NYU Medicine Grand Rounds Clinical Vignette

Matt Weiss MD, PGY-2

1/29/14

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 58 year-old man presenting on 10/19/13 with two days of generalized weakness

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Two days prior to presentation, patient went to work and was immediately escorted home by colleague for generalized weakness•Has since had two days confusion/ altered mental status, increased fatigue•No history of recent fevers, chills, change in urine output or abdominal girth•Given recent admission for confusion/ hepatic encephalopathy one month prior, wife brought patient in to Urgent Care

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: no distress, laying comfortably in bed, speaking in full sentences, appropriately responding•Vital Signs: T: 98F BP: 118/51 HR: 80 RR: 16 O2 sat: 99% RA•Scleral icterus•Obese abdomen, soft, non-tender, distended, +shifting dullness•Mild pitting lower extremity edema•Remainder of Physical Exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC: WBC 12.8, Hgb 11.1, Plt 417, 81% PMNs, MCV 97.5•Basic Metabolic panel: Na 117, K 6.5, Cl 86, CO2 23, BUN/Cr 51/2.4•Hepatic panel: AST/ALT 248/141, Alk P 276, Tbili 8.2, Dbili 2.7•Ammonia 21•Lipase 1673•Venous lactate 1.8•1,3-Beta-D-glucan positive; 182•Procalcitonin 0.49

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient admitted to Transplant Surgery service with diagnoses: Acute Kidney Injury (Cr 2.5 from 1.9), hyponatremia, hyperkalemia, pancreatitis, as well as concern for Spontaneous Bacterial Peritonitis and Hepatocellular Carcinoma

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:

– MELD Score 34; listed for transplant

– Antibiotics continued for possible SBP: vancomycin/ piperacillin/tazobactam; fluconazole

– Lactulose/ rifaximin for hepatic encephalopathy

– Abdominal paracentesis negative for SBP

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 9:

– Na and mental status improved s/p hypertonic saline and diuresis

– MELD rising to 40

– Cadaveric liver transplant from 56M with intra-cranial hemorrhage

– 4 pressor requirement; procalcitonin now 48 from <1

– Vancomycin and cefepime empirically started

– Transplant ID consulted for “post-OLT shock”

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 11:– Donor cultures: gram negative rods, probable staph aureus,

enterobacter; kidneys VRE (sensitive to ampicillin); diverticular abscess with E. coli; urine with pseudomonas,

– ID consensus: “patient effectively dosed a load of enterobacter intraoperatively, which likely explains extreme elevation in procalcitonin level and may have contributed to patient’s shock.”

– Piperacillin/tazobactam, vancomycin, micafungin

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Days 30-45:

– New left lobe liver infarct

– Ascitic cultures: pseudomonas aeruginosa and VRE

– Bile culture: pseudomonas aeruginosa and putida, sensitive only to amikacin

– Minocycline added for improved gram positive coverage

– Micafungin re-started

– Metronidazole/ciprofloxacin transitioned to meropenem/ polymixin B after concern for increased WBC and hepatic abscess

– Continued bactrim prophylaxis and add valganciclovir prophylaxis

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• January 25th, Hospital Day 95, POD 89:

– Blood cultures: now negative for recent VRE bacteremia.

– Respiratory cultures: MDR pseudomonas aeruginosa and stenotrophomonas maltophilia.

– Blood culture fungal: recurrent C. parapsilosis: thought to be intraabdominal source.

– Possible candida endophthalmitis

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• January 25th, Hospital Day 95, POD 89:

Current medications:

–Aztreonam, ceftazidime (pneumonia)

–Polymixin B/ amikacin, inhaled (pneumonia)

–Bactrim (prophylaxis)

–Amphotericin B, liposomal (Ambisome from Abelcet)

–Flucytosine (fungemia synergy)

–Valganciclovir (prophylaxis)

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• End-stage liver disease secondary to hepatitis C requiring liver transplant, complicated by multiple multi-drug resistant bacterial and fungal infections and hospital stay > 100 days

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS