Table of Contents
Washington University Experience | VASCULAR | Hypoxia-Ischemia, fetal-neonatal | Status Marmoratus | 5A0 Case 5 History
Case 5 History ---- The patient was a 3 month old boy born at 31 4/7 weeks gestation to a 34 year old G1P0 mother with tobacco use during pregnancy. There were also prenatal concerns for chronic subchorionic hemorrhage. On 8/20, the mother presented to an OSH with a sudden gush of vaginal blood. treated with celestone for 2 days. Then on 9/3, she bled again and had a C-section. At birth, the patient had a weak cry and poor respiratory effort with retraction. He was given face mask CPAP. His HR was 107 and increased to 150. He received fluid boluses and dopamine. He was placed on a ventilator. Infasurf was administered with minimal oxygen saturation response. An echocardiogram showed a total anomalous pulmonary venous return. He underwent a surgical repair on 9/3. A chest x-ray was performed and showed complete white out of the lungs with a ground glass appearance consistent with severe RDS. Small bilateral grade 2 germinal matrix hemorrhages were found. He developed non-oliguric acute tubular necrosis. On 9/29, peritoneal dialysis was started. On 10/28, he developed a fever of 38.3oC and was started on meropenem. Between September and October, he was on cefepime and vancomycin for the possibility of necrotizing enterocolitis. On 11/13 his cannula began leaking again and he was restarted on vancomycin, cefepime, and fluconazole. Throughout his stay, the patient was dependent on the ventilator and dialysis. A chylous effusion. resulted in a chemical pleurodesis. He was also diagnosed with panhypopituitarism and replacement therapy with Decadron and levothyroxine begun. On 11/13, a subependymal hemorrhage grade 1 on the left became an IVH grade 2 bilaterally and right posterior subdural hematoma. It was thought that the patient had an absent septum pellucidum and an eye center evaluation was performed to look for septo-optic dysplasia and hypoplastic optic nerve. He was not a candidate for renal transplant and dialysis was failing. The patient expired on 12/18. ---- At autopsy, the unfixed brain weighed 310g (normal = 413 g), with grossly unremarkable external and cut surfaces. Normal appearing optic nerves, olfactory bulbs and septum pellucidum were present. Focal areas of white matter astrocytosis with extensive microcalcifications were identified. Focal areas of necrosis with neuronal drop out, microcalcifications, and macrophages were striking within the thalamus. Extensive granular ependymitis with hemosiderin laden macrophages was found in the occipital lobes with extensive microcalcifications. There was no evidence of local or systemic TORCH infections. (H&E)
