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NYU Medicine Grand Rounds Clinical Vignette

NYU Medicine Grand Rounds Clinical Vignette. Matt Weiss MD, PGY-2 1/29/14. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. 58 year-old man presenting on 10/19/13 with two days of generalized weakness.

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NYU Medicine Grand Rounds Clinical Vignette

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  1. NYU Medicine Grand Rounds Clinical Vignette Matt Weiss MD, PGY-2 1/29/14 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 58 year-old man presenting on 10/19/13 with two days of generalized weakness

  3. History of Present Illness 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

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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 • Spironolactone 100mg 2x/day • Furosemide 40mg 2x/day • Bactrim 800-160mg 3x/day • Insulin glargine 30units daily • Insulin glulisine 8units with meals • Epotinalfa 1 injection every 2 weeks • Romiplostim 500mcg injection once weekly • Dexlansoprazole 60mg daily

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  7. 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

  8. 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

  9. 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”

  10. 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

  11. 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

  12. 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

  13. 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)

  14. 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

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