you guys are slower
where you got hey man i just saw a 65 year old gentleman
previously healthy he's a retired farmer likes to hunt deer into country music he's we can
star at the bar apparently there's no smoking or drinking history comes to the clinic today because
he has been burning up a fever of 103 degrees some muscle aches feeling a little short of
breath a little bit of a cough respirations are 23 and oxygen saturation of 94 percent negative
if he was covered positive would i be calling you touche any other symptoms yeah he has been quite
diaphoretic and lethargic i had some confusion too in fact his wife saw him go unresponsive on
the car right here and she kept slapping him ah and when did he get sick five days ago did
he do anything unusual i mean nothing out of the ordinary he answers no to all of these questions
and what did his x-ray show yeah no lung infiltrates no plural effusion
and guess what his white count is actually normal and so are the rest of his labs
so he's acutely unwell he's febrile diaphoretic dysnick some cough but not bringing up any phlegm
this might be the onset of pneumonia even with the normal white count and chest x-ray
it's possible that this hasn't blossomed on the chest x-ray yet it's also possible that
this is starting out as a bronchitis which could progress to pneumonia regardless this screams
infection he's gonna need to get blood cultures pro-calcitonin level and start a monozythromycin
and cephuroxime to cover for community acquired pneumonia agreed i mean he looks well enough for
now and he's hell-bent on getting to the wedding so i'll send him home and check on him in a couple
of days yeah and with his respiratory status we're gonna have to keep a close eye on him
and five days later he's feeling like [ __ ] and when you listen to his lungs he has decreased
breath sounds at the right base and he feels more short of breath his primary care doctor
sends him to the er which he only agreed to do because his wife said no woohoo for you
eventually in the er he gets a chest x-ray which shows fluid building up around his right lung and
i would classify this as a moderate-sized pleural effusion after that he gets a ct scan of his chest
which is basically a higher quality picture version of an x-ray the ct scan again shows
the pleural effusion and it also shows mediastinal lymphadenopathy meaning in the mediastinum of the
chest there's lymph nodes there that are enlarged even though the supplemental oxygen they gave him
makes him feel a little better for the time being the er doctor of course still wants to admit him
to the hospital and do a thoracentesis meaning stick a needle in his back to drain that fluid
one because that'll make him feel better and two because that might give us a diagnosis
but he wants none of it he rips out the iv and he leaves ama and on his way out he yells
you guys are slower than [ __ ] molasses i'm not gonna miss her wedding amazingly he makes
it to the wedding and it's his big moment he says i wrote this song for the groomsmen today
who will be part of our family on this very special day and onward born to richard he was born
to he drops to the floor everyone can't believe what they just saw and someone calls 911.
now he's in the icu requiring 100 oxygen and he's getting some powerful
antibiotics zosin and vancomycin and so we do a thoracentesis and we drain one liter of fluid
now tests on the pleural fluid usually provide some clues
but usually doesn't give a conclusive answer the first thing we want to know with these tests is
this a transudate or an exudate a transudate means that the fluid is more like water while an exudate
is more like a protein shake or maybe a beer is more of your thing he look like number three and
if it meets any of these criteria we call it an exudate the tests show that he has an exudate
but looking at the other lab parameters that can help narrow down the differential diagnosis
we look at things like total red blood cell count white blood cell count even the numbers
of the different types of white blood cells like number of neutrophils and lymphocytes the amount
of glucose in there triglycerides cholesterol and even ph we look to see if there's any bacteria in
there cancer cells and a whole lot more exudative effusions and someone who has a fever is usually
infectious now when it's bacterial pneumonia or lupus or acute pancreatitis these exudative
effusions typically have white blood cell counts more than ten thousand chronic exudates for
example with tuberculosis and with cancer they typically have white blood cell counts less
than five thousand his was about 3300 plural fluid lymphocytosis particularly with lymphocyte counts
representing 85 to 95 of the total white blood cells that typically occurs with tuberculosis
lymphoma sarcoidosis and rheumatoid arthritis it's tuberculosis think about it fevers cough
shortness of breath and a lymphocytic pleural effusion what else could it be if you're
hearing hoof beats think horses not zebras i know but in this case all i see is stripes
i mean we're still waiting on the afb smear and the pcr to come back but i'd be shocked if they
don't come back positive well he lives in the midwest never traveled to a tuberculosis hot spot
and he hasn't been in contact with anyone who's had it i don't know how he got it but how else
would you explain his lymphocytic pleural effusion technically yeah it was lymphocytic predominant
but only 69 percent typically with tuberculosis pleural effusions the lymphocytes are around 90
also the glucose level was normal which if this were tuberculosis that would be low so what do
you want to do unless the tb tests come back positive we're assuming this is a different
infection it's possible he has some resistant bacteria brewing in there yeah man that or we
don't have the right infection i would broaden his antibiotics yeah we just started marrow adapto
it's not looking good man the daughter shows up to the icu in her wedding gown balling her eyes
out so i'm handing her kleenex and she tells me she saw her dad two weeks ago at dinner where he
had cooked some deer heart for her and she turned that down which obviously broke his heart but then
she said he had hunted a deer a year ago saw that the liver was black and the meat looked rotten
so he threw it away but kept the heart because it looked good this case forced me to comb through my
medical books for hours on end to figure out this mystery i like to look at it from different angles
and see how the pieces of the puzzle fit together like what is the differential diagnosis of fever
cough and chest pain what is the differential diagnosis of fever with lymph node involvement
the differential of fever and zoonoses fever and mycoses fever with pleural effusion
and what infections could cause this that would not be killed with zosin and vancomycin and
when you narrow it down there's three diagnoses that keep popping up on my radar one anthrax two
bubonic plague and three tularemia which come to think about it they're all biological weapons mind
blown dude what happened i thought you were in love with horses i am but i also love unicorns
do you actually think he has anthrax fair enough bubonic plague did he kiss a rat and travel from
the 14th century well there are five cases in the midwest every year it's unlikely but
still can't rule it out at this point did the blood cultures come back yet yeah still negative
oh it's tularemia man think about it he hunts the deer he fillets it open he sees that the liver is
black and the only thing he takes is the heart because it doesn't look like it's ruined but
usually tularemia is in rodents and rabbits not deer and even if the deer had tularemia the meat
was frozen for an entire year i hear you but this bacteria franciscella tularensis it can survive in
a dead animal for a long time and it can survive freezing temperatures for several years in the
united states there are over 100 different species that it can infect including deer oh dear he needs
the staff gentamicin and the serologies eh yes let's check igg in igm antibodies
that's all for this one if you like these types of videos go ahead and hit that like and subscribe
button and hit that bell notification that way you can get notified of when my next one comes out
and maybe you have an interesting medical case that you want me to do a video on
or maybe you just have a medical case that you want to share in the comments below
also you can check me out on instagram for other updates so see you soon you