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Washington University Experience | VASCULAR | Hypoxia-Ischemia, fetal-neonatal | Porencephaly | 12A0 Case 12 History
Case 12 History ---- The patient was a 20 year old man with a past medical history significant for choroid plexus carcinoma diagnosed at four months of age by biopsy and subsequent resection. He was treated with intensive chemotherapy for 72 months without radiation therapy in 1991. This was complicated by secondary panhypopituitarism, sensorineural hearing loss, and acute lymphoblastic leukemia (ALL) diagnosed in 2001. The patient was initially treated with vincristine, prednisone, daunomycin and L-asparaginase and went into remission. He then underwent consolidation therapy and did well until December of 2002. At that time, he developed recurrent disease; circulating blasts were noted on his peripheral smear. He was treated with additional chemotherapy (ifosphamide and VP16) and subsequently underwent a 6/6 matched unrelated donor bone marrow transplant in March of 2003. He developed graft-versus-host disease (GVHD) of the skin in May of 2003 and had a testicular relapse in June of 2003. His testicular relapse was treated with radiation and chemotherapy with resultant testicular failure. On 8/1/2010, he presented to Barnes Jewish West County Hospital after experiencing 4 days of nausea, coffee ground emesis, profuse diarrhea that appeared melanotic and bloody, and suprapubic abdominal pain. His initial evaluation showed a low systolic blood pressure (76 mmHg by ultrasound) and he was treated with 1L of normal saline (NS) bolus, ertapenem, and transferred to the SLCH ED. He had a stormy course with hypotension, mental status deteriorated and he became unresponsive. Aggressive fluid rehydration continued with an additional 8L NS, but his blood pressure continued to drop and he had tachycardia of 130-140 bpm. Abdominal CT showed colitis (infectious vs. ischemic vs. less likely GVHD), ascites, and lymphadenopathy (reactive versus cancer recurrence). Surgery was consulted and exploratory laparotomy showed ascites (7.5 L drained) and patchy ischemic-appearing changes in the small bowel. He became severely oliguric and renal ultrasound showed decreased vascular flow in the right kidney and nearly absent flow in the left kidney. Despite escalation of therapy with epinephrine, norepinephrine, dopamine, and stress dose steroids, the patient had refractory shock, resulting in bradycardia and cardiac arrest. Shortly prior to his cardiac arrest, he was made DNR status as requested by family. The patient passed away in the company of his family.
