurrent aspiration as a complication of gastric banding

The patient

A 42-year-old woman with multiple sclerosis presented with cough, fever, and malaise. The patient had been admitted two weeks prior with similar symptoms; she was given a diagnosis of community-acquired pneumonia and discharged with oral antibiotics, but symptoms persisted. Her multiple sclerosis was controlled on natalizumab without functional limitations. Past medical history is otherwise significant for laparoscopic adjustable gastric banding in 2007.

Upon admission, examination revealed a low-grade temperature of 99°F and normal oxygen saturation on room air. Lungs were clear to auscultation bilaterally. White blood cell count was 37,000 cells/µL with bandemia. Chest radiograph was unremarkable. Chest computed tomography (CT) revealed bilateral ground-glass opacities, and plans were made for inpatient bronchoscopy.

The diagnosis

Recurrent pulmonary symptoms and bilateral pulmonary ground glass opacities in a patient on immunomodulatory therapy yield an extensive differential diagnosis that includes resistant bacterial pathogens, opportunistic fungal and viral pathogens, and interstitial lung diseases. However, the diagnosis in this case was made by returning to the bedside. Further history revealed her cough occurred exclusively at night, specifically while she was lying flat. She described an associated sensation of “a column of fluid coming up my chest.” Her gastric band had been tightened in an outpatient visit with her surgeon approximately one week prior to developing all pulmonary symptoms. Upon further review, the chest CT demonstrated a dilated, fluid-filled esophagus suggestive of distal restriction.

Laparoscopic adjustable gastric banding is currently the least invasive surgical intervention for morbid obesity. Commonly encountered late complications of this procedure include pouch expansion and band slippage or erosion; less frequent are late pulmonary complications, such as recurrent aspiration pneumonia due to severe restriction. The patient's surgeon withdrew all fluid from her gastric band, with immediate symptomatic relief. Bronchoscopy was cancelled. She was discharged the following day with oral antibiotics, and her symptoms did not recur.

Pearls

  • Surgical procedures for morbid obesity are increasing in frequency, and hospitalists require knowledge of commonly encountered complications of each procedure.
  • Recurrent aspiration is an infrequent but important late complication of laparoscopic adjustable gastric banding, which can be definitively addressed by fluid removal from the gastric band.
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Case 3: Laboratory abnormalities as a clue to hypertriglyceridemic pancreatitis

The patient

A 24-year-old woman without chronic medical comorbidity presented with acute onset epigastric abdominal pain radiating to her back after a meal at a fast-food restaurant. The patient has never previously experienced similar symptoms, but other members in her family had “high cholesterol” and pancreatitis. She uses a vaginal estradiol ring for contraception. She said she binge drinks alcohol on weekends.

Upon admission, examination revealed a low-grade temperature of 100°F and tachycardia. She was obese (BMI 30 kg/m2), with epigastric abdominal tenderness. No xanthelasma or tenidnous xanthomas were noted. Laboratory results were significant for multiple “cancelled” values on three consecutive blood draws; potassium, bilirubin, aminotransferases, alkaline phosphatase, and lipase were all ordered but reported as cancelled by the laboratory. The next blood draw revealed a triglyceride level of 2,540 mg/dL and a lipase level of 177 U/L, along with persistently cancelled values for all other chemistries.

The diagnosis

The diagnosis in this case is hypertriglyceridemic pancreatitis (HTGP), an uncommon (~5%) but well-documented cause of acute pancreatitis. Triglyceride levels of at least 1,000 mg/dL are thought to be necessary to cause HTGP, though there is no direct correlation between triglyceride level and severity of HTGP. Causes of hypertriglyceridemia are varied, and require further investigation. Our patient's hypertriglyceridemia was thought to be multifactorial, with contributions from a familial dyslipidemia, estrogenic contraception, obesity and diet.

A commonly encountered but incompletely described clinical phenomenon is the association between lipemia and difficulties in measurement of many laboratory indices. There are known effects of hypertriglyceridemia upon sodium, amylase, and low-density lipoprotein calculation; however, the clinical laboratory will frequently defer reporting common tests, and in some cases note overt lipemia. Confirmation of severe hypertriglyceridemia resulted in appropriate revision of triage to the stepdown unit for insulin drip and euglycemic clamp to mitigate her triglyceride level. Fibrate therapy was also initiated, and her vaginal estradiol ring was discontinued. Her triglyceride level normalized, pancreatitis symptoms remitted, and she was discharged with arrangements to follow up in the endocrinology clinic.

Pearls

  • Hypertriglyceridemic pancreatitis (HTGP) is an uncommon but well-documented cause of acute pancreatitis, the interventions for which may require a higher level of care than a general medicine ward.
  • Repeated cancellation of routine laboratory indices should raise suspicion as to the possibility of hypertriglyceridemia.
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Case 4: Chest pain with low risk for acute myocardial infarction

The patient

A 35-year-old black man with a history of well-controlled asthma presented with acute-onset chest pain associated with dyspnea, diaphoresis, and presyncope. His symptoms lasted approximately 15 minutes and spontaneously resolved. He noted a significant amount of baseline anxiety. Urine toxicology revealed marijuana, but no cocaine or amphetamines. He took no medications (prescribed or herbal), and had no family history of premature coronary artery disease.

Upon admission, vital signs were normal and examination revealed a thin, healthy-appearing man without remarkable findings. Laboratory testing was normal, including a negative D-dimer. Admission electrocardiogram (EKG) showed less than 0.5-mm ST elevations in the lateral leads, with morphology consistent with early repolarization. Repeat EKG showed no dynamic changes. Three negative troponin T values (Roche high-sensitivity assay) were obtained over the subsequent 24 hours. The next morning, he was discharged to follow up with his primary care physician.

Upon exiting the hospital, he experienced recurrent chest pain and returned immediately to the emergency department. The cardiac catheterization lab was activated, and his study revealed normal coronary arteries. He was subsequently discharged after another brief and uneventful hospitalization.

The diagnosis

This case illustrates a scenario frequently encountered by hospitalists: chest pain in a young individual without typical symptoms or risk factors for ischemic cardiac disease. While coronary ischemia is essential to consider, there are many non-lethal masqueraders that cause “atypical” chest pain, many of which recur frequently and over a protracted duration of time. Further testing, with the associated costs and possible complications, is often pursued.

For patients with atypical chest pain, the yield of coronary angiography is generally low and carries risks of puncture site vascular injury, coronary injury and contrast nephropathy, among others. Early repolarization (ER) describes a group of normal EKG variants, generally in young patients; these are more frequent in males, African-Americans and adolescents. While certain “J-point” abnormalities are associated with sudden cardiac death, increasing data suggest lateral ER is a benign finding. Cardiac-specific, high-sensitivity troponin has been demonstrated as the principal predictor of early risk in patients with rest angina, superior to EKG. Published 30-day and six-month rates of mortality or myocardial infarction with negative troponin results (minimum of two, measured at least six hours after onset of pain) are less than 2% and 5%, respectively.

Many patients with atypical chest pain undergo additional testing with unclear benefit. Hospitalists need to be facile with identifying low-risk patients in whom the cost and possible complications associated with further diagnostic testing may be obviated.

Pearls

  • Currently available high-sensitivity troponins yield a high negative predictive value for mortality and myocardial infarction for up to six months in patients with rest angina.
  • Additional investigation for coronary ischemia in patients at low risk for myocardial infarction is of uncertain clinical benefit, and may result in further testing with risk of possible complications.
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Case 5: Pseudomonas aeruginosa septic arthritis

The patient

A 59-year-old man without chronic medical comorbidity presented with two weeks of right ankle pain and swelling after twisting his ankle on his poultry farm. He was initially seen in the ED, and after a negative plain radiograph was discharged with crutches and recommendations for symptomatic treatment. Over the three days preceding admission, he noted increasing erythema, swelling, and inability to bear weight.

Upon exam at admission, he had normal vital signs. The right ankle was swollen, with palpable joint effusion and large area of overlying cellulitis. No trauma or breaks in the skin were seen. Empiric therapy with intravenous vancomycin was given. Erythrocyte sedimentation rate was 87 mm/h and C-reactive protein level was 180 mg/L. Arthrocentesis showed over 100,000 nucleated cells with 91% granulocytes.and the gram stain unexpectedly revealed gram-negative organisms. Anti-pseudomonal antibacterial coverage was added. He ultimately underwent two separate operative irrigation and debridement procedures. Arthrocentesis and operative cultures all demonstrated a pansensitive Pseudomonas aeruginosa. Blood cultures were all negative.

The diagnosis

This case illustrates an infrequent occurrence of septic arthritis in an immunocompetent host with P. aeruginosa. Skin, soft tissue, and joint infections with P. aeruginosa are typically restricted to the immunocompromised, the elderly, and intravenous drug users. P. aeruginosa in reviewed case series is responsible for fewer than 5% of septic arthritis cases in adults. In immunocompetent hosts, the most common skin and soft tissue infection associated with P. aeruginosa is a cutaneous follicular dermatitis related to whirlpool use. It is unclear whether this patient's initial mechanism of injury provided sufficient trauma to allow for the introduction of bacteria; the patient's occupation is a similarly uncertain risk factor. An investigation for occult immunocompromise, other than a glycosylated hemoglobin level of 4.9%, was not pursued.

This case further underscores the need for rapid diagnostic and therapeutic interventions in the management of an acute septic arthritis. Our patient made a full recovery after eight weeks of ceftazidime and ciprofloxacin therapy.

Pearls

  • Pseudomonas aeruginosa is an uncommon cause (<5%) of septic arthritis in adults, especially in the immunocompetent host.
  • Commonly prescribed empiric gram-positive antibacterial coverage is insufficient in such cases, which underscores the imperative to promptly follow up the arthrocentesis gram stain result.

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