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ISSN 1930-6741







Medical Quiz Analysis

 77 year old man presents with small digital gangrenous skin lesions, (these lesions were found to be small vessel vasculitis).

he is hypotensive and mild short of breath. He is not  confused and mental status is good. He has splinter hemorrhages in the nail beds (vasculitis sign)

 and Cardiologist diagnoses him as Endocarditis starts him on Intravenous antibiotics including Penicillin and Gentamycin.       (Excellent choice as initially thought to be Endocarditis treating with Pen & Gentamycin is standard)

                                                                                  Patient is also  noted to be anemic and Hemoglobin is 9 grams BUN and Creatinine are proportionately elevated at 30 and 2.4, suggestion of dehydration versus renal disease with anemia

 blood gases show increased A-a gradient and PO2 of 55 on 50% aerosol mask. almost any lung disease can elevate A-a gradient shunt , embolism or COPD

CT chest is done shows infiltrates with solid mass like sub pleural consolidations bilaterally. Suspicious for pneumonia and tumor. this is interesting is this all due to cancer patient with atypical pneumonia or is it a rheumatologic disease

 ESR was greater than 115, Hemoglobin 9 gm this favors rheumatologic disease

Na is 125.Anion gap was Normal .Is it SIADH or rheumatologic disease or lung cancer hard to say

Pulmonologist diagnoses him as sepsis syndrome with Gagrenosa pyoderma and Cefepime with vancomycin is given and patient is monitored in the ICU. Infectious cause is Possible Pulmonologist is just playing safe like the cardiologist

 Patient is started on moderate dose steroids. Pulmonologist is probably playing safe for rheumatologic condition associated with the disease.

Nephrologists starts working up for vasculitis and Wegner's granulomatosis and aggressively hydrates the patient. He is right on the money it is Wagner's granulomatosis.

Rheumatologist starts the work up and suggests patient be transferred to a tertiary care Hospital. He wants plasma-pherisis and kidney biopsy and lung biopsy to be done.

Patient is anticoagulated and on oxygen face mask and starts having hemoptysis, he is intubated placed on the ventilator and Bronchoscopy is done.

Tests done show P-ANCA and C-ANCA test to be positive.

Bronchoscopy shows alveolar hemorrhage.

   Diagnosis  is Wagner's granulomatosis

                                                                                            

Contributors :         A. Acosta MD, R. Kaul MD, P. Wawrzynski MD, Z. Iqbal MD, M. Islam MD

Lupus information :   Lupus site (SLE)- information on lupus

                                                                                                                                                              

 


 

 
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