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 A 60-Year-Old Woman With

Fever, Cough and Low Back Pain

 ± Chapter 8

Based upon: LABORATORY MEDICINE CASEBOOK.

 An introduction to clinical reasoning 

Jana Raskova, MDProfessor of Pathology & Laboratory Medicine

Stephen Shea, MDProfessor of Pathology & Laboratory MedicineFrederick Skvara, MD Associate Professor of Pathology & Laboratory Medicine

Nagy Mikhail, MD Assistant Professor of Pathology & Laboratory Medicine

UMDNJ-Robert Wood Johnson Medical School Piscataway, NJ 

8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007

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History and Physical Exam

 A 60 y.o.

Chief complaing: fever and pr oductive cough f or appr oximatelytwo months

Fatigue and low back pain Physical Exam

 Aler t , oriented

BP: 120/90

HR: 90 bpm; RR: 23

Temp. 102.2 oF Bilater al r ales

Rest of  exam - unremar kable

EGM2

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Slide 2

EGM2 What is the significance of bilateral rales?Eugene G. Martin, 8/21 /2003

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Differential diagnosis?

Tests?

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Radiology

Normal Flat Plate Patient ± On AdmissionBilateral infiltrates

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CBC

Patient Normal

WBC 12.0 X 103/uL (3.3-11.0)

Neut 76 % (44-88)

Band 12 % (0-10)

Lymph 8% (12-43)

Mono 2% (2-11)

Eos 1% (0-5)

Baso 1% (0-2)

Nucleated RBC 5% (0)

RBC 3.1 X 106/uL (3.9-5.0)

Reticulocytes 1.1% (0.5-1.5)

Hgb 8.5 g/dL (11.6-15.6)

HCT 25.6 % (37.2-50.4)

MCV 82.6 fL (79-99.0)

MCH 27.5 pg (26.0-32.6)

MCHC 32.2 g/dL (31.0-36.0)

Plts 188 thousands/uL (130-400)

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Is this a Shift to the Left? Includes:

Unilobed and two lobednucleus predominate

Seen in:  Acute infection

Metaboloc acidosis

Necrosis : myocardialinfarct. malignant tumors

Blood disease:

hemolytic crises,

severe blood loss

chronic granulocyticleukemia,

Band cell

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CHEMISTRYTest Patient Normal

Glucose 97 mg/dL (65-110)

Creatinine 1.5 mg/dL (0.7-1.4)

BUN 28 mg/dL (7-24)

Uric Acid 7 mg/dL (3.0-8.5)Cholesterol 200 mg/dL (150-240)

Calcium 11.4 mg/dL (8.5-10.5)

Protein 9.8 g/dL (6-8)

 Albumin 3.2 g/dL (3.7-5.0)

LDH 265 (100-225)

 Alk. Phos. 190 U/L (30-120)

 AST 30 U/L (0-55)

GGTP 40 U/L (0-50)

Bilirubin/Bil. Direct 0.4 mg/dL/(.13 mg/dL) (0.0-1.5)/(.02-18)

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ElectrolytesTest Patient Normal

Na 137 mEq/L (134-143)

K 3.5 mEq/L (3.5-4.9)

Cl 99 mEq/L (95-108)

tCO2 25 mEq/L (21-32)

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Culture results Gram positive cocci

in pairs and chains

Consistent with:Streptococcus

 pneumoniae

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Two weeks later 

Fever gone, chest clear 

Back pain worse

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Differential diagnosis?

Tests?

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HEMATOLOGY ± 2 weeks later 

Patient Normal

WBC 3.4 X 103/uL (3.3-11.0)

Neut 9 % (44-88)

Lymph 27% (12-43)

Mono 4% (2-11)

Eos 0% (0-5)

Baso 0% (0-2)

RBC 3.2 X 106/uL (3.9-5.0)

Reticulocytes 1.% (0.5-1.5)

Hgb 8.6 g/dL (11.6-15.6)

HCT 26.1 % (37.2-50.4)

MCV 81.5 fL (79-99.0)

MCH 26.8 pg (26.0-32.6)

MCHC 32.9 g/dL (31.0-36.0)

Plts 110 thousands/uL (130-400)

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CHEMISTRY ± 2 Weeks later Test Patient Normal

Glucose 90 mg/dL (65-110)

Creatinine 1.9 mg/dL (0.7-1.4)

BUN 29 mg/dL (7-24)

Uric Acid 9 mg/dL (3.0-8.5)

Cholesterol 199 mg/dL (150-240)

Calcium 12 mg/dL (8.5-10.5)

Protein 10.9 g/dL (6-8)

 Albumin 3.7 g/dL (3.7-5.0)

LDH 270 U/L (100-225)

 Alk. Phos. 210 U/L (30-120)

 AST 50 U/L (0-55)

GGTP 35 U/L (0-50)

Bilirubin/Bil. Direct 0.7 mg/dL/(.11 mg/dL) (0.0-1.5)/(.02-18)

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UrinalysisTest Patient Normal

pH 6 (5.0-7.5)

Protein 3+ (Neg)

Glucose Neg (Neg)

Ketone Neg (Neg)

Occult blood Neg (Neg)

Color Yellow (Yellow)

Clarity Clear (Clear)

Sp. Grav. 1.050 (1.010-1.055)

WBC 3/HPF (0-5)

RBC 1/HPF (0-2)

Cast Hyalin (Neg)

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Peripheral Blood Smear 

PatientNormal

RouleauxNormochromic,

normocytic

anemia

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Skull x-rays

Randomly distributed, rounded, punched out lytic lesionsthroughout the skull. Multiple myeloma could also resemblemetastatic breast carcinoma. Treated breast carcinoma,however, often appears sclerotic rather than lytic.

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Serum Protein Electrophoresis Note sharp peak in

the gamma region

indicative of amonoclonal protein

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Serum Immunoelectrophoresis

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Bone Biopsy Bone biopsy

representing morethan 90 percent

replacement of normalmarrow with plasmacells.

Definitive diagnosisrequires > 10 to 15percent plasma cell

involvement of thebone marrow.

http://www.aafp.org/afp/990401ap/1885.html