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Washington University Experience | VASCULAR | Infarct - Lacunar | 7A0 Case 7 History
Case 7 History ---- The patient was a 45 year-old man with a history of Type 2 diabetes, hepatitis C, hypertension, cerebrovascular accident, polysubstance abuse (cocaine, heroin, marijuana), gunshot wound x 2, chronic kidney disease, and diastolic cardiac dysfunction. He was admitted to BJH on February 1st of 2011 after being found agitated and confused in a pool of vomit and urine. Initial findings/studies included: BP=255/142 mmHg, Glucose=653 mg/dL, HgbA1C=11.5%, BUN=31 mg/dL, Cre=3.64 mg/dL, Urine drug screen was positive for cocaine metabolites, Troponin I<0.07 ng/mL, CK=1869 IU/L, and CK-MB=11 ng/mL. While in the MICU the patient had aphasia and a left-sided facial droop. Head CT showed cerebral atrophy, chronic small vessel ischemic changes, and multiple unchanged lacunar infarcts involving the right centrum semiovale and right thalamus; however, no acute intracranial pathology was seen. The patient had seizures treated with intravenous Ativan, Dilantin, and was intubated with seizure resolution. MRI (2/4) showed multiple lacunar infarcts within the basal ganglia, thalami, and pons. There were also multiple foci of hemosiderin deposition in the left brachium pontis, thalami, and left cerebellum. No areas of acute infarction were seen. EEG was abnormal and showed moderate generalized slowing. He was extubated on 2/7 and, per reports, his mental status also improved. He was awake and alert and oriented x 3, but had slow mentation. On 2/13 the patient developed stridor and was found to have supraglottic swelling on fiberoptic endoscopy. He required reintubation on 2/15, and tracheostomy on 2/16. Urine culture from 2/15 grew methicillin resistant Staph aureus and a tracheal aspirate from 2/15 grew beta hemolytic streptococcus. He was started on Vancomycin and Zosyn. While in the post intensive care rehabilitation unit (PICRU), his mental status deteriorated (3/18). He was febrile, found to be septic, and was transferred to the ICU for further care. On 3/19/2011 he had an episode of hypotension (blood pressure 55/29) and bradycardia (heart rate 38) after which he was minimally responsive and developed decerebrate posturing. Head CT (3/20) showed no acute intracranial process. He was started on continuous veno-venous hemodialysis on 3/23. He developed severe thrombocytopenia with Plt=19 K/cumm (3/21) and a peripheral smear showed burr cells but no schistocytes. Lower extremity venous Doppler (3/21) showed an acute deep vein thrombosis in the right common femoral vein. On 3/28, the patient developed hypotension followed by ventricular fibrillation. Based on multiple family discussions, his code status was do not resuscitate. He continued to have fever of 41.6 C (106.9 F). He passed away at 21:03 on 3/28. ---- General autopsy findings showed bronchopneumonia and cardiac hypertrophy (530 grams) with increased thickness of the left ventricle.
