![Page 1: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/1.jpg)
NYU Medicine Grand Rounds Clinical Vignette
Matt Weiss MD, PGY-2
1/29/14
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
![Page 2: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/2.jpg)
• 58 year-old man presenting on 10/19/13 with two days of generalized weakness
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
![Page 3: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/3.jpg)
•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
![Page 4: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/4.jpg)
Additional History
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
![Page 5: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/5.jpg)
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
![Page 6: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/6.jpg)
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
![Page 7: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/7.jpg)
• 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
![Page 8: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/8.jpg)
• 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
![Page 9: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/9.jpg)
• 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
![Page 10: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/10.jpg)
• 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
![Page 11: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/11.jpg)
• 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
![Page 12: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/12.jpg)
• 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
![Page 13: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/13.jpg)
• 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
![Page 14: 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](https://reader034.vdocument.in/reader034/viewer/2022050805/56649dfe5503460f94ae650d/html5/thumbnails/14.jpg)
• 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