Today’s morning report case involved a 34 year old male with an unknown psychiatric history who was brought in after being found altered, with left sided drooling and increased tone in all extremities. Vital signs showed hypertension and tachycardia and labs were significant for elevated liver enzymes (AST>>ALT), mild AKI and a CK level of 30,618. Patient was diagnosed with neuroleptic malignant syndrome (NMS) after it was discovered that he had been taking Haldol, Risperdone and Sertraline.

Take home points from today’s case:

• NMS most commonly occurs with use of 1st generation antipsychotics but can also occur with 2nd generation (clozapine, risperidone) and certain antiemetics (metoclopramide, prochlorperazine)
  • Remember that the abrupt discontinuation or dose reduction of Parkinson medications (dopaminergic agents such as levodopa) can also cause NMS!
• NMS generally occurs after weeks of therapy, but can occur as early as after the 1st dose or after several years.
• The mnemonic FEVER (from Step 1) can help identify NMS: Fever, Encephalopathy, Vital sign instability (tachycardia, labile BP), Enzyme elevation (CK), Rigidity (lead-pipe)
• The main differential diagnoses for NMS include serotonin syndrome (see below table) and malignant hyperthermia (occurs after inhalational anesthetic agents and succinylcholine)
• Prompt recognition and discontinuation of the causal agent is important, followed by aggressive supportive care and benzodiazepines for agitation.
  • In severe cases, pharmacologic agents such as dantrolene/bromocriptine can be used, however these have not been studied in large trials and are based upon case reports.
• Oral antipsychotics can be slowly reintroduced and slowly titrated after 2 weeks.

Hussain Basrawala presented an interesting case of a 51 year old male complaining of chronic non-productive cough and weight loss, and was found to have diffuse pulmonary infiltrates (CXR and CT Chest shown below). The patient was eventually diagnosed with metastatic pancreatic cancer.

Evaluation of diffuse pulmonary infiltrates

• Differential can be split into benign diseases and malignant diseases.
• Malignant disease is more likely to have multiple pulmonary nodules greater than 1 cm while those less than 5mm are more likely to be associated with benign disease.
• Benign causes:
  • Abscesses
  • Septic emboli
  • Fungal and parasitic infections
  • Tuberculosis and MAC
  • Vasculitides (GPA most common), RA, sarcoidosis, hypersensitivity pneumonitis
  • Pneumoconioses
• Malignant causes:
  • Solid organ tumors
    • Most
  • Non-Hodgkin lymphoma
  • Kaposi’s sarcoma in HIV+ patients
• Typically sarcoidosis, lymphomas, tuberculosis, fungal diseases, pneumonconioses and malignancies are associated with lymph node enlargement.

Today’s intern morning report involved 93 year old woman who presented with altered mental status and syncope, found to have MRSA in her urine as well as blood and eventually diagnosed with MRSA endocarditis.

Important teach points regarding endocarditis:
-MRSA is NOT a usual organism found in the urine, even in the presence of an indwelling foley catheter. Anybody with staph aureus bacteriuria needs further work-up for another source, and bacteremia/endocarditis always needs to be evaluated.
-The sensitivity of TTE for detecting endocarditis is <80%, therefore if suspicion is high (especially in the case of MRSA bacteremia), a TEE is indicated.

Diagnosis of endocarditis is based upon the Duke criteria (2 major, 1 major + 3 minor or 5 minor):
Major- 1. Positive blood cultures (typical organism from 2 separate cultures or 3 cultures with a common skin contaminant organism) 2. Evidence of vegetation, abscess or prosthetic valve dehiscence or new valve regurgitation (change in murmur not sufficient)
Minor- 1. Risk factors (IVDU, prosthetic valve) 2. Fever ≥38 deg C 3. Vascular phenomena (septic emboli, pulmonary infarct, Janeway lesion, mycotic aneurysm) 4. Immunologic phenomena (+Rheumatoid factor, glomerulonephritis, osler nodes, roth spots) 5. Positive blood cultures not meeting major criteria or serologic evidence of infection

-Empiric therapy while awaiting cultures is vancomycin, gentamicin is not indicated. Rifampin can be added in the setting of prosthetic valve endocarditis.

For additional information, see the infective endocarditis handout, which is also posted under “Quick References”.

Thank you Edward Lin for teaching us all about endocarditis!