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This case study explores the clinical course and differential diagnosis of delirium in an immunosuppressed patient with severe Crohn's disease. The patient's symptoms, treatment, and eventual cause of death are examined.
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CASE STUDIES IN NEUROPATHOLOGY Kenneth Clark, MD Neuropathology Fellow, UPMC
CLINICAL HISTORY • 56-year-old man with severe Crohn’s disease short gut syndrome small intestinal transplant • Immunosuppressants – prednisone, tacrolimus • Multiple episodes of rejection and recurrent infections – • EBV enteritis • Pneumonia • Staphylococcal sepsis (line)
Clinical Course • 14 days prior to death presents with cough, fever, malaise CT scan of the chest reveals a consolidation of right lower lobe • Empiric antibiotics (including antifungals and antivirals) • Blood cultures were negative • Admitted • Conditioned remained unchanged for the next 12 days
Clinical Course • 3 days prior to death he developed tachycardia and episodic hypotension (70/20) • At the same time began showing indications of delirium
Delirium (small groups) • Typically caused by processes inside or outside the brain? • What are the causes? • Manifestations?
Summary • Delirium in an immunosuppressed patient with fever, hemodynamic instability and right lower lobe mass • What is the differential diagnosis in this patient?
Clinical Course • Intubated and BAL performed numerous WBC and no organisms on gram stain sent for culture • 36 hours prior to death sustained a tonic-clonic seizure • Unresponsive off sedation, no gag or corneal relfexes • EEG generalized slowing • Multi organ system failure died
Cause of Death Disseminated Aspergillosis