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Washington University Experience | VASCULAR | Cardiac Arrest Encephalopathy | 1A0 Case 1 History
Case 1 History ---- The patient was a 56-year-old woman with a history of type 2 diabetes mellitus, hypertension, hepatorenal syndrome, hepatitis C, alcoholic cirrhosis, ascites, and end-stage liver disease with subsequent transjugular intrahepatic portosystemic shunt placement (TIPS) on 5/24. Following TIPS placement she had ~8 hospital admissions with the majority for altered mental status secondary to hepatic encephalopathy, and additional admissions for anasarca, and hypoglycemia. During these hospitalizations she had elevated ammonia concentrations, and underwent multiple adjustments in her lactulose doses (among other medical therapies). Multiple head CTs that demonstrated a well marginated low density lesion in the left basal ganglia thought to represent an old infarct. The patient was re-admitted on 10/24 for altered mental status and underwent orthotopic liver transplantation on 11/8. She was transferred on 11/17 to a rehabilitation center and, doing well, to home on 12/8. The patient had done well following discharge from rehabilitation. She was admitted on 12/27 secondary to abdominal pain and shortness of breath with a one week history of a runny nose, fevers, chills, productive cough, and wheezing. During her hospital course, she had repeated pleural effusions and multiple thoracenteses. Liver biopsy on 1/11 showed no features of acute cellular rejection but did show features of recurrent HCV. She was admitted to the surgical ICU on 1/12 following an episode of acute respiratory distress requiring mechanical ventilation and remained on ventilatory support for much of her hospital course. Chest CT showed large bilateral pleural effusions, multiple mucus plugs, complete collapse of the right middle, right lower, and left upper lobes, moderate severe collapse of the left lower lobe, and a rounded pleural based infiltrate in the right upper lobe. Bronchoscopy to re-expand her lungs was performed. Microbial studies showed the presence of bacteremia with growth of a highly resistant strain of E. coli (suspected ESBL producer) and Enterococcus faecium. Bronchial washings grew Klebsiella oxytoca and Aspergillus. During her hospitalization, she was treated with multiple antibiotics, including meropenem. linezolid, and micafungin. She also developed renal failure and CVVHD was initiated on 1/27. She was transferred out of the SICU into an observation unit on 2/3. However, on 2/14 the patient was found in PEA, was resuscitated, and was transferred back into the SICU. On arrival she was obtunded with fixed pupils, had no spontaneous movements, and intermittently would over-breathe the ventilator. Her neurological status did not improve and MRI of the brain on 2/18 showed findings indicative of diffuse global anoxic brain injury and suspected focal infarction within the right thalamus. After discussions between health care teams and family members, the patient was subsequently extubated and passed away on 2/24. ---- At autopsy, the weight of the unfixed brain was 1100g. There was widespread, predominantly subacute, diffuse hypoxic-ischemic injury involving cortex, white matter, deep gray matter, brainstem and spinal cord. Subacute infarcts involved right thalamus, midbrain, pons, medulla and the anterior horns of the spinal cord. Alzheimer type II astrocytes were numerous in the basal ganglia. The histological picture is somewhat variable and predominantly suggests a subacute time course with the patient's history of pulseless electrical activity (PEA) and resuscitation approximately 10 days prior to death.
