Department of Medicine Department of Medicine Grand RoundsGrand Rounds

Clinical VignetteClinical Vignette

Ilana BraginIlana Bragin

January 14 January 14 thth, 2009, 2009

NYU Langone Medical CenterNYU Langone Medical Center

Internal Medicine Residency ProgramInternal Medicine Residency Program

Chief ComplaintChief Complaint

The patient is a 61 year old Caucasian male who presented with 2 weeks of increasing edema and decreased urine output.

History of Present IllnessHistory of Present Illness

Approximately one year prior to presentation, Approximately one year prior to presentation, the patient presented with new onset ascites.the patient presented with new onset ascites.

Work-up at that time included a diagnostic Work-up at that time included a diagnostic paracentesis, which revealed atypical cells. paracentesis, which revealed atypical cells.

Subsequent CT scan showed a 6 cm mass at Subsequent CT scan showed a 6 cm mass at the pancreatic tail and 3 cm omental caking. the pancreatic tail and 3 cm omental caking.

Core biopsy showed moderately differentiated Core biopsy showed moderately differentiated adenocarcinoma consistent with adenocarcinoma consistent with pacreaticoviliary cancer.pacreaticoviliary cancer.

History of Present IllnessHistory of Present Illness

He was enrolled in a clinical trial and started on He was enrolled in a clinical trial and started on Gemcitabine (Gemzar), Bevacizumab (Avastin), and Gemcitabine (Gemzar), Bevacizumab (Avastin), and Erlotinib (Tarceva). He was also started on aldactone Erlotinib (Tarceva). He was also started on aldactone for his ascites.for his ascites.A follow up CT scan showed some improvement in A follow up CT scan showed some improvement in the size of the mass and the amount of ascites. the size of the mass and the amount of ascites. Six months later, routine labs revealed an increased routine labs revealed an increased creatinine of 2.2 from his baseline of 1. The aldactone creatinine of 2.2 from his baseline of 1. The aldactone was discontinued.was discontinued.One week later, he presented to clinic with increased One week later, he presented to clinic with increased edema (legs, hands, face), fatigue, and decreased edema (legs, hands, face), fatigue, and decreased urine output. His creatinine at that time was 2.6.urine output. His creatinine at that time was 2.6.Chemotherapy was held.Chemotherapy was held.

Additional HistoryAdditional HistoryPast Medical History:Past Medical History:– HypothyroidismHypothyroidism– Benign Prostatic HypertrophyBenign Prostatic Hypertrophy– Coronary Artery DiseaseCoronary Artery Disease

Past Surgical History:Past Surgical History:– Coronary Artery Bypass Grafting, 4 years agoCoronary Artery Bypass Grafting, 4 years ago

Social History:Social History:– No toxic habitsNo toxic habits

Family History:Family History:– Non-contributoryNon-contributory

Medications:Medications:– Atorvastatin 20 mg at nightAtorvastatin 20 mg at night– Aspirin 81 mg dailyAspirin 81 mg daily– Levothyroxine 125 mcg dailyLevothyroxine 125 mcg daily– Famotidine 20 mg twice dailyFamotidine 20 mg twice daily– Darbepoetin alfa 200 mcg weeklyDarbepoetin alfa 200 mcg weekly– Gemcitabine, Bevacizumab, Erlotinib (HELD)Gemcitabine, Bevacizumab, Erlotinib (HELD)

Physical ExamPhysical Exam

Gen: sitting comfortably, no acute distressGen: sitting comfortably, no acute distress

Vital Signs: T 98, HR 80, BP 160/90, RR 16 Vital Signs: T 98, HR 80, BP 160/90, RR 16

Extremities: 3+ pitting edema bilaterallyExtremities: 3+ pitting edema bilaterally

The remainder of the physical exam was The remainder of the physical exam was normalnormal

LaboratoryLaboratoryCBC: WBC- 2 Hgb-10.2 Platelets-13CBC: WBC- 2 Hgb-10.2 Platelets-13– MCV 99, Differential: 44% Neut, 38% Lymph, 16% MonosMCV 99, Differential: 44% Neut, 38% Lymph, 16% Monos– Smear: occasional schistocytesSmear: occasional schistocytes

Basic Metabolic: BUN 44 Creatinine 2.6 Basic Metabolic: BUN 44 Creatinine 2.6 – Remainder of values were within normal limitsRemainder of values were within normal limits

Liver Function Panel: AST-152 ALT-106 Albumin 2.7Liver Function Panel: AST-152 ALT-106 Albumin 2.7– Remainder of values were within normal limitsRemainder of values were within normal limits

Coagulation Panel: INR-1.02 PTT-28.9Coagulation Panel: INR-1.02 PTT-28.9Fibrinogen-595Fibrinogen-595D-dimer-734D-dimer-734Fibrin Degradation Products >5Fibrin Degradation Products >5LDH 1951LDH 1951Urinalysis: large blood, 3+ protein, 11-25 RBCsUrinalysis: large blood, 3+ protein, 11-25 RBCs

Differential DiagnosisDifferential Diagnosis

Obstruction secondary to massObstruction secondary to mass

Thrombotic Thrombocytopenic Purpura Thrombotic Thrombocytopenic Purpura (TTP)(TTP)

Acute Tubular Necrosis (ATN) secondary Acute Tubular Necrosis (ATN) secondary to chemotherapy regimen or infectionto chemotherapy regimen or infection

GlomerulonephritisGlomerulonephritis

Nephrotic syndromeNephrotic syndrome

Renal artery thrombosisRenal artery thrombosis

Hospital CourseHospital CourseA renal ultrasound was done:A renal ultrasound was done:– Kidneys normal in size, echotexture and parenchymal Kidneys normal in size, echotexture and parenchymal

thickness. No solid mass, hydronephrosis, shadowing thickness. No solid mass, hydronephrosis, shadowing calculi or perinephric abnormality.calculi or perinephric abnormality.

A renal MRI:A renal MRI:– Patent renal veinsPatent renal veins

Renal Biopsy:Renal Biopsy:

– changes of thrombotic microangiopathy consistent changes of thrombotic microangiopathy consistent with TTPwith TTP

Final DiagnosisFinal DiagnosisRenal Thrombotic Microangiopathy Renal Thrombotic Microangiopathy consistent with Thrombotic consistent with Thrombotic Thrombocytopenic Purpura (TTP)Thrombocytopenic Purpura (TTP)