MUNEZ

• 3 months PTA, patient had fever, cough and colds. Consult done at a local health center where she was given amoxicillin for 1 week with noted resolution of symptoms. However, after 1 week, there was recurrence of fever, for which she was given co-amoxyclav. There was note of a palpable abdominal mass at this time.

• 2 months PTA, (+) recurrence of fever, consult done at local health center, given cotrimoxazole with relief of symptoms.

• 1 ½ months PTA, (+) recurrence of fever, given cefuroxime for 2 days. Patient then had abdominal pain, gradual abdominal enlargement,(+) inguinal mass on the right. Consult done at local health center, given cloxacillin with no resolution

• 3 days PTA, (+) difficulty of breathing associated with on and off fever -> consult

Review of systems

• (+) weight loss• (+) anorexia• (+) easy fatigability• (+) abdominal enlargement• (+) constipation

Physical Exam on Admission

• Awake, in cardiorespiratory distress• BP 90/60 HR 152 RR 40 T 38 Wt 10.8 kg• pale conjunctivae, anicteric sclerae, (+)multiple cervical

lymphadenopathy• Equal chest expansion, (+) crackles, bilateral, decreased

breath sounds, right lower lung field• Globular abdomen, liver edge 10 cm below right costal

margin (+) 6x7 mass on L flank, (+) multiple inguinal mass, R

• full pulses, (+) edema, (-) cyanosis (-) clubbing

• Initial CXR: pneumonia, pleural effusion, right

Initial Assessment

• Pleural effusion, probably – parapneumonic process– PTB– MalignancyIntraabdominal mass, probably- Wilm’s tumor- Neuroblastoma- GI TIBRule Out Disseminated TB

First thoracentesis

• Thoracentesis revealed an exudative pleural effusion 300 cc

• yellow, slightly cloudy, RBC 2700 WBC 987 PMN 1% Ly 99%

Pleural Fluid Serum

Glucose 6.12 5.28

Total Protein 48.52 52

LDH 293 412

• Bacterial cultures and AFB smears were negative. Histopathologic findings showed negative for malignant cells.

• Antibiotics started were cefuroxime and amikacin.

• Post thoracentesis, chest xray showed decreased pleural effusion. CTT insertion was done and removed after 3 days

• CT scan showed extensive mediastinal and intraabdominal lymphadenopathy, hepatosplenomegaly and pulmonary nodules.

• Patient was referred back on the 19th day of admission.

• Awake, in mild respiratory distress, RR 45 HR 120

• Pink conjunctivae, anicteric sclerae, multiple lymphadenopathies

• Equal chest expansion, (+) crackles, bilateral, decreased breath sounds, right

• Chest xray showed increasing infiltrates with recurrence of pleural effusion, Right

• Assessment: Recurrent pleural effusion, right probably nosocomial pneumonia vs lymphoma

• Repeat thoracentesis was done aspirating 550 cc of light yellow, purulent fluid

Second thoracentesis

• Thoracentesis revealed an exudative pleural effusion

• reddish orange, hazy, RBC 12,750, WBC 4,480

Pleural Fluid Serum

Glucose 7.48 4.64

Total Protein 204 50

LDH 29.72 222

• Repeat CXR showed decreased pleural effusion, expanded right lung

• Antibiotics shifted to Vancomycin and Meropenem• CTT insertion was done on the right• On the 5th day after CTT insertion, patient was

referred for difficulty of breathing and was intubated. CXR showed fluid accumulation on the left

• CTT insertion was done on the left

• Patient was extubated after 10 days. Work up was facilitated for possible immunodeficiency.

• 1 week prior to demise, patient again started having episodes of fever, with growth of klebsiella on urine culture

• 3 days prior to demise, patient was seen drowsy to irritable

• 2 days prior to demise, patient was noted with increasing severity of difficulty of breathing.

• CBC showed increased WBC count at 31.11 with neutrophils 77%.

• 2 days prior to demise, patient was noted tachypneic at 50s, febrile 39.8.

• ABG at 10 lpm showed uncorrected hypoxemia 7.465/42.3/61.4

• Patient was intubated and hooked to MV 100% 8 ccc/kg Peep 5 RR 20

• Ciprofloxacin started and Amphotericin B ordered.

• Day prior to demise, patient was seen with poor sensorium, harsh breath sounds on all lung fields.

• Patient had progressively increasing respiraotry distress

• ABG on 100% TV 9.3 cc/kg 20 5• 7.399/45.7/63.5 100% TV 9.3 cc/kg

20 5 • 7.167/57.2/76.6 100% 11 cc/kg 20

7• 7.142/62.6/62.1 100% 11

cc/kg 30 7

• PCOD: Septic shock