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Washington University Experience | NEURODEGENERATION | Alzheimer Disease | Synaptic Pathology | 1A0 Case 1 History
Case 1 History The patient was a 90-year-old female who had recently developed a neurological illness characterized by a rapidly progressive, profound dementia, thought initially secondary to meningitis and treated empirically with vancomycin, ceftriaxone and ampicillin. However, CSF revealed negative cultures and no clear etiology for her progressive dementia was determined. The patient underwent significant workup by the Neurology Service during that hospitalization, and eventually a trial of steroids for possible cerebral vasculitis did lead to some improvement in the patient's condition. However, she was unable to be nourished adequately by mouth and, as a result, a G-tube was placed. The patient was discharged to an extended care facility and subsequently experienced a fall at the extended care facility leading to G-tube dislodgement, and she was seen again in BJH ER. A CT examination of the abdomen revealed pneumoperitoneum along with some free fluid, as well as dislodgement of the G-tube, consistent with peritonitis. The patient was started on IV Zosyn and Diflucan and subsequently was admitted to the hospital. The patient was continued on intravenous antibiotics. Her initial creatinine level of 1.31 however began to rise reaching a peak of 3.36. The patient's vancomycin went from scheduled doses to random dosing and vancomycin levels per initial Gram's stains also revealed evidence of possible yeast in the abdomen. Despite continuing intravenous Zosyn, random dose vancomycin and intravenous fluconazole, the patient's condition continued to worsen as her renal failure lead to oliguria. The Division of Infectious Disease was consulted and recommended her antibiotics be changed to meropenem and anidulafungin for the patient's fungal and bacterial peritonitis. However, she became completely anuric and began to develop volume overload. Her condition was discussed with the patient's sister who agreed that she would not want hemodialysis nor transfer to an intensive care unit given the low probability of meaningful recovery. Given these wishes, her antibiotics were changed to meropenem and anidulafungin but otherwise pressors were not initiated when she began to develop hypotension. Subsequently, her respiration that had become shallow and labored earlier in the evening, ceased. --- At autopsy the weight of the unfixed brain was 1050g and cerebral atrophy appeared moderately severe. Part of the specimen was tested and found negative for prion protein at the Prion Surveillance Center to rule out a clinical suspicion of Creutzfeldt-Jakob disease.
