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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Fat Embolism | 4A0 Case 4 History
Case 4 History ---- The patient was a 77 year old woman who presented with changed mental status, acute renal failure, thrombocytopenia, anion gap acidosis, urinary tract infection, and severe abdominal pain. Subsequent evaluation revealed a urinary tract infection, meningitis, and acute cholecystitis. The patient also had positive rapidly increasing troponins, lactic acidosis, and worsening renal function. An EKG revealed poor LV function, severe mitral and tricuspid regurgitation, pulmonary hypertension and bilateral atrial enlargement. Her hematocrit and coagulation studies stabilized after receiving transfusions of blood, platelets, FFP, and vitamin K. The patient's pertinent past medical history included coronary artery disease status-post CABG, peripheral vascular disease status-post abdominal aortic aneurysm repair, bilateral carotid endarterectomies, stroke, and hypertension. She did smoke but did not drink alcohol. Her exposure history was significant for being bitten by a cat several days prior to her admission, but blood cultures were negative. She was initially awake and alert x2-3. Cranial nerves were grossly intact. She had moderate generalized weakness and symmetric reflexes. The patient continued to have neurologic deterioration in the hospital in addition to hemodynamic instability. Further evaluation included a CT of the head which revealed old bilateral occipital infarcts and lacunar infarcts in the right cerebellum and basal ganglia. CSF studies revealed 14 red blood cells and 144 nucleated cells (75% neutrophils). CSF glucose was 112 and protein 166. The spinal fluid was xanthochromic. An EEG was performed, revealing continuous seizure activity (status epilepticus). She was treated with multiple antibiotics and anticonvulsants. The patient continued to do poorly and was noted to be unresponsive with equally round and reactive pupils, present corneal and oculocephalic reflexes. She was breathing with a Cheyne-Stokes respiratory pattern. She moved her lower extremities to stimulus, but more on the right side. She had myoclonus. Her toes moved down on the right and up on the left to plantar stimulation. No organism was identified on CSF or blood cultures. An MRI study performed revealed old infarctions in the right occipital, left occipital, and medial temporal lobes. There was also an occlusion of the right internal carotid. One day later the patient became pulseless, without spontaneous breathing. Her pupils were fixed and dilated without light response and she was declared dead. ---- General autopsy examination showed fat embolism in the lung and kidney. In addition, there was evidence of acute pancreatitis and fat necrosis in the adjacent mesentery around the pancreas. Therefore, the most likely cause of cerebral fat embolism in this case is pancreatitis.
