Fatigue, nausea, vomiting, dysphagia, bowel incontinence, blurry vision, and change in mental status.

The patient is a 70-year-old Caucasian woman who presented to the ED of an outside hospital with a 7-10 day history of fatigue, nausea, vomiting, dysphagia, bowel incontinence, blurry vision, and change in mental status. Workup at the outside hospital revealed the patient to be in atrial fibrillation with a rapid ventricular response. Laboraratory studies were notable for hyperglycemia (glucose >400 mg/dl) and pancytopenia. Following admission to the outside ED, the patient decompensated and required intubation and mechanical ventilation. She was started on broad spectrum antibiotics, filgrastin, amiodarone, and transfused with packed red blood cells. She was then transferred to the JHH MICU.
The patient was diagnosed with Type II diabetes approximately 3 months prior to admission when she presented with osteomyelitis of the toe. At that time she was found to be anemic. Evaluation for GI bleeding only showed moderate to severe gastritis although evaluation for H. pylori was negative. Colonoscopy was unremarkable. Follow-up laboratory examination one month prior to this admission showed normal white cell and platelet counts.

Hypertension
Diabetes mellitus
Left 5th toe amputation for osteomyelitis
Gastritis
Appendectomy
Tonsillectomy & adenoidectomy

The patient's family history is significant for hypertension and heart disease. Her father contracted HIV/AIDS from a blood transfusion and died at an unspecified age of acute interstitial pneumonitis. Mother is still alive and has a pacemaker.

The patient is a homemaker who lives in rural Wisconsin. She is married and lives with her husband, a pastor. She has two daughters, both grown. She travels for church activities, and was visiting Baltimore for a church conference at the time of admission. Has traveled internationally in the past including a cruise to Mexico in 2004 and a trip to Guatemala in 2001. She does not smoke, drink alcohol, or use drugs.

Glucophage
Ferrous Sulfate
Felodipine
Lansoprazole

No known drug allergies.

Positive for slurred speech, fevers, chills, shortness of breath, dyspnea on exertion, dysphagia, abdominal pain, nausea, vomiting the day of admission.
40-pound weight loss over 5 months
No recent history of night sweats, fevers, bruising, bleeding, or skin infections other than noted.

• T: 36.4 C BP: 124/61 P: 86 RR: 20 SaO2: 99% on mechanical ventilator
• General: Sedated, on ventilator, occasional grimace with examination
• HEENT: Normocephalic, atraumatic, pupils equal, round, and reactive to light and accommodation
• CV: Regular rate and rhythm, 2/6 systolic murmur, no displacement of the PMI, no carotid bruits, 2+ carotid, brachial, radial and dorsalis pedis pulses
• Lungs: Clear to auscultation bilaterally
• Abdomen: Soft, nontender, nondistended, positive bowel sounds
• Lymph Node Exam: Multiple enlarged nodes in the right anterior cervical region
• Extremities: No clubbing, cyanosis, or edema, status-post right 5th toe amputation
• Neuro: Positive response to sternal rub, positive corneal reflex, positive gag reflex, no deep tendon reflexes, no Babinski reflex, decreased rectal tone
• Skin: fresh bruises from IVs, no old echymoses or petechiae

• Na 143; K 3.7; Cl 108; HCO3 22; BUN 66; Cr 1.2; Glucose 171; Calcium 7.6; TP 4.6; Albumin 2.2; TBili 2.4; AST 11; ALT 11; Alk Phos 87
• WBC 320; Hct 26.7%; Platelet 53,000; Absolute neutrophil count: 0
• PT 15.5; INR 1.6; PTT 30.9

• Chest CT: Left lower lobe consolidation. Nodular infiltrates involving the right lower lobe. 1.1 cm spiculated nodule in the left lower lobe with surrounding ground glass haziness. 4 mm nodule in the right upper lobe. Multiple calcified lymph nodes in the right hilar and mediastinal regions.
• Abdomen/Pelvis CT: Significant thickening of the rectum extending into the sigmoid colon and up to the splenic flexure suggestive of colitis. Calcified granulomata in the spleen
• Brain MRI: Multiple foci of restricted diffusion in the left centrum semi ovale, left splenium, right occipital pole, and right frontal pole consistent with acute to subacute infarcts, possibly embolic in origin. Encephalomalacic changes in the right frontal and left parietal regions. Old lacunar infarcts in the centrum semi ovale. Chronic ischemic changes.

The patient was treated with amiodarone, insulin, and broad spectrum antibiotics. CT scans of the brain were performed immediately following transfer to the JHH MICU, which were unrevealing. A bone marrow biopsy and aspirate were performed, which showed a cellular marrow with erythroid predominance, polyclonal plasmacytosis, and increased histiocytes suggestive of a reactive process. An MRI of the brain suggested embolic CVAs, but a TEE showed no valvular vegetations or thrombi, and no PFO (Image 1). CSF analysis, blood cultures, and viral serologies were all negative. Sputum cultures grew only yeast. HIV serology was negative. Despite treatment with G-CSF for severe neutropenia and broad-spectrum antibiotics, as well as aggressive supportive care, the patient developed pneumonia and ARDS (Images 2-5) requiring continual mechanical ventilation, acute renal failure requiring CVVHD, and shock requiring vasopressor support. She continued to decline, and after discussion with the patient's family life support was eventually withdrawn, and she expired 8 days after admission.

Image 1: MRI of the Brain
Image 2: Chest X-ray 6 days after admission. CT of the chest shows nodular infiltrates involving the right lower lobe of the lung.
Image 3: Chest X-ray 8 days after admission.
Images 4-5: CT scan of chest 6 days after admission.

What are the possible causes of this patient's pancytopenia? Given her hematologic abnormalities, what are the possible causes of her lung radiographic abnormalites?