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Washington University Experience | VASCULAR | Infarct - Spinal Cord | 5A0 Case 5 History
Case 5 History ---- The patient was an 83 year old man with a reported history of a progressive neurological disorder characterized by dementia, gait difficulty and incontinence, whose differential diagnosis included multisystem atrophy, normal pressure hydrocephalus and alcoholic dementia. He had a history of seizure disorder treated with topiramate, a history of sleep apnea treated with BiPAP, restless legs syndrome treated with Neurontin, severe coronary artery disease with ischemic cardiomyopathy, chronic kidney disease, abnormal liver function, a history of DVT treated with warfarin, an indwelling supra-pubic catheter, adult-onset diabetes mellitus and hypertension. On Nov 21, he presented to the BJH ER after several falls. He was suspected to have a cervical spine fracture at C5. In the ER he developed episodes of bradycardia and hypotension and was noted to be lethargic. His family had noted worsening confusion and increased falling frequency over the past 2 weeks. Initial head CT showed diffuse atrophy and ex vacuo dilation of the ventricles. He was intubated and sedated. Over the next several days, he was found to be intermittently confused during wake-up trials. On 12/1, he received a permanent pacemaker for persistent bradycardia. He was treated for MRSA pneumonia, underwent tracheostomy and was then transferred to extended care. He returned to the ED on 12/26 with refractory hypotension on a dopamine infusion. He developed atrial fibrillation with RVR, but an attempt to switch to Levophed failed, and he was started on amiodarone for PVC’s and NSVT. Chest radiograph showed a multifocal pneumonia and blood cultures grew Acinetobacter and Staphylococcus epidermidis. The patient became transiently pulseless the next day in the ICU but recovered with CPR. The next day care was withdrawn due to refractory hypotension, sepsis and poor prognosis.
