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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Fat Embolism | 1A0 Case 1 History
Case 1 History ---- The decedent was a 72 year old woman who was admitted to Barnes-Jewish Hospital after being found locked in her bathroom with altered mental status, hypotension and acute renal failure. Past medical history included hypertension, chronic dementia, and hyperthyroidism status-post radioablation in 2009. On 6/28, she was found down and locked in her bathroom for an unknown amount of time and was brought to the ED. She was initially found to be hypotensive (systolic blood pressure in the 80s), hypernatremic (Na = 159), and to have elevated troponins. She was also thrombocytopenic (platelet count=92K) and had an elevated white blood cell count (WBC=16.1). EEG impression was of a non-ST segment elevation myocardial infarction (N-STEMI). CT showed no acute intracranial abnormality. Chest roentgenogram showed clear lungs with no findings suggestive of pneumonia, pleural edema, pleural effusion, or pneumothorax. She had acute renal failure which responded to intravenous fluids. Elevated cardiac enzymes were thought to be secondary to either a pulmonary embolus or hypotension with unclear down time. Her troponins peaked on 6/29 and were trending down on 6/30. Lower extremity Doppler ultrasound showed no evidence of deep vein thrombosis. From 6/30 to 7/1, the patient's condition worsened; she became tachypneic and hypoxic, requiring increasing oxygen supplementation, and showed mental status changes. A ventilation-perfusion (V/Q) scan showed low probability for pulmonary embolus but with reverse mismatch in the lower left lobe which was interpreted as atelectasis vs. infiltrate. Repeat head CT on 7/1 showed two new punctate foci of increased attenuation in the right cerebral hemisphere, most consistent with microhemorrhages. Multiple antibiotics were administered for presumptive infection. On 7/1, the patient had an episode of supraventricular tachycardia and was cardioverted with adenosine and transferred to the critical care service and her antibiotic coverage was broadened. Soon after transfer, she required intubation for increased work of breathing and inability to protect her airway. The patient coded shortly thereafter. Despite resuscitation efforts, she expired on 7/2. ---- Neuropathology: The patient had evidence of Alzheimer Neuropathologic Change, intermediate and modest amyloid angiopathy.
