Case Conference February 19th 2013 Scott Laura Confusion and worsening back pain for 2 weeks Chief Complaint 55 yo male with hx of HIV CD4 count 0110 was 23 Below 200 since ID: 741616
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Slide1
Hepatic Encephalopathy… Maybe?
Case Conference
February 19th, 2013
Scott LauraSlide2
Confusion and worsening back pain for 2 weeks
Chief ComplaintSlide3
55 y.o. male with
hx
of
HIV (
CD4 count 01/10 was 23: Below 200 since 2005), emphysema, Hep B and C, depression, AoCD, GERD, chronic back pain, who presents with confusion and back pain x 2 weeks that has progressively worsened.Pt presented to ED under his own volition, with complaint of pain in his “bones and back” Also reported minimal weakness.
HPISlide4
Patient stated he had been confused since a female
acquaintance stole
his home
prescription of morphine
. On chronic pain meds for LBP.Unsure of causeNo previous mention in chart reviewHe was slow to answer questions and perseverating during exam.Patient was noted to be removing IV access and agitated HPISlide5
HIV with CD4 of 23 and % of 4.8 (1/10)Pulmonary MAC
Diagnosed in 4/2010 treated with
Clarithromycin
,
Ethambutol and Rifampin.Smear negative 1/2011 x 1Followed by NO/AIDS and pulmonary (1 visit in 1/11)Hep B and Hep CEmphysema Anemia of Chronic Disease Chronic low back painDepressionPoly-substance abuse Past Medical HistorySlide6
No Known Surgical Procedures Per chart review
Past Surgical HistorySlide7
Morphine of unknown dosage/prescriberPer Chart review Jan 2011
Azithromycin
1200mg weekly
Bactrim
DS 1 tab dailyEthambutol 400mg 2.5 tabs dailyClarithromycin 500mg 2 tabs dailyRifabutin 150mg 3 tabs dailyRaltegravir 400mg BIDAbacavir/Lamivudine 600/300mg dailyAlbuterol HFA 2 puffs q 4-6 hours PRN: SOB/wheezingTiatropium 18mcg dailyFluoxetine 20mg daily
Ibuprofen 200mg 1-2 tabs q 8 hours PRN: pain
Lansoprazole
30mg daily
MedicationsSlide8
IV Contrast: AnaphylaxisPenicillins: Throat Swelling
AllergiesSlide9
Father passed away from unknown causes at 34 y/o.Maternal grandfather died of mesothelioma at unknown age.Mother unknown.
Family HistorySlide10
Per Chart Review80 year tobacco historyDenied current alcohol use
History of Heroin Use – unknown quantity/duration
H
eterosexual
Incarcerated 3 years priorHas lived in homeless shelters in pastWorked as a “boiler-maker” for ~10 yrs.Social HistorySlide11
PCP with NO AIDS task force.Unknown Flu, pneumo
, tetanus.
No colonoscopy per records.
Health
Maintenance Slide12
Gen: No weight changes, fever or chillsHEENT: No visual changes, sore throat,
rhinorrhea
but +
conjunctival
erythema CV: No chest pain, palpitations, SOB, DOE, orthopnea or PNDRESP: No cough, SOBGI: No N/V/Diarrhea/melena/BRBPR, + constipation Skin: No new rashesGU: Denied Dysuria or change in frequencyNeuro: + for dizziness Musculoskeletal: Low back pain x 1 year acutely exacerbated 2 weeks priorROS LimitedSlide13
VitalsTriageT 99.1
BP
134/82
P
105 RR 19 O2 100% on RA6’ 68kg BMI 20ExamT 98.3 BP 121/68 P 90 RR 28 O2 100% on RAPhysical ExamSlide14
GENERAL: Thin,
cachectic
&
dishelved
. Altered with slurred speech and difficult to understand. Uncooperative with examHEENT: Normocephalic, atraumatic. MMM with no dentition. PERRL, EOMI, unable to assess optic nerve. No scleral icterus No obviously elevated JVP. CARDIOVASCULAR: Regular
rate and rhythm
. No murmurs, S3 or S4 noted
RESPIRATORY:
CTA however patient uncooperative with deep inspiration and palpation
Physical
ExamSlide15
ABDOMEN:
Bowel
sounds present.
Soft
. Nontender. Nondistended. No organomegaly.No rebound, guarding , shifting dullness, fluid wave, or caput medusa appreciated.EXTREMITIES: No clubbing, cyanosis, or edema.Back: Uncooperative with straight leg raise or range of motion.Lumbar paraspinal muscle TTPSkin: Multiple tattoos
Some professional and multiple homemade.
No signs of
telangiectasias
Physical
ExamSlide16
NEUROLOGIC:
Mental
:
Oriented to self and place, not to time (day, month or year)
Sensation intact to light touch. Reflexes unable to assess Strength is 5/5 bilaterally in the upper and lower extremities. Cerebellar function: Patient seen standing and ambulating on exam CN II-XII: EOMI intact, PERRLA, sensation intact to light touch, raises eyebrows, closes eyes tight, symmetric facesPhysical ExamSlide17
NEUROLOGIC:
CN II
Not assessed
CNIII, IV, VI
EOMI intact and PERRLA B/LCN VSensation intact to light touch B/LCN VIIRaises eyebrows & closes eyes tight symmetrical B/LCN VIIIGross hearing intact CN IX, XPhonation and swallowing intactCN XINot assessed secondary to being un-cooperative but moving shoulders and neckCN XIITongue appeared mid-linePhysical ExamSlide18
Labs Admit
6.5
10.9
13.5-17.5
31.7
40-51
121
130-400
95
14
140
102
56
(7-25)
4.1
20
(24-32)
3.3
(0.7-1.4)
92
15
(8.4-10.3)
TP
ALB
AST
ALT
AP
TB
11
(6-8)
3.2
(3.4-5.0)
81
(<45)
47
(<46)
50
0.8
Ammonia
80
(9-35)
LA
2.1
Aceta
<10
Salicylate
<4
N 71
L 20
M 9
E 0
B 0
CCa
15.64
Mg 2.4 P 3.7
PT
13.0 INR 1.2 PTT
35.3
Baseline
labs:
Cr 1.0-1.5 from 12/05 – 3/10
Ca 8.4-9.1 from 12/05 - 3/10 Slide19
Labs Admit
UA
Sg
1.020
pH
5.0
Prot
25
Glu
Norm
Ket
Neg
Bili
Neg
Blood
25
Nitrite
Neg
Urobil
Norm
LE
Neg
UA
RBC
0-2
WBC
6-10
(0-5)
SqEp
20-100
Bact
Neg
Casts
0-2
Hyaline
& calcium oxalate crystals
Methanol
<4
Ethanol
<15
Isopropanol
<4
Opiate met
+
THC
+
Cocaine
met
+Slide20
CXRNo acute abnormality identifiedSlide21
Overnight/Day 1 Underwent CT head W/O contrast Patient received Ativan 2 mg for LP around midnight
Did not receive Lactulose
X ray of lumber spine
Multilevel degenerative changes in the spine with no significant interval change.
Urine: No organisms on smearUpep/Spep Pending Hospital CoarseSlide22
CT Brain
Atrophy and chronic
microvascular
ischemic changes. Left mastoid
disease. No acute intracranial findings.Slide23
LP (Tube 4)CSF Clear
WBC 4 (differential not performed for <6)
RBC
12
(0-5)LDH 23Glucose 55 (40-70)Total Protein 40.2 (15-45)Crypto Antigen Negative Gram Stain:No Organisms LabsSlide24
Labs Day 1
141
108
54
3.8
18
3.04
90
13.5
TP
ALB
AST
ALT
AP
TB
9.4
2.6
65
38
43
0.9
Ammonia
80
->
118
LA
1.8
TSH
0.31
(0.5-5.0)
FT4
0.8
CCa
15.58
Mg 2.2 P 3.4
Baseline labs:
Cr 1.0-1.5 from 12/05 – 3/10
Ca 8.4-9.1 from 12/05 - 3/10
PT 13
INR 1.2
PTT 32.8
CBC Stable but platelets clumped Slide25
Blood
Ferritin
454
(20-300)
Iron
109
Transferrin
152
(200-360)
TIBC
198
(250-425)
Iron
Sat
55
(15-50)
Folate
6.1
Vit
B12
330
Urine
Creatinine
229.5
Na
36
FENA
0.34
TP/Cr ratio
298
(<200)
Additional LabsSlide26
Hospital Coarse
Day 2
Transferred to floor overnight
Received 1-2 doses of Lactulose
Began vomiting, no hematemesis notedAmmonia80 > 118 > 125 > 95
BUN
56 > 54 > 50
Creatinine
3.3 > 3.04 > 2.97
Calcium
15 > 13.5 > 13.7 > 14.2Slide27
Day 3:Patient
received Ativan 2 mg overnight for “excessive restlessness
”
Mental status waxing and waning, AM of Day 3 he was able to answer questions but still with slurred speech and confusion
Outputs unrecordedCalcium still elevated with only slight improvement in renal functionCalcitonin 250U Q12 started with considerable increase in IVFsHospital CoarseAmmonia
80 > 118 > 125 > 95 > 112
BUN
56 > 54 > 50 > 51
Creatinine
3.3 > 3.04 > 2.97 > 2.75
Calcium
15 > 13.5 > 13.7 > 14.2
> 12.9
PTH
9
(12-65)Slide28
Late that afternoon (Day 3)
Hospital
Coarse
Large Monoclonal Band in Beta Region Adequate amount of normal serum immunoglobulin presentIgM KAPPA specificity
UPEP: Extra Band in the mid Gamma Region
Immunofixation
: Free Kappa Light Chains
Heme
-Onc
consultedSlide29
Day 4:
Mental status still waxing and waning, he was able to answer questions but still with slurred speech and confusion
Received Lactulose as scheduled
Net negative 10 Liters from admission
4.7 Liters in past 24 hrs Hospital CoarseAmmonia
80 > 118 > 125 > 95 > 112 > cancelled
BUN
56 > 54 > 50 > 49 > 60
Creatinine
3.3 > 3.04 > 2.97 > 2.91 > 2.24
Calcium
15 > 13.5 > 13.7 > 14.2 > 12.9 > 12.6Slide30
Day 4:
Heme
/
Onc
: Kappa/lamba ratio, IgM, IgG, IgD, and beta-2 microglobulin orderedBone Marrow Biopsy pendingDecadron 40 mg IV Q24Pamindronate 60 IV X-ray Bone survey completed and compared with completed CT of Head (Day1).CT chest/abdomen/pelvis
Hospital
CoarseSlide31
Bone SurveySlide32
CT abdomen/pelvisSlide33
CT Abd/Pelvis without contrastSlide34
CT Abd/Pelvis without contrastSlide35
CT of Chest without contrastSlide36
Day 5:Patient found in afternoon with feces covering patient and bed
NG tube placed
Pt
transferred to ICU for worsening mental status and higher level of care
Added RifaximinHospital CoarseKappa/lambda
Pending
IgM
5812
(40-168)
IgG
726
IgA
83
Beta-2
Microglobulin
7.5
(0.6-2.4)
Ammonia
80 > 118 > 125 > 95 > 112 > 194
BUN
56 > 54 > 50 > 49 > 60 > 70
Creatinine
3.3 > 3.04 > 2.97 > 2.91 > 2.24 > 2.14
Calcium
15 > 13.5 > 13.7 > 14.2 > 12.9 > 12.6 > 11.5Slide37
ICU Transfer Labs
7.4
8.9
25.4
99
95
13.6
144
114
69
3.9
18
2.16
107
12.3
TP
ALB
AST
ALT
AP
TB
9.5
2.3
52
34
32
0.7
Ammonia
194
LA
2.3
PT
16.6
INR
1.5
N74
B8
L11
M4
Meta2
Mylo1
CCa
13.66
Mg
1.8
P 2.2
ROULEAUX
SEEN ON SMEAR
Slide38
Day 6:
Dark Brown NG Tube output sent for occult blood testing returned as positive
H/H stable
Plasmaphoresis
initiated Albumin InfusionBone Marrow Biopsy doneHospital CoarseAmmonia
80 > 118 > 125 > 95 > 112 > 194 > 146
BUN
56 > 54 > 50 > 49 > 60 > 70 > 68
Creatinine
3.3 > 3.04 > 2.97 > 2.91 > 2.24 > 2.14 > 2.05
Calcium
15 > 13.5 > 13.7 > 14.2 > 12.9 > 12.6 > 11.5 > 10.9
Serum Viscosity
4.8
RR(1.6-1.9)Slide39
Flow Cytometry
APPROXIMATELY 22.3% OF TOTAL CELLS ANALYZED IN THIS BONE MARROW ASPIRATE SAMPLE ARE KAPPA LIGHT CHAIN RESTRICTED PLASMA CELLS THAT ARE BRIGHT CD138+, BRIGHT CD38+, AND DIM CD45+. THEY ARE NEGATIVE FOR CD117 AND CD56.
MATURE
LYMPHOCYTES
COMPRISE APPROXIMATELY
11% OF TOTAL CELLS AND CONSIST OF A MIXTURE OF T AND B CELLS. THE T CELLS SHOW AN INVERTED CD4:CD8 RATIO, CONSISTENT WITH THE PATIENT'S HIV STATUS. THE B CELLS SHOW NO EVIDENCE OF LIGHT CHAIN RESTRICTION.
CONSISTENT
WITH PLASMA CELL MYELOMA
.Slide40
Bone Marrow Biopsy
Aspirate smear, 20x
Numerous atypical plasma cells with variable size, prominent nucleoliSlide41
Bone Marrow Biopsy
Aspirate 100x,
binucleated
plasma cellSlide42
Bone Marrow Biopsy
Core biopsy, 2x
Hypercellular
marrow, bone destruction.Slide43
Bone Marrow Biopsy
Marrow, 20x
Sheets of plasma cell
Bone destruction
OsteoclastSlide44
Bone Marrow Biopsy
Marrow, 40x
Sheets of plasma cell
Bone destruction
Slide45
CD138 stain
Highlights the numerous plasma cells
Bone Marrow BiopsySlide46
Bone Marrow Biopsy
Ki-67 stain
Proliferation index markerSlide47
Day 7:Multiple BMs overnight
Improving Mental Status
Started Feeds Per NGT
Consulted Urology for
hyrdonephrosisDeferred to IRIVF and lasix discontinuedCalcitonin continuedHospital CoarseAmmonia
80 > 118 > 125 > 95 > 112 > 194 > 146 > 159
BUN
56 > 54 > 50 > 49 > 60 > 70 > 68 > 54
Creatinine
3.3 > 3.04 > 2.97 > 2.91 > 2.24 > 2.14 > 2.05 > 1.75
Calcium
15 > 13.5 > 13.7 > 14.2 > 12.9 > 12.6 > 11.5 > 10.9 > 8.5Slide48
Day 8:
Continued multiple BMs overnight
Mental Status still improving
Calcitonin
discontinuedIR consult for biopsy of retroperitoneal mass and access for chemo Hospital CoarseAmmonia
80 > 118 > 125 > 95 > 112 > 194 > 146 > 159
BUN
56 > 54 > 50 > 49 > 60 > 70 > 68 > 54 > 51
Creatinine
3.3 > 3.04 > 2.97 > 2.91 > 2.24 > 2.14 > 2.05 > 1.75 > 1.71
Calcium
15 > 13.5 > 13.7 > 14.2 > 12.9 > 12.6 > 11.5 > 10.9 > 8.5 > 8Slide49
Day 9: Ativan given for agitation
Worsening mental status
Day 10: IR placed
nephrostomy
tube and performed biopsy of retroperitoneal mass.Anaplastic appearing cells, many with plasmacytoid features. The malignant cells stain with CD138 andare negative for CD3, CD20, and CD56. Ki-67 stains approximately 90% of cells. Findings most consistent with diagnosis of a plasma cell neoplasm, most likely plasma cell myeloma CT head (no changes)Hospital CoarseSlide50
Hospital Coarse
Day 11: Corrected Sodium, but physically abusive to staff.
No family/contacts could be reached.
Patients mental status
improved.Ethics and Palliative care consult placed.Patient had coherent conversation with Oncology teamUnderstood disease processWished to not pursue further treatment.Slide51
Day 12: Two of patient’s friends were located, meeting with ethics committee.
They stated prior to presentation, patient was usual self [walking, riding bikes, buses etc].
Patient has made comments in recent past of “ready to go.”
Estranged son in FL [
unk name or contact info]. Patient status changed to DNR/DNITransfer to HospiceHospital CoarseSlide52
Thank You