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Washington University Experience | VASCULAR | Infarct - Lacunar | 3A0 Case 3 History
Case 3 History ---- The patient was a 46-year-old man with a diagnosis of HIV infection in 2009, chronic severe hypertension (with systolic pressures of ~250), chronic kidney disease, alcoholism and smoking. An episode of questionable seizure followed by a period of confusion resulted in a workup showing a CD4 count of 122, and HIV RNA copy number of 154,000 copies/mL; the patient was non-compliant in actively taking antiretroviral medications. He was anemic, with a hemoglobin of 7.1 and hematocrit of 20.8. MRI in December 2014 showed diffuse FLAIR hyperintensity thought to represent PML (JC virus PCR was negative) as well as multiple old lacunar infarcts. Serum antibody testing for hepatitis A & B was positive, He was found to have a urinary tract infection with a urine culture positive for group B streptococci. Fungal studies were negative. The patient was discharged to home on antiretroviral and hypertensive medications as well as Keppra for his seizure activity. . Nausea, vomiting, and abdominal pain caused him to refuse taking any medication. He re-presented to BJH on late December 2014 with a hypertensive emergency (blood pressure of 240/130), nausea, retching, vomiting (without hematemesis), and abdominal pain over several days-weeks. An esophogram showed a mucosal tear or Mallory-Weiss tear. The patient was on HAART at home, but was noted to be noncompliant. Finally, in February 2015, he was brought to BJH with a 2-3-day history of general malaise, shortness of breath (CXR RLL infiltrate), and a 2-day history of chest pain, and hypoglycemia (37 mg/dL) on Feb 2, 2015. Laboratory studies showed a high serum troponin I of 1.09 ng/mL and elevated creatine kinase. Urinalysis showed proteinuria and hematuria and was positive for leukocyte esterase. The patient was started on vancomycin and azithromycin and was admitted to the Medical ICU. Within 15 minutes of arrival, however, the patient became obtunded and was intubated, followed by CPR x 2 which was ultimately unsuccessful. ---- General autopsy showed hypertrophic cardiomyopathy, chronic and acute myocardial infarcts, multiple small pulmonary emboli, a large right atrial thrombus and atherosclerosis.
