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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Central Pontine Myelinolysis (CPM) | 7A0 Case 7 History
Case 7 CPM ---- The patient was a 46 year old female with HIV/AIDS who expired from multiple complications of that disease. She was admitted in December 1998 with a 3-4 day history of nausea, vomiting, anorexia, diarrhea, and abdominal pain. She had shortness of breath, dyspnea on exertion, cough with whitish then green sputum, and fever with chills. On admission she was noted to have thrombocytopenia and evidence of hepatic dysfunction with elevated total bilirubin, but normal transaminases. She had an icteric appearance and bilirubin in her urine. Her serum sodium was 124 on admission. She was noted to be tachypneic, febrile with hepato-splenomegaly, and multiple palpable lymph nodes. She was anemic with her most recent CD4 count prior to admission of 200. She also had evidence of pancreatitis. She had cryptosporidium oocysts in her stool and Strep viridans that grew from bile that was obtained when a cholecystotomy was placed for her cholangitis and acalcular cholecystitis. She was treated with broad spectrum antibiotics throughout her course. She had evidence of hepatitis infection with serologies positive for Hepatitis B core, Hepatitis C, Hepatitis A IgG, and IgM. She was diagnosed with pan-cytopenia and bone marrow showed hypercellular marrow with tri linear hematopoiesis, reactive plasmocytosis, and leukocytosis. In the work-up of her hepatitis and cholangitis she had a liver biopsy which showed mixed portal tract inflammation with acute pericholangitis, mild cholestasis, and early fibrosis. In a work-up of lymphadenopathy she had a lymph node excision which on pathologic examination showed cortical lymphoid depletion, fibrocytosis and vascular transformation. Multiple chest radiographs showed pulmonary edema with diffuse interstitial infiltrates. Work-up also included thoracentesis which showed no evidence of infectious agents or malignancy. Abdominal paracentesis did not reveal evidence of infection or malignancy. She was on triple coverage with DDI, 3TC, and Sucteva; she received Neupogen and Ethogen biweekly. From a neurologic standpoint, she was described as having waxing and waning mental status at times. A suboptimal MRI of the brain was done early in the admission which failed to show abnormal areas of enhancement or masses. After roughly three weeks of hospitalization, her vital signs started to deteriorate, the decision was made to make her 'do not resuscitate' status and she was switched to comfort measures only and expired in mid-January 1999.
