Reference no: EM133976022

Question

A 55year-old female with past medical history significant for stage III breast cancer on maintenance Tamoxifen, along with prior alcohol abuse, was admitted to the hospital with chief complaints of headaches, intermittent fevers, and altered mental status. She lived primarily in Central America since retirement 3 years ago and came to the United States to live with her daughter 3 months ago. She had a prior hospitalization one month ago with intermittent fever and leukocytosis. CT body imaging was negative, along with negative infectious and rheumatologic workup. Past medical history was remarkable for heavy alcohol use for more than 25 years with recent sobriety. She also had hypertension and hypothyroidism. Upon arrival she was obtunded and verbally non-responsive. Her exam included BP162/99, pulse 150, RR 72, and temperature 102.7o F. She was on BiPAP with O2 saturation of 99%. Head and neck exam was unremarkable without adenopathy. Her lungs had bibasilar crackles. Cardiac exam was only significant for tachycardia with regular rhythm and no murmurs. Laboratory values on arrival included white blood cell count 15.13 x 103 /uL, hemoglobin 9.7 g/dL, hematocrit 29.5%, platelet 78, neutrophil 67.7%. Sodium 131, potassium 3.8, chloride 105, CO2 12, BUN 30, creatinine 1.5, glucosetroponin 20, BNP 3070, ESR > 100, and lactate 19.

CT scans of the chest, abdomen, and pelvis were unremarkable other than signs of aspiration. CT scan of the brain showed no acute findings, and MRI brain imaging showed no acute abnormalities. She was diagnosed with sepsis of unknown etiology and supportive measures were started for her ongoing signs of septic shock. The patient quickly deteriorated and required intubation and vasopressors support for hypotension. She developed acute renal failure and Dialysis was started for oliguria. In addition, spot EEG monitoring revealed seizure activity, and patient was loaded on levetiracetam. Lumbar puncture revealed elevated protein of 944 and elevated white blood cell count of 873 with lymphocytic predominance. Infectious Disease advised empiric therapy for tuberculosis and fungal meningitis, as well as broadened bacterial coverage. Doxycycline was added for atypical vs. zoonotic infection. Multiple infectious serologies were sent (mycoplasma, hantavirus, rickettsia, Q fever, HIV, dengue fever, and malaria) and returned negative. All cultures (blood, urine, sputum, CSF, and stool) also returned negative. Unfortunately, the patient then developed new symmetric mottling of her feet that rapidly ascended up the extremities, consistent with livedo reticularis and pruritic papulovesicular lesions.

1. What would be the next step in diagnosis with this patient?

2. Work through Vindicate for differentials.

3. Brief pathophysiology of your primary diagnosis causes and symptoms.

4. Develop a treatment strategy for your diagnosis, including medication, and mechanism of action of this medication.