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

2. 58 year-old man presenting on 10/19/13 with two days of generalized weakness Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History 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 Epotin alfa 1 injection every 2 weeks Romiplostim 500mcg injection once weekly Dexlansoprazole 60mg daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. January 25 th, 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. January 25 th, 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS