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Washington University Experience | VASCULAR | Hemorrrhage - Subdural | 15A0 Case 15 History
Case 15 History ---- The patient was a 45 year-old man who presented to the emergency room with diffuse body aches, fever and chills. His past medical history was known to include a non-ischemic cardiomyopathy (alcohol and drug-related) with decreased ejection fraction (25%), congestive heart failure, stroke (deficit unknown and head CT negative), hepatitis C, COPD and end-stage renal failure on hemodialysis for one year. The patient presented to the ER with the above constitutional symptoms as well as worsening "light sensitivity", headache with neck pain for approximately two days. The patient also mentioned cough with shortness of breath and chest "pressure." The patient had had increasing abdominal pain for 2-3 days with nausea and vomiting of brown emesis (not classical coffee grounds), initially brown diarrhea, but changing to bright red blood or melena. The patient was treated for a suspected MI with aspirin, nitroglycerin, morphine and Lopressor. The patient received fluid and hemodialysis. WBC in serum were 17.2K and gram positive cocci (S. aureus) in clusters grew out of blood cultures later typed as S. aureus resistant to penicillin thought to be due possibly to line infection. The patient received vancomycin, ceftriaxone, and ampicillin. In the medical ICU the patient's neck, abdominal pain and guarding initially improved. More blood cultures were drawn and also turned up positive. Endocarditis was raised as a concern. Vancomycin resistant enterococcus was detected in the stool and the patient was placed on isolation. Borderline troponins were detected on 8/5. He was transferred back to MICU on 8/7 and noted to be minimally responsive. The patient required intubation around noon and ultimately was placed in CCU with hypotension and significant pulmonary edema. On August 8, he was noted to be unresponsive and was seen by Neurology service. Cortical and brainstem signs were absent (pupils were unreactive and dilated, absent corneal, cough or gag reflexes and no response to cold calorics). The etiology was uncertain although there was strong evidence of significant meningitis. The patient expired in asystole the same day. ---- At autopsy, the weight of the unfixed brain was 1380g. There was a large subdural hematoma over the right frontal and temporal lobes. The blood clot obtained from the hematoma measures 55g in weight and 8 x 5 x 3 cm in aggregate size. The leptomeninges are blood-stained with diffuse subarachnoid hemorrhage which is most prominent on the base of the brain and the area around the Circle of Willis. There is marked cerebral edema with flattened gyri and narrowed sulci. The general postmortem exam demonstrated exophytic vegetations on both leaflets of the cardiac mitral valve. Microscopic examination of the vegetations showed a diffuse layer of polymorphonuclear cells on the valve surface but no bacterial forms demonstrated with Gram stain.
