אבחנה מבדלת

1. Patient: 71 years old male, married with 3 children, lives in Taibe (has cats
and roosters at home)
PMH: IHD, HFmrEF, Atrial Fibrillation, Dyslipidemia, COPD, MDS, s/p EVAR
Habits: Heavy smoker, no alcohol or substance abuse.
Medications: Butrans, Cardiloc, Escitalopram, Fusid, Litorva, Losec, Lyrica,
Pradaxa, Ramipril, Trixeo
Recent hospitalizations:
December 2024 – Acute kidney failure
November 2024 – Pneumonia
October 2024 – Rhinovirus

2. 12/1/25 – TEE for evaluation of mitral valve: Severe MR due to rheumatic
heart disease.
15/1/25 – Admitted to medicine due to syncope and general deterioration.
Vital: BP – 100/80mmHg, HR – 100/min, S-O2 – 94%
Laboratory: WBC normal, Bipenia similar to previous tests,
INR=2.16,
Tot. Bil.=2.6mg/dl, Cr=2.2mg/dl, CRP=6mg/dl
EKG: Atrial flutter 100/min
Head CT: No acute finding.
During hospital stay patient is deteriorating (mostly neurologically).
At the 6th
day he had massive aspiration (after NG tube
insertion) and intubation was performed.

3. Labs During Hospital Stay:
CBC – Stable
CMP – Na, K: Stable
Cr: 2.5mg/dl  3.8mg/dl
LFT: AST – 230 U/L  1,226 U/L  360 U/L
ALT – 268 U/L  793 U/L  599 U/L
Total Bilirubin – 3mgdl  2.16mg/dl
CRP – 6.2mg/dl  2.7mg/dl
Coagulation – INR: 2.16  3.35
Fibrinogen (measured): 209  116
VBG – Lactate: 16mg/dl  50mg/dl  35mg/dl

4. Labs During Hospital Stay:
Microbiology – Respiratory Viruses: Negative
HIV: Negative
HAV: IgM & IgG Negative
HCV: Negative
HBV: Negative (only HBs Ag)
EBV: Past Infection
CMV: Positive for IgM & IgG
Q-Fever: IgM & IgG Negative
Cultures (urine & blood): Negative
Blood Smear - >1% Schistocytes
Ammonia - Normal

5. Imaging During Hospital Stay:
Head CT (14/1) – No acute intra-cranial findings
Abdominal US (16/1) – No acute intra-abdominal finding.
Abdominal CTA (18/1) – No acute intra-abdominal finding, bilateral pleural
effusions.
Echocardiography (19/1) – Severe MR d/t rheumatic disease, moderate TR,
moderate-severe pulmonary HTN.
Chest CT (20/1) – Large bilateral pleural effusions, GGO opacities in the upper
portion of both lungs.
Head CT (20/1) – No acute intra-cranial finding.

6. Discussion:
Autoimmune: Encephalitis, Acute Liver Failure
Infectious: CMV (PCR was sent), Rickettsia, Meningoencephalitis, Parvovirus
Degenerative: Carotid dissection during TEE, TTP / HUS, Cardiac Forward
Failure
Malignancy – Nothing was foudn
Metabolic: Myxedema Coma (normal TSH in 16/12/24), Vitamin B-12
Deficiency (high values in 16/12/24)
Drugs: Any illicit drug