Transcript Journal Club

NYU Medicine Grand Rounds
Clinical Vignette
Matt Weiss MD, PGY-2
1/29/14
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 58 year-old man presenting on 10/19/13
with two days of generalized weakness
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hepatitis C, cirrhosis, HE/SBP,
thrombocytopenia, diabetes
•Past Surgical History:
•Cholecystectomy
•Social History:
•No high risk behavior
•Family History:
•Unknown
•Allergies:
•No Known Drug Allergies
•Medications:
•Lactulose 20g/30ml 3x/day
•Rifaximin 550mg 2x/day
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
•Spironolactone 100mg 2x/day
•Furosemide 40mg 2x/day
•Bactrim 800-160mg 3x/day
•Insulin glargine 30units daily
•Insulin glulisine 8units with
meals
•Epotin alfa 1 injection every 2
weeks
•Romiplostim 500mcg injection
once weekly
•Dexlansoprazole 60mg daily
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
Working Diagnosis
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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”
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS