Table of Contents
Washington University Experience | VASCULAR | Infarct - Spinal Cord | 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 after being found agitated and confused in a pool of vomit and urine. Initial findings/studies included: BP=255/142 mmHg, HR=104 beats/min, WBC=10.3 K/cumm, Hgb=14.9 g/dL, Plt=256, Glucose=653 mg/dL, HgbA1C=11.5%, BUN=31 mg/dL, Cre=3.64 mg/dL, Anion gap=18, Beta-hydroxybutyrate=0.8 mmoL/L, serum ethanol negative, urine drug screen 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 remote lacunar infarcts; however, no acute intracranial pathology was seen. The patient was transferred to the floor in stable condition on 2/3 and the next day had seizures. He was given intravenous Ativan, Dilantin, and intubated with seizure resolution. Repeat head CT and MRI were negative for an acute intracranial process. EEG was abnormal and showed moderate generalized slowing. 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. He was diagnosed with a deep venous thrombosis of the upper extremity on 2/21 and started on a heparin drip. On 2/25 the patient had a fever of 38 C and a tracheal aspirate grew pseudomonas aeruginosa. He was febrile, found to be septic, and was transferred to the ICU for further care. On 3/19 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. A blood culture (3/18) grew Enterococcus faecalis, coagulase negative Staphylococcus, and gram positive cocci in pairs and chains. He developed severe thrombocytopenia with Plt=19 K/cumm (3/21). 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 on 3/28. ---- Autopsy findings included a brain weight of 1220 g and unremarkable gross appearance. Infarcts, numerous, of varying ages, involving cerebral hemipheres, white matter, basal ganglia, thalamus, cerebellum and spinal cord. The overall findings in this case reflect the impact of numerous infarcts, likely resulting from the vasculopathic effect of severe hypertension, hypoxic-ischemic insult, diabetes and superimposed sepsis.
