Case Study: Fever - page 2

The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in... Read More

  1. 1
    Quote from blondy2061h
    I'm curious on a BNP and a d dimer, but I'm definitely thinking infectious. I'd anticipate bipap being added if he's still working hard on hi-flow NC and possible prepare for intubation if things don't turn around. Jadelpn, why is a glucose of 87 glaring at you?
    Young, relatively usually/historicaly healthy guy 87 a tad on the low side., unless there's some fasting involved.
    juan de la cruz likes this.

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  2. 2
    Was a rapid HIV done?
    juan de la cruz and jadelpn like this.
  3. 2
    87 is a completely normal blood glucose. Not at all a "tad on the low side". If he is fasting so much the better his fasting BG then would be completely normal
    juan de la cruz and blondy2061h like this.
  4. 2
    Agreed, his glucose is fine. Especially when you consider that he probably has been fasting (not feeling well, working hard to breathe). Also his PCO2 is not high (maybe you were looking at his PO2 instead). 36 is actually on the lower range of normal, which makes sense because he is tachypneic. So we know that this isn't a ventilation problem, it's an oxygenation problem. Why is he hypoxic on 100% FiO2? I'm anticipating that he'll need to be intubated. Maybe we could try turning up his flow on the high flow for a little PEEP, but I think we're running out of options. I guess we could try NIPPV as long as he can manage his secretions. Overall I think he'll probably need a bronchoscopy, so intubation is looking like the best idea to me.

    As for a diagnosis? For some reason the eosinophilia caught my eye, which is making me think fungal/parasitic, maybe even toxin related. What about carbon monoxide poisoning?? With the headache, flu-like symptoms and hypoxia?
    juan de la cruz and blondy2061h like this.
  5. 1
    What about lymphoma? Check out the what looks like small masses on both sides of the trach. Also, elevated lactate is a classic sign of lymphoma.

    Final answer = Non Hodgkin's Lymphoma
    Last edit by ScoobieSnack on Jun 23, '13
    juan de la cruz likes this.
  6. 2
    My first thoughts were TB, or influenza? Was a LP done?
    Completely agree that he seems to be starting to CTD. BiPap and intubation seem likely. Also, since pulmonary embolism seems possible, prepare for IV heparin/sc lovenox? Not sure if still acceptable treatment for this, but it was last time I was working in an acute setting lol.
    Last edit by uRNmyway on Jun 23, '13
    juan de la cruz and blondy2061h like this.
  7. 1
    I think Rolando is on the quick path to intubation. Bipap doesn't seem that it will likely be beneficial given his hypoxemia and most likely has an underlying process that will resolve over days rather than hours. I wonder about contacts with animals. I really wonder about viral etiology something like hantavirus that is endemic to the area and presents with fever and respiratory failure.
    juan de la cruz likes this.
  8. 1
    Never seen it on real life and just throwing it it there, but legionairres?
    juan de la cruz likes this.
  9. 0
    I'm (only) a student but I too was thinking lymphoma or fungal infection. My first thought before seeing the CXR was HIV or another STD.
  10. 1
    Eh, 80 is the low side of normal for glucose, so it caught my eye. And I know absolutely little about ABG's, but not in my normal practice. And yes, Sara, PO2--
    He is not oxgenating well--

    Legionairres is a good thought too. Lymphoma, fungal infection also good thoughts...

    Was a CT of the chest done, and what did that show?
    juan de la cruz likes this.


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