Mystery disease...

[Christie RN2006]

A few days ago there was a patient that came into the ED with a fever, tachycardia, unproductive cough, SOB, and diaphoretic. The did a CXR and chest CT and it showed possible lymphadenopathy.

They have drawn tons of labs including a bone marrow biopsy. So far this pt has been negative for legionella, and the first PPD was negative. The sed rate, WBC, and platelet levels were very high, H&H low, but the rest of the labs looked okay.

Does this sound like anything you have ever seen? The docs are totally stumped at the moment, but they are thinking maybe histoplasmosis, lymphoma, autoimmune disease, etc.

Does a patient with histoplasmosis need to be in isolation?

[BBFRN, BSN, PhD]

You know, it's been so long ago that I've had a pt. with histo, that I don't remember if they are in isolation- but I don't think so. You may want to ask for an HIV test, just in case. I believe my last couple of histo pt's were HIV positive. Sorry I couldn't be of more help.

[mom4josh]

We have a very similar pt right now just diagnosed with AML (leukemia) after bone marrow biopsy. WBCs very high at first, H&H low (got a few units RBCs). Then got a week of chemo. A few days after the chemo was done (and WBC dropped from 50's to about 2), he started spiking fevers. Infectious disease was called in and he was started on a ton of antibiotics. Also tried amphotericin B (amphoterrible), which he could not tolerate at all! He's still on antibiotics, but now is constantly complaining of pain and getting Dilaudid q2h.

Now, he's also developed some facial edema and pustules on his face and chest, and going to have a skin punch biopsy.

I really hate this because he's so much younger than most of our patients, and I hate to see him struggling. Doctor has told him that he'll be in the hospital for at least a few more weeks until his next round of chemo.

UGH!

[Christie RN2006]

You know, it's been so long ago that I've had a pt. with histo, that I don't remember if they are in isolation- but I don't think so. You may want to ask for an HIV test, just in case. I believe my last couple of histo pt's were HIV positive. Sorry I couldn't be of more help.

They are testing for HIV, and almost every known STD... I read that histoplasmosis usually doesn't get bad unless there is an underlying disease that suppresses the immune system.

[Christie RN2006]

We have a very similar pt right now just diagnosed with AML (leukemia) after bone marrow biopsy. WBCs very high at first, H&H low (got a few units RBCs). Then got a week of chemo. A few days after the chemo was done (and WBC dropped from 50's to about 2), he started spiking fevers. Infectious disease was called in and he was started on a ton of antibiotics. Also tried amphotericin B (amphoterrible), which he could not tolerate at all! He's still on antibiotics, but now is constantly complaining of pain and getting Dilaudid q2h.

Now, he's also developed some facial edema and pustules on his face and chest, and going to have a skin punch biopsy.

I really hate this because he's so much younger than most of our patients, and I hate to see him struggling. Doctor has told him that he'll be in the hospital for at least a few more weeks until his next round of chemo.

UGH!

I sure hope that isn't the case for this patient! Do they have any idea what is causing the pustules?

[leslie :-D]

We have a very similar pt right now just diagnosed with AML (leukemia) after bone marrow biopsy. WBCs very high at first, H&H low (got a few units RBCs). Then got a week of chemo. A few days after the chemo was done (and WBC dropped from 50's to about 2), he started spiking fevers. Infectious disease was called in and he was started on a ton of antibiotics. Also tried amphotericin B (amphoterrible), which he could not tolerate at all! He's still on antibiotics, but now is constantly complaining of pain and getting Dilaudid q2h.

Now, he's also developed some facial edema and pustules on his face and chest, and going to have a skin punch biopsy.

I really hate this because he's so much younger than most of our patients, and I hate to see him struggling. Doctor has told him that he'll be in the hospital for at least a few more weeks until his next round of chemo.

UGH!

my mom went to the doctor for persistent, dry cough & sob.

her cxr also showed probable lymphadenopathy.

wbcs, platelets-critically high; h&h, critically low.

she did have a temp (unknown to her) and tachycardia.

she was inevitably dx'd with aml.

she eventually became septic and died.

but i remember in the icu, that she had blown up like a balloon.

she too, received her chemo inpatient and immediately became very ill.

the prognosis for aml is dismal anyway.

i'll be curious to hear the marrow results.

leslie