2021-11-10-mr-sunthankar.md (2173B)
1 # Morning Report 2 3 Katie Sunthankar, MD 4 5 # case 6 7 CC: Fever 8 9 HPI: 10 ~30F, 11 2d general body aches, 12 TMax 103.8, 13 nausea, 14 diffuse abd pain and HA. 15 Unresponsive to APAP. 16 NBNB emesis -> presentation VUMC ED. 17 UTI x2, 4 and 2 wk PTA, tx w macrobid and bactrim. 18 UTI sx never truly resolved. 19 Recently returned from glamping trip in the MidWest, 20 3wk prior to now. 21 22 PMHx/PSHx: none 23 Meds: OCPs 24 FHx: Dad w afib, sis w eczema/scoliosis, PGF leukemia 25 SHx: from northern Europe (here for >10y), 26 1ppd x2y, 27 no pets, 28 little EtOH, 29 works in an office setting 30 31 Exam: 32 100.9F, HR 149, BP 120/70, on RA 33 HEENT: mildly red tonsils, tender anterior cervical LA 34 Abd: suprapubic tenderness 35 Skin: no rashes 36 37 Labs: 38 Na 133, WBC 1.1, Hgb 13.2, plt 233 (CBC 6-7mo prior totally wnl) 39 ANC 0.0, ALC 920, 3% atypical lymphs, no blasts 40 LFTs fine. 41 UA: +ketones, +bili (no urobilinogen), >500 protein 42 UPC: 0.2 grams/day 43 CRP: 252 44 Huge infx (tickborne, viral, urine/serum fungal), w/u -ve. 45 46 ## Dx: 47 Agranulocytosis d/t bactrim 48 49 ### Agranulocytosis 50 51 ANC <200. 52 53 Inherited: BEN, familial neutropenia, congenital neutropenia 54 55 Infx: HIV, EBV, CMV, HHV6, measles, rubella, varicella, brucella, tularemia, TB, shigella, anaplasmosis, 56 57 Drugs: 58 - weeks-months after initiation of drug, typically ~4wks, 2-15 cases/y/10^6 people, mean age 51, M==F 59 - anti-thyroid (PTU, _MMI_), psych: _clozapine_ (MCC), antibacterial (_bactrim_, macrolides, cephalo, dapsone, penicillin), NSAIDs, colchicine, _sulfasalazine_ 60 61 MoA drug-induced: not clear, two hypotheses (good review in Blood) 62 - hapten (covalent binding to cell surface protein by reactive metabolites) 63 - danger signal (+inflammasome by drug-protein conjugates w/in PMN, +oxidized) 64 - some GWAS studies underway, may have association w HLA 65 66 Duration - mean 8d, but can be much longer 67 68 Presentation - ~50% present w infx 69 70 BMBx - usually hypoplastic, but could be hyperplastic or have other goofiness 71 72 Outcomes - possibly improved over the years. No significant difference wwo GCSF, however most folks do get GCSF. 73 74 Some learning points: 75 - acute toxo can look exactly like mono, down to splenomegaly 76 - no one should die w/o a dose of doxy 77 - don't mix azathioprine w allopurinol