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Washington University Experience | NEOPLASMS (METASTASES) | Melanoma | 1A0 Case 1 History
Case 1 History ---- The patient was a 43 year old male with HIV documented by a positive serology and hypertension of at least 20 years duration. The patient was in apparent good health until 5-7 days prior to admission when he had onset of weakness, falling to one side, and subsequent confusion. On 6/11 he developed multiple neurologic deficits. The patient was a smoker with a 25 pack year history, had a history of extensive alcohol ingestion and reported using shared intravenous needles. A head CT scan at admission showed a 4x3x3 cm intracranial hemorrhage and two smaller lesions, as well as a lesion in the skull itself. A bronchioalveolar lavage was negative for organisms, as were blood cultures. Serologies for multiple organisms were negative. The underlying etiology of the intracranial bleed was still unidentified, but given the relatively high CD4 count (200-300), it was thought unlikely to be lymphoma or infection, and most likely to be due to hypertension and crack cocaine use, complicated by a coagulopathy from liver disease secondary to chronic ethanol ingestion. The patient's mental status had decreased; he was unable to follow with gaze, had uncertain volitional grasp to command with the right hand and was intermittently positive for Babinski response. The patient continued to run low fevers, and one blood culture bottle grew Staph epidermidis, for which he received Vancomycin. The patient showed steadily rising LFTs and serum creatinine. An MRI of the head on 6/18 showed extension of the right basal ganglia hemorrhage with intraventricular hemorrhage and four other lesions, including a left frontal parafalcine and right occipital cortical lesion. The patient was thrombocytopenic (80-100K), thought possibly due to ethanol or myeloma or other malignancy. A bone marrow aspirate was obtained on 6/19 and showed extensive involvement by metastatic melanoma. By 6/21 the patient was without response to voice or simple command. Because of the extremely poor prognosis, after consultation with the family, the patient was given a "do not resuscitate" status and died shortly thereafter.
