CLINICOPATHOLOGIC CASE PRESENTATION

A 22-YEAR-OLD
BRAZILIAN FEMALE
STUDENT WITH INTENSE
FATIGUE

TEAM COMPASSIONATE
AUSEJO | CA-AT | CABALLES | DEMEGILLO | MALAYAG | MANGUDADATU | PA-ALISBO | SALIPODEN
 CLINICOPATHOLOGIC CASE PRESENTATION

A 22-YEAR-OLD
BRAZILIAN FEMALE
STUDENT WITH INTENSE
FATIGUE

TEAM COMPASSIONATE
AUSEJO | CA-AT | CABALLES | DEMEGILLO | MALAYAG | MANGUDADATU | PA-ALISBO | SALIPODEN
22y/o I Female
22y/o I Female Ms. K
Brazilian
Single Student
Sao Paulo, Brazil

CHIEF COMPLAINT:
INTENSE FATIGUE
22y/o I Female Ms. K
Brazilian
Single Student
Sao Paulo, Brazil

CHIEF COMPLAINT:
INTENSE FATIGUE
 HISTORY OF PRESENT ILLNESS
CHIEF COMPLAINT:
INTENSE FATIGUE 50 days ago

Systemic Lupus
Erythematosus
Fatigue Malaise Low-grade fever

Muscle Pain Arthritis

 LABORATORY WORK UP
CHIEF COMPLAINT:
Normocytic anemia
INTENSE FATIGUE Leukopenia with lymphopenia
Hematology Elevated ESR
(+) ANA
(+) Anti dsDNA
Serology (+) IgG response to cardiolipin
Clinical Elevated
Elevated creatinine
creatinine
Chemistry
(+) Hematuria
(+) Proteinuria
Urinalysis (+) Cylindruria
 COURSE IN THE WARD
22 I Female
Hypothesis: Progressive
glomerulonephritis
DAY 1
Pulse therapy:
Methylprednisolone with
creatinine normalization

Renal biopsy was not

performed
 COURSE IN THE WARD
22 I Female
Febrile
FOLLOWING WEEKS
Blood culture: Oxacillin
sensitive Staphylococcus
aureus

Systolic murmur in the mitral

area was heard
 COURSE IN THE WARD
22 I Female Petechiae on the
conjunctivae
FOLLOWING WEEKS
Vegetation on the posterior
mitral leaflet

General status: Improved

after oxacillin administration
 COURSE IN THE WARD
22 I Female Patient developed acute
pulmonary edema, along with
intensification of the
2 WEEKS LATER
regurgitant murmur in the
mitral area

Suspected ruptured chordae

tendineae

Was transferred to cardiology

center for surgical evaluation
 COURSE IN THE WARD
Intense Fatigue
22 I Female
Afebrile

Cardiology Center Vital signs:

● BP: 100/60 mmHg
● PR: 96 bpm
● Oximetry: N at the
expense of O2
supplementation
PE findings:
● No jugular distention
● No peripheral edema
● Heart auscultation:
Loud holosystolic
murmur in the mitral
area, with axillary
irradiation
 COURSE IN THE WARD
Intense Fatigue Sparse rales on the
22 I Female pulmonary bases
Afebrile
Slightly diminished
Cardiology Center Vital signs: peripheral perfusion
● BP: 100/60 mmHg
● PR: 96 bpm Hepatomegaly
● Oximetry: N at the
expense of O2
supplementation Diagnostic exam findings:
PE findings:
● No jugular distention
Normal left ventricular
● No peripheral edema
● Heart auscultation: size and function
Loud holosystolic
murmur in the mitral Mitral valve regurgitation
area, with axillary
irradiation IV dobutamine
 ANCILLARY RESULTS

Patient Values Reference Range

Hemoglobin 8.0 g/dL 12-14 g/dL
White blood cell count 6.9 g/dL 4.4-11.3 x 103/mm3
Platelet count 194/mm3 150-400 x 103/mm3
Creatinine 1.3 mg/dL 0.4-1.3 mg/dL

Normal electrolytes
 x
CARDIAC ARREST
Differenti
al
Diagnoses
Differenti
al
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis

AUTOIMMUNE
 Myocarditis
RULE IN RULE OUT
(+) fatigue
(+) fever The myocardium is
(+) ST wave changes affected (affected
(+) inflammatory structures of the px are
biomarkers valves and chordae
(+) rales and wheezes tendineae– located in
(+) hepatomegaly the endocardium
(+) pulmonary edema
(+) mitral/tricuspid
regurgitation
(+) hypotension
 Myocarditis
RULE IN RULE OUT
(+) fatigue
(+) fever

O UT The myocardium is

ED
(+) ST wave changes affected (affected

RUL
(+) inflammatory
biomarkers
(+) rales and wheezes
structures of the px are
valves and chordae
tendineae– located in
(+) hepatomegaly the endocardium
(+) pulmonary edema
(+) mitral/tricuspid
regurgitation
(+) hypotension
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis Iron deficiency

anemia

AUTOIMMUNE
 Iron Deficiency Anemia
RULE IN RULE OUT

(+) fatigue IDA is a microcytic

(+) low hemoglobin hypochromic anemia
(patient presents with
normocytic anemia)
No dizziness nor
lightheadedness
No cravings of non
nutritional objects (pica)
 Iron Deficiency Anemia
RULE IN RULE OUT

(+) fatigue

O UTIDA is a microcytic

ED
(+) low hemoglobin hypochromic anemia

RUL (patient presents with

normocytic anemia)
No dizziness nor
lightheadedness
No cravings of non
nutritional objects (pica)
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis Iron deficiency

anemia

AUTOIMMUNE

SLE nephritis
 SLE Nephritis
RULE IN RULE OUT

(+) proteinuria No reason to rule out

(+) hematuria
(+) cylindruria
(+) elevated creatinine
(+) history of steroid
intake (nephrotoxic)
 SLE Nephritis
RULE IN RULE OUT

(+) proteinuria No reason to rule out

(+) hematuria
(+) cylindruria
(+) elevated creatinine
(+) history of steroid
intake (nephrotoxic)
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis Iron deficiency Cytomegalovirus

anemia

AUTOIMMUNE

SLE nephritis
 Cytomegalovirus
RULE IN RULE OUT

(+) fatigue No jaundice

(+) low-grade fever No splenomegaly
(+) leukopenia
(+) muscle pain
(+) hepatomegaly
(+) fatigue
(+) low hemoglobin
 Cytomegalovirus
RULE IN RULE OUT

(+) fatigue

O UT No jaundice

ED
(+) low-grade fever No splenomegaly

L
(+) leukopenia

RU
(+) muscle pain
(+) hepatomegaly
(+) fatigue
(+) low hemoglobin
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis Iron deficiency Cytomegalovirus

anemia
Rheumatic
AUTOIMMUNE Fever
SLE nephritis
 Rheumatic Fever
RULE IN RULE OUT

(+) intense fatigue No history of

(+) valvular pharyngitis
abnormality Usually caused by S.
(+) fever pyogenes
(+) arthritis Did not meet the
(+) mitral valve Jones Criteria for RF
vegetations and
regurgitation
(+) ESR
 Rheumatic Fever
RULE IN RULE OUT

(+) intense fatigue

O UT No history of

ED
(+) valvular pharyngitis

L
abnormality Usually caused by S.

RU
(+) fever
(+) arthritis
(+) mitral valve
pyogenes
Did not meet the
Jones Criteria for RF
vegetations and
regurgitation
(+) ESR
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis Iron deficiency Cytomegalovirus

anemia
Rheumatic
AUTOIMMUNE Fever
SLE nephritis
Severe sepsis
 Severe Sepsis
RULE IN RULE OUT

(+) fatigue No evidence of

(+) fever multiorgan dysfunction
(+) hypotension No leukocytosis
(+) hypoperfusion
(+) proteinuria
 Severe Sepsis
RULE IN RULE OUT

(+) fatigue

O UT No evidence of

ED
(+) fever multiorgan dysfunction

L
(+) hypotension No leukocytosis

RU
(+) hypoperfusion
(+) proteinuria
 DIFFERENTIAL DIAGNOSIS
CC: INTENSE FATIGUE

CARDIAC HEMATOLOGIC INFECTION

Myocarditis Iron deficiency Cytomegalovirus

anemia
Rheumatic
AUTOIMMUNE Fever

SLE nephritis Severe sepsis

IE
 Infective Endocarditis
RULE IN RULE OUT

(+) fatigue No reason to rule out

(+) malaise
(+) mitral valve
vegetations and
regurgitation
(+) has met the Duke
criteria for IE
 Infective Endocarditis
RULE IN RULE OUT

(+) fatigue No reason to rule out

(+) malaise
(+) mitral valve
vegetations and
regurgitation
(+) has met the Duke
criteria for IE
 Infective Endocarditis

IE is a microbial infection of the heart valves or the

mural endocardium that leads to the formation of
vegetation composed of thrombotic debris and
organisms, often associated with the destruction of
the underlying cardiac tissues.
 PATHOGENESIS

PROSTHETIC HEART VALVES HACEK RHEUMATIC HEART DISEASE

Infective Endocarditis

DENTAL PROCEDURES ANTIBIOTIC THERAPY

CONGENITAL DEFECT MITRAL VALVE PROLAPSE

PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
 FINAL DIAGNOSIS

Acute decompensated heart

failure secondary to severe
Immediate Cause
mitral valve insufficiency and
ruptured chordae tendineae

Antecedent Cause Infective endocarditis

Underlying Cause SLE in disease activity

 COMPASSIONATE

Thank
For Your Attention

You
AUSEJO | CA-AT | CABALLES | DEMEGILLO | MALAYAG
| MANGUDADATU | PA-ALISBO | SALIPODEN
 COMPASSIONATE

Thank
For Your Attention

You
AUSEJO | CA-AT | CABALLES | DEMEGILLO | MALAYAG
| MANGUDADATU | PA-ALISBO | SALIPODEN