Clinicopathological Conference #5

January 8, 2008 David M. Cromwell, M.D.

Salient Clinical Features

 89 y.o. altered mental status, abd pain  Abx 6 weeks PTA  GI sx’s during Abx Rx  Abd pain, non-bloody diarrhea, nausea, vomiting  GI sx’s persisted  JHH admission #1 ~3 weeks PTA  Non-reducible ventral hernia  WBC nl, prerenal (68/1.3)

Salient Clinical Features

 CT: no free air; no obstr; diffuse colon thickening; ventral hernia containing loop of transverse colon; small AAA with thrombus.

 Stool studies (+) for c. diff  Discharged home on 2 weeks of flagyl  Improved until 2d PTA

Salient Clinical Features

 2d PTA, malaise and diffuse weakness  Then increased abd pain, dysarthria, headache  Cat and healthy parrot  No high risk infectious food exposures

Salient Clinical Features

 BP 82/46; HR 120; RR 20  Slurred speech; no facial droop; no focal neuro findings  B/L coarse rales  Tender abdomen; no rebound; hypoactive bowel sounds; ventral hernia  Heme (+) stool  3+ lower leg edema

Salient Clinical Features

 K 1.7, prerenal, glucose 7  Normal WBC but left shift with 13% Bands  Low serum protein, low albumin  Normal LFT’s  Lactate 9.8, serum myoglobin 1572  ABG 7.21/47/101 2L NC  CXR: no CHF, hypoinflation

Salient Clinical Features

       Admitted to MICU Fluids, vasopressors, empiric antibiotics AXR: no perforation Blood cultures positive for group G strept.

Worsened metabolic acidosis, ARF Family meeting Worsened hypotension, cardiac arrest + death 24 hours after admission

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Salient Clinical Features Summary

89 y.o.

 No focal neuro sx’s Antibiotics  Severe hypo K Abd pain / diarrhea  Severe hypoglycemia ∆ MS / HA  Lactic acidosis CT: hernia / colitis  Rhabdomyolysis Prerenal azotemia  No perforation per AXR C. diff +  Refractory to Rx Cat and parrot  Cardiac arrest Shock  Expired

Differential Diagnosis #1

 Psittacosis (parrot fever): fever, headache, dry cough, altered mental status, diarrhea  Pasteurella multocida: sepsis, meningitis, intraabdominal infection  Infectious (non- c. difficile) enteritis  Primary cardiac event with pan-ischemic colitis  Primary Group G streptococcal sepsis with pan-ischemic colitis

Differential Diagnosis #2

 Highly toxigenic strain of c. difficile colitis leading to fulminant colitis  Fulminant c. difficile colitis with ordinary strain  “toxic megacolon” from c. diff colitis depending on x-ray results  c. difficile colitis complicated by ventral hernia strangulation and ischemic bowel, peritonitis

Cause of Neuro Sx’s?

 In the CNS:  Metabolic delirium / sepsis  Glucose, acidosis, hypotension  In the PNS:  Hypokalemia

The End

Notes

    Myoglobin = heme containing resp protein released from damaged muscle (other muscle enzymes? Creatine kinase?) 23% of Group G strept infections were primary bacteremias in two pooled studies without overt clinical focus.

Type A lactic acidosis > Type B lactic acidosis  For type A: decreased BP, oligoanuria, altered mental status Occam’s razor