1. CPC Conference Patient: RT May 16th, 2017
Neurology Resident: Michael Isfort
Pathologist: Dr. Hamilton

2. HPI
58yo morbidly obese male with PMHx of chronic EtOH abuse, Afib not on AC, HTN transferred to PUH on 04/28/17 with falls, LBP, BLE weakness c/f spinal cord injury.
Progressive weakness for around 1 year following fall, unable to get OOB on morning of admission. L>R hand numbness. Neck pain radiating to shoulders (months). Walker for around 1 month.
PMHx: chronic EtOH abuse, Afib not on AC, HTN
PSHX: CCY
FHX: Non-contributory
Social Hx: Long H/o EtOH abuse. Lives alone
Meds: Coreg,, ibuprofen, lisinopril, omeprazole,
Admitted 08/2016 for L hand abscess/cellulitis

3. Hospital course VS: T: AF, P 90s-100s (afib), BP 110s/90s, Wt 130kg
Exam: AOx3, RUE 4/5, LUE 4/5, RLE 4/5, LLE3.5, + hoffmans BL, 3+ BR
LABS (04/28): BMP wnl, BUN 43, TBili 5.2, AST/ALT 230/550, CRP 5.5, WBC 12 with L shift/plts 29
MRI spine: C3-C4 osteophyte with mod canal stenosis, flattening of cord, ?cord signal motion degraded
Abd US: Cirrhosis

4. MRI C spine

5. Hospital course (continued)
04/28: Admitted to NSGY, c-collar, dexamethasone PO, med clearance for ACDF
04/29: NH3: 120
04/30 and 05/01: Somnolent (Aox2), hypotensive, afebrile. NH > ?HE +lactulose/rifaximin. +HCV. L elbow erythematous, WBC 8.8/Plts 35 Cr 1.0->2.3, k 5.3, NH Transfer to TICU. Lasix and spironolactone. Ortho drained L olecranon bursitis, + MSSA + Vanco. BCx later grew MSSA
05/02: VTach, K 7.5/BUN119/Cr 3.7/Ph 6.5, Plts: 32, INR 2.3, CRP 11. Intubated. EKG with STEMI. Went into Vfib. ACLS started multiple epi rounds, defibrillations. Pronounced at on 03:16 on 05/02.

6. Autopsy (prelim)
COD: Multisystem organ failure 2/2 renal/liver failure and MI, caused by sepsis.
Cavities: Rib fracture x3 (CPR), 150mL of ascites in abd
CV: LVH
Resp: Lungs congested with bloody, frothy fluid
Liver: Multiple nodules seen
GI: Esophageal varices, pancreas with calcifications
Renal: Kidneys with multiple pinpoint hemorrhages, white lesions in rnal cortex and medulla

7. Neurologic Complications of EtOH abuse
Acute:
Intoxication
Withdrawal
Acute alcoholic neuropathy, Alcohol related compression neuropathies
Acute alcoholic myopathy
Chronic:
Wernicke syndrome: B1 def. Cognitive disorder, ataxia, ophthalmoparesis
Korsakoff syndrome: B1 def. Anterograde/retrograde amnesia Confabulation. Vacuous speech and abulia
Alcohol related dementia
Alcohol related cerebellar atophy
Marchiafava-bignami disease
PNS: Chronic alcoholic neuropathy, Chronic alcoholic myopathy

8. Neurologic Complications of EtOH abuse: Acute
Intoxication
Facilitates GABA, Inhibits glutamate = CNS depression in reticular formation -> cerebellar hemispheres
Blackout: impaired memory encoding possibly from direct hippocampal effect
Withdrawal
GABA downregulated and glutamate receptor upregulated -> excitatory
Seizures, tremors, hallucinations, DTs (previous +autonomic dysfunction)
WAS + BZDs: diazepam or lorazepam (severe) or oral chlordiazepoxide

9. Neurologic Complications of EtOH abuse: Chronic
Wernicke syndrome: B1 def. cognitive disorder, ataxia, ophthalmoparesis
Decreased attention, impaired memory, disorientation, diminished speech
Exam: Nystagmus, bilateral but asymmetric LR palsy, trunchal/gait ataxia, coma
Imaging: Restricted diffusion/FLAIR signal in thalamus, hypothalamus (mammillary bodies), midbrain (PAG/oculomotor regions) and pons (abducens and medial vestibular nuclei_
Tx: Thiamine 1g IV/24hr
Korsakoff syndrome:
Anterograde/retrograde amnesia without EOM problems or impaired attention. Confabulation. Vacuous speech and abulia.
Damage to both anterior thalamic nuclei and hypothalamus
Tx: Thiamine

10. Neurologic Complications of EtOH abuse: Chronic
Alcoholic related dementia:
Underdiagnosed with few neuropathologic hallmarks may have concurrent micronutrient def, trauma, hepatic insufficency
Early cognitive decline. Overlap with other cognitive disorders, but more globally impaired
Neurotoxic glutaminergic excitation -> neuronal loss in hippocampal and neocortical neurons. Reduced brain volume
Marchiafava-bignami disease:
Gait impairment, LOC, dysarthria, amnesia, cortical disconnect syndrome
CC involvement especially splenium-> DWI changes
Thiamine def
Cerebellar degeneration:
Most common complication of EtOH. Similar to Wernicke but does not recover
Cerebellar vermis and WM loss

11. Neurologic Complications of EtOH abuse: Chronic
Chronic alcoholic neuropathy
EtOH impairs retrograde axonal transport
Slowly progressive sensory loss involve small fibers/nociception -> painful senory neuropathy and paresthesias. Later motor. + autonomic.
Thiamine def neuropathy: large fiber, weakness/ataxia
Exam: Length dependent sensory, loss of ankle jerks-> distal weakness
NCS: Axonal sensori>motor neuropathy
Chornic alcoholic myopathy:
Affects 2% of western adults (most common skeletal muscle disease)
Progressive proximal weakness/atrophy, normal CK, lose type II fibers
Mostly skeletal myocytes also cardiomyocytes
EMG: polyphasic waves and early recruitment, proximal denervation

12. Neurologic Complications of EtOH abuse: Chronic
Acute EtOH neuropathy: Acute to subacute. Axonal. Mimics GBS.
EtOH related compression neuropathies: + peripheral neuropathy higher risk of compression. Conduction block or axonal loss
Acute EtOH Myopathy:
Mechanism: (1) impairs sarcolemma Ca channels (2) compromise sarcolemmal integrity
Increased CK. Fiber necrosis and phagocytosis. Type I fibers.
Toxic effect. Decr K or PO4. Glycolytic inhibition
Could be cause of 20% of rhabdo cases. Follows binge
Proximal pain and weakness. Bulbar involvement
Recovers with nutrition, lytes, hydration

13. References:
Noble JM, Weimer LH. Neurologic Complications of Alcoholism. Continuum. 2014; 20(3):

14. NEUROPATHOLOGY
EXTERNAL GROSS EXAMINATION IS UNREMARKABLE
FURTHER DISSECTION REVEALS NO ABNORMALITIES. (NO GROSS IMAGES)
MICROSCOPIC EXAMINATION AND FINAL DIAGNOSIS:
Alzheimer Type II astrocytes –
swollen pale nucleus
1. Multiple microabscesses with gram-positive cocci
(also found in heart, lungs and kidneys)
2. Hepatic encephalopathy, mild
CD68 - macrophages
Gram stain – G+ cocci