Case of the Week COW #8

CC: Altered Mental Status

HPI: 50 -year-old Male with PMH of HIV, CVA and Meningitis presents to the Emergency Department (ED) for altered mental status. As per the patient’s girlfriend at bedside, the patient woke up confused and was not making any sense when he spoke. He even urinated on the floor but does not remember doing so. Patient had been complaining of back pain, testicular pain and leg pain for the past couple of weeks and had been evaluated for it in the ED. Patient also states he is currently taking “something for his HIV” but is unclear what his last CD4+ count was. Denies sick contacts. The rest of the review of systems was limited by confusion, but denied vomiting, diarrhea, abdominal pain, or any other complaints.

Physical Exam:

BP 128/78   HR 129     RR 14   SpO2 96% on RA   Temp 102.4F

Constitutional: Diaphoretic, confused and intermittently following commands.

HEENT: NCAT, pupils PERRLA, neck supple

Respiratory: CTA B/L, no wheezing, rales or rhonchi

Cardiac: +S1/S2, tachycardia, no MRG, regular rhythm

Abdomen: soft, mildly distended with mild tenderness in RUQ and LUQ.  Was not able to appreciate any focal masses . No rebound or guarding

Neuro exam: Not oriented to time or situation, No focal deficits, moving all four extremities. Unable to complete a more detailed exam as patient remained confused.

Extremities: no edema, no tenderness or swelling

Skin: pink and warm with diaphoresis, no rashes, lacerations, or abrasions

Pertinent Labs:

(Per Sorian Inpatient) CD4 = 120 on June 2017

Sepsis workup summary (normal if not reported):

  • Trop 0.045ng/ml
  • Sodium 126
  • WBC 5.8       Chloride 93
  • RBC 3.72      CO2 19
  • HBG 10.3      Glucose 116
  • HCT 30.3       BUN 89
  • Platelets 108
  • Cr 2.90 (↑ from baseline)
  • Bands 27        Total Bili 4.5
  • Lymphs 3       Total Protein 5.7
  • Monos 2         Albumin 2.6
  • Lymphocytes 0.2
  • Alk Phos 346   Monocytes 0.1
  • AST 143
  • ALT 58
  • Lactic acid 3.4
  • U/A negative
  • CSF negative

Pertinent Imaging and other tests:

EKG remarkable for sinus tachycardia, left axis deviation, and an old RBBB

CT head w/o contrast remarkable for only mild frontal volume loss

Chest XR – unremarkable

RUQ Bedside US and then official US completed and showed:

Working Diagnosis:

Hepatic hydatid cysts from Echinococcus tape worm

Hepatic abscesses

Metastatic cancer

Multiple biliary hamartomas

Polycystic liver disease

Caroli Disease

ED/Hospital course:

In the ED, the patient received IV Fluid boluses of NS 30mg/kg and one 1000mL of NS along with Tylenol, Vancomycin and Zosyn. The patient was admitted to Infectious Disease service. Throughout the hospital stay, CT Scan of abdomen and pelvis w/o contrast (due to AKI) was remarkable for infiltrated liver, splenic lesions, and destructive lesions of the bilateral iliac wings and L5 with pathologic fracture of the posterior right rib, which may be due to metastatic disease. The underlying etiology is uncertain. Without contrast, it was not certain if there was underlying macronodular cirrhosis. There was also associated ascites. Initial blood cultures from the ED grew Salmonella species. The patient was initially admitted the medical floor but was transferred to the Medical ICU on day 7 of hospitalization for increased lethargy and worsening lactic acidosis, transaminitis, and AKI. He later went into multisystem organ failure and was intubated thereafter. His code status was also changed to DNR/DNI. The patient unfortunately expired before endoscopy, colonoscopy, and biopsy could be performed.

Official Ultrasound read – Findings consistent with metastatic disease to the liver.

Pearls:

Hepatic Hydatid infection

  • Caused by Echinococcus granulosus or Echinococcus multilocularis
  • granulosus – Endemic in North America & Australia with dogs & wolves main as main host
  • multilocularis – Found in Northern Hemisphere with red fox, dogs, & cats as main host
  • Ultrasound would show a multiseptate cyst with daughter cysts
  • X-ray would show calcified rings
  • CT Abd/Pelvis may show the water-lily sign, which occurs when the endocystic membrane becomes detached, resulting in floating membranes within the pericyst, which mimics the appearance of a water lily ( Refer to Figure 1).

Figure 1. A detached membrane within the contents of the cyst, known as the water-lily sign

Pearls

Hepatic Hydatid infection

  • Infection may be asymptomatic for many years, with a long latent period (up to 50 years of age!)
  • Albendazole for confirmed infection
  • Reserve antibiotics for those in which diagnosis is uncertain due to risk of anaphylaxis
  • Most cases in U.S. occur in immigrants from endemic countries (South America, Middle East, eastern Mediterranean, sub Saharan, African, West China, former Soviet Union)
  • Confirmed cases in U.S. are rare

Patients with HIV

  • Always ask for CD4+ count and if they are on medications for their HIV/AIDs
  • Have a low threshold for doing an aggressive workup for these individuals, especially if poor follow up
  • HIV is a risk factor for Salmonella bacteremia
    • Other risk factors include any immunosuppressed state, liver disease, hemoglobinopathies (decreased splenic function)
    • Most salmonella bacteremia can have a preceding diarrheal illness
    • Major complication is endovascular infection
    • Treatment is IV fluoroquinolones or 3rd generation cephalosporin

Case presented by Jessica Williams, MD, PGY1

Case of the Week #3 – Why my flap sunken?

CC: Altered mental status and frequent falls

HPI: 55 y/o male presents from rehab with altered mental status (lethargy and agitation) and frequent falls for the past 2 days. Patient has a PMHx of large traumatic subdural hematoma 9 months ago treated with a craniectomy, seizure disorder, and HTN. Patient complains of headache and is a difficult historian. Pt does answer some questions appropriately.

Pertinent PE and Vitals: BP 121/81 HR 98 RR 16 Temp 98.1 100% on RA

GCS=14 and in no acute distress

L pupil dilated at 4 mm and nonreactive. R pupil 1 mm and reactive.

Pt. with moderate R arm and leg weakness (patient has baseline weakness but this is worse).

Pertinent Labs (if any): Unremarkable workup

Imaging

Working Diagnosis at time of Disposition Sinking Skin Flap Syndrome (also known as Syndrome of the Trephined) with possible Paradoxical Herniation

ED & Hospital Course Patient was admitted and received neurology and neurosurgical consultations. Medications were adjusted to control agitation. It is questionable per the consultants if his symptoms were due to paradoxical brain herniation. Plan is for an outpatient cranioplasty.

Pearls & Takeaways

  • Sinking skin flap syndrome is a delayed complication of a decompressive craniectomy. As the herniated brain tissue recedes, the skin flap from the surgical site can become sunken.
  • Symptoms include headaches, dizziness, seizure, and mood changes.
  •  Symptoms worsen when is head elevated vs reclined; treatment option is cranioplasty. Symptoms are much worse in an upright posture.
  • If atmospheric pressure exceeds intracranial pressure, patients can get paradoxical herniation and midline shift. This is more of an emergency and symptoms include focal deficits, pupillary changes, and alterations in consciousness.
  •  Paradoxical herniation is a state of low intracranial pressures; therefore traditional measures to treat midline shift and ICP will worsen the condition such as mannitol, hyperventilation, etc.
  • Treatment of sunken skin flap with paradoxical herniation is to elevate the intracranial pressure, including Trendelenburg position, hydration, and clamping of any CSF drains. Definitive treatment is cranioplasty.

Brain pus

Having pus in your brain is a problem no matter how you cut it, but finding it in there can be a challenge.  While the classic triad is usually fever, headache and a focal neuro deficit, this isn’t always present.  Dave Traficante (@davetraf) just published a pretty cool case of bifrontal brain abscesses in the International Journal of Emergency Medicine of a gentlemen with this very problem.  Interestingly, he didn’t have any focal neuro deficits, but he did have a very flat affect and could care less of the pus accumulating in his brain which coincided with the frontal lobe location of his abscesses. Check it out here.