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Washington University Experience | METABOLIC | Alcoholism - Overview | Marchiafava-Bignami Disease | 2A0 Case 2 History
Case 2 History (CANP unknowns 2004, Case 3) ---- This 58 year old man had been on dialysis for chronic renal failure, thought to be due to diabetic nephropathy and hypertension, although he had been a type II diabetic for only five years. Hypertension was controlled (BP 140/80 on admission) and other values included BUN 87, creatinine 11.4 and glucose 153. He underwent dialysis several times and was discharged a week later. He was readmitted six weeks later with increasing confusion and paranoia. BP at that time was 200/105. Urine toxicology was positive for cocaine. He was admitted to ICU with a diagnosis of hypertensive encephalopathy. With dialysis and control of BP, his condition improved. A psychiatric consultant noted a history of cocaine and alcohol abuse. He was then admitted to the psychiatric hospital for evaluation of dementia. He was disorganized, disoriented and agitated, and unable to complete a mental status examination. Ativan had been given IV during dialysis; it was determined later that the medication worsened his symptoms. The psychiatric staff considered Korsakoff psychosis syndrome because of his confabulation. Later, increasing delirium was attributed to septicemia, and he was transferred back to the general medical service with a diagnosis of dementia probably secondary to alcohol and cerebrovascular disease with lacunar infarct of thalamus, hypertension, end-stage renal disease and type II diabetes. On admission to the medical ICU, he was febrile (102oF) and severely encephalopathic, non-verbal without spontaneous eye opening and responding only to pain. Culture of the catheter tip grew Staph. aureus. CSF: RBC 3, WBC 1; protein 45, glucose 66; negative Gram stain and culture. MRI showed striking abnormalities in the white matter, involving the middle cerebellar peduncles, corpus callosum and subcortical white matter. Lesions were hyperintense on T2 and FLAIR and diffusion positive. Neurological evaluation failed to establish a definitive diagnosis. Supportive therapy, including antibiotics, failed to improve his condition, and he died a week later. Autopsy was limited to the brain. No distinct gross abnormalities were visible, aside from a suggestion of softening of the middle cerebellar peduncles. H&E stained slide taken from cerebellar peduncle which is representative of the bilateral peduncular, corpus callosum and deep white matter lesions. (Thanks to Drs. Chris Dunham and Rob Hammond for the history)
