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Morbidity and Mortality

Conference

Gil G. Fareau

May 29, 2002A# 50084135-8

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57 year old woman presented to another ER

with nausea, vomiting, and headache

Nausea, vomiting, and diarrhea for 6 days.

New headache associated with feeling off

balance for 2 days.

No fevers, chills, SOB, chest/abdominal

pain, or urinary symptoms. No other

neurological symptoms

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Past History Cirrhosis

Hepatitis C Hepatic Encephalopathy

Type II Diabetes

Peripheral Neuropathy

GERD, PUD Arthritis

+ANA

Fibromyalgia

Bells Palsy

Chronic right facial palsy

Restless Leg Syndrome

Anemia of ChronicDisease

Medications Glipizide 20mg qd

Carbi/Levodopa

25/100mg qd

Lansoprazole 30 mg qd

Furosemide 40mg bid

Neomycin 500mg bid

Potassium Chloride

40meq bid

Spironolactone 50mg bid

Lactulose 20g bid

Insulin 70/30 25 units bid

Multivitamin qd

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Physical Exam

gen: uncomfortable, pale

vitals: T: 37.7, BP: 140/57, P: 98, RR: 18

heent: + right facial droop, + dry mucus membranes

neck: + tender right strap muscles, supple, no LAD cvs: rrr, + II/VI systolic murmur

resp: clear to auscultation bilaterally

abd: soft, +diffuse mild tenderness, no masses

ext: no cyanosis, edema

cns: A&Ox3, PERRLA, non-focal

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Labs:

10.8 130 93 24 LFTs: normal

7.6 103 5.0 17.8 1.0

31.5

Assessment:Viral gastroenteritis, musculoskeletal headache

Plan:

- Admit to hospital

- IV fluids to rehydrate

- Meperidine for headache pain, diazepam for muscle relaxation

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Outside Hospital Day 2:

- Felt improved with no nausea or vomiting and less headache.

Outside Hospital Day 3:

- Minimal headache and deemed fit for discharge.

Two days after discharge:

- Worsening headache, confusion, blurred vision, and recurrent

problems with balance.

- Exam notable for asterixis, reduced coordination, and poor

balance.

- Ammonia level of 37, other labs unchanged.

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Head CT: C/W old infarction, no masses or hematomas.

Assessment/Plan:

- Hepatic encephalopathy secondary to hyponatremia and recent

narcotic use. Persistent musculoskeletal headache.

- Meperidine and diazepam for headache, IV normal saline to correct

her hyponatremia, and ophthamology consult.

Outside Hospital Day 2:

-Fever of 38.9

-Decreased visual acuity (right>left), reviewed by ophthamology

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Lumbar Puncture:

WBC: 297 (54% N, 36% L, 10% M)RBC: 7

Protein: 204

Glucose: 3

-Blood cultures taken

-Cefotaxime 2g IV q4h

-Acyclovir 500mg IV q8h

-Vancomycin 500mg IV q6h

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Outside Hospital Day 3

Progressively worsening vision

Persistent Confusion

Cryptococcal antigen sent, returns positive with

titre of 1:1000

Arrangements made for transfer to

Dartmouth-Hitchcock Medical Center

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Physical Exam at DHMC

gen: lethargic, conversant on waking, difficulty with wordfinding

vitals: temp: 38.2, BP: 120/57, P: 90, RR:20, 97%RA

heent: oropharynx clear, fundi normal

neck: +neck stiffness with pain on flexion

ext: + asterixis, no clubbing/cyanosis/edema

cns: alert and oriented x 2; vision limited to movement;

right VII nerve palsy; tone, power, reflexes and sensationintact; downgoing plantars, finger to nose testing limited by

vision.

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Labs:

10.7 133 99 12 Ca++: 8.8 PT: 15.3

9.0 128 4.5 23 1.0 Mg++: 0.59 INR: 1.3

30.1 Phos: 33 PTT: 30

Ammonia level: 21

Urinalysis: normal

Lumbar Puncture:Opening pressure=250

WBC:293 (11% N, 85% L), RBC: 3

Total Protein: 236, Glucose: 5

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Summary

57 year old woman

Known diabetes, cirrhosis, anemia

N/V, Headache, Visual loss, Confusion

LP: High WBC, Low Glucose,

Positive Cryptococcal Antigen

Admit to Infectious Disease Service

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Problem List

Cryptococcal Meningitis

Amphotericin 60mg IV qd

Flucytosine 2grams PO q6h

MRI Brain HIV test

Neurology Consult

Hepatic Cirrhosis

Follow LFTs

Continue Lactulose

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Problem List

Diabetes Mellitus Diabetic diet

Insulin sliding scale

Anemia Follow CBCs

Erythropoietin 40,000 u SQ qweek

Disposition Poor prognosis given comorbid illnesses, low CSF

glucose, and poor mental status prior to treatment.

Living will

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Hospital Course: Days 2-3 Resolution of her headache

Improvement in vision (could discern motionless hand)

Mild abdominal discomfort and axterixis

HIV test negative. Cryptococcal Ag in CSF (1:128)

* Neurology consult: advised stopping sinemet,

minimizing narcotics, consider vasculitic process if no

improvement with tx.

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MRI Flare Images

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Diffusion Images

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Enhanced Images

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Hospital Course: Days 4-6

Confusion and speech subjectively improved Vision improving otherwise exam unchanged

Labs:

Creatinine: 1.9 -> 2.2 -> 2.3

Plan:

Cautious optimism with clinical improvement

Change to liposomal amphotericin

Reduce flucytosine dose to 2grams po q12h

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Hospital Course: Days 7-10

Not taking lactulose (causes gagging, vomiting)

Reduced bowel movements

PE:

Vital Signs stable

Somnolent, confused

Distended, tender, tympanitic abdomen with reduced bowelsounds.

+ Asterixis

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Hospital Course: Days 7-10

Labs:Hgb: 10.3 9.6 8.5

Plts: 150 145 136

PT: 18.2, INR: 1.8, PTT: 30 Haptoglobin: 115

TT: 19, Fibr: 275, Dimer: 8330

RTC: 0.8, RTA: 21, RTI: 0.4

Ammonia: 74 76 102

Imaging: abdominal plain film

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Abdominal Series

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Hospital Course: Days 7-10

GI

Ileus

Hepatic Encephalopathy Dobhoff tube +/- enemas for lactulose delivery

Neomycin 500mg BID

Abdominal US

Heme

Anemia, thrombocytopenia Check flucytosine level

Transfuse 2 units RBC

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Hospital Course: Days 11-12

Agitated overnight, received risperidone

PE:

Increased confusion and drowsiness

Tachycardic, tachypneic, +abdominal distension and tenderness.

Lab:140 116 30 145 122 26 ABG: 7.40 19 102 11.4

3.7 11 1.6 3.7 9 1.6

Urine: pH: 5.0, Na: 111, K: 29, Cl: 122, Osm: 375

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Hospital Course: Days 11-12

Labs (Continued):

Flucytosine level: 226 (toxic > 100)

Lumbar Puncture:

OP: 270 CP: 190

WBC: 387 (98% lymphocytes, 2% neutrophils)

RBC: 855, Tot. Prot: 140, Glucose: 79

Cryptococcal Ag. positive (1:2), India Ink Stain negative

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Hospital Course: Days 11-12

Meningitis CSF inflammation

Toxic flucytosine level

D/C flucytosine

Continue amphotericin

Metabolic Acidosis

Type I RTA Due to Amphotericin

Replete HCO3

R/O other infections

Encephalopathy Hepatic v. meningits v.

risperidone

Increase lactulose

Disposition

Patient made DNR perfamily wishes.

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Hospital Course: Days 13-14

PE:

Worsening somnolence

Tachycardic

Tender abdomen

Labs:

8.8 150 118 35

13.0 81 3.1 18 2.6

25.8

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Hospital Course: Days 13-14

Imaging: Repeat abdominal ultrasound

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Abdominal Ultrasound

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Hospital Course: Days 13-14

Imaging: Repeat abdominal ultrasound

A/P:

Meningitis: d/c amphotericin, start fluconazole

Hepatic Encephalopathy: increase lactulose, lactulose enemas

Abdominal Pain: ? Flucytosine toxicity

FEK: worsening renal function

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Hospital Course: Days 15-16

Low urine output with intermittent hypotensive episodes Deeply somnolent and unresponsive

Abdomen distended, with hypoactive bowel sounds

Labs:

WBC:12.4, Hgb:8.9, Plt:86

BUN:61, Cr:5.3

Family Meeting:

Patient made CMO as per her living will

Continuous hydromorphone infusion started

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Hospital Day 17

The patient was found unresponsive

She was pronounced dead at 10:00am

An autopsy was granted by the family

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Cirrhosis

Trichrome stain H&E stain

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Portal vein thrombus

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Cryptococcal meningitis

H&E stain GMS stain

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Cryptococcal encephalitis

H&E stain GMS stain

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I. Cryptococcal meningitisA. Cryptococcal encephalitis

II. Hepatitis C

A.Cirrhosis

1.Ascites

2.Ileus

3.Portal vein thrombosis

4.Esophageal varices

5.Hepatic encephlopathy

6.Spenomegaly

7.Clinical history of thrombocytopenia

III. Diffuse alveolar damageIV. Incidental findings

A.Gastric ulcer

B.Chronic cholecystitis and cholelithiasis

C.Right ovarian cystic corpus albicans

Final Pathologic Diagnosis