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Washington University Experience | VASCULAR | Infarct - Spinal Cord | 8A0 Case 8 History
Case 8 History ---- The patient was a 46 year old white male with a history of chronic active Hepatitis C, cirrhosis and esophageal varices who was admitted on 8/7 with sudden onset lower extremity paraplegia. On the evening prior to admission he experienced low back and left hip pain and when he awoke the next morning the pain was much more severe. He then developed tingling in the left leg which rapidly progressed to bilateral weakness and the paralysis. He also noted sensory loss and inability to void. His physical examination demonstrated a motor and sensory level at T10-T11. On admission his neurologic work up included an LP, MIR, CT, and myelogram all of which were largely unrevealing, although the myelogram showed lumbar stenosis and the MRI showed a slight L4-5 disc bulge but no evidence of a pathologic entity to cause his signs and symptoms. On 8/9 he was noted to have bright red blood per rectum and gastric lavage was positive for blood. Endoscopy showed severe variceal bleeding. He soon became hypotensive despite aggressive fluid and blood replacement. He also developed respiratory distress requiring intubation. A linten tube was placed in order to halt variceal bleeding. However, he continued to bleed and remained hypotensive and on 8/11 he received an emergency intrahepatic shunt. The day after admission he was noted to be febrile and blood and urine culture grew E coli. On B/11 a paracentesis yielded pus. By this time he showed evidence of renal failure and had a severe metabolic acidosis. On 8/11 he was taken to the operating room where he was found to have extensively infarcted and necrotic omentum. He returned from the operating room hypotensive despite maximal pressure support and he continued to be severely acidotic despite receiving 38 ampules of bicarbonate. Several hours prior to his death he became progressively more hypoxic and blood pressure diminished as his rhythm changed to a wide complex bradycardia. He was soon without pulse or measurable blood pressure and a code was called to no avail.
