1. Case Presentation- Hx 36 y.o female Admitted-SPH 11/07/2007 (73 previous visits) Brought in via EHS agitated, spitting, naked and running into traffic at the scene. No voiced complaints. There was a report of a query seizure which is not clearly documented. Remote history of foul stools over the previous week before admission Shortly upon arrival to sph patient had sudden LOC and was intubated

2. Case Presentation- Hx PMHx 1. Hepatitis C. 2. BAD Meds –None Allergies –None SHx –Prostitution –Polysubstance abuse (cocaine/heroine IVDU).

3. On Examination HR-144 sinus tach/ RR-22/ Temp-41 C/ BP-90/40/ Pressure support 15, PEEP of 5, FiO2 of 0.5, CPP was 11, mixed venous 81% and a MAP of 75 with no pressor support. Overall Physical exam was non- contributory

4. Admission labs Glucose-6.8 Sodium-142 Potassium-5.4 Chloride104 Bicarb 11 Urea 6.3 Creatinine 147 Total Bili 8 Osmolality 319 CK -405 Troponin0.19 Amylase-1018 TSH -0.52 B-HCG- weakly positive Ethalene glycol/methanol- cancelled Tox serum screen (asa, acetaminophen, etoh)-negative

5. Labs- Next Day Infectious workup –Genital C/S- Normal flora –Stool C/S – Negative –Sputum-Negative –Urine –Negative –Blood C/S- 1 bottle gram positive cocci in clusters-coag negative staphlococcus Hypoglycemia- Glucose-0.7 (24 hrs after admission) Hyponatremia-Sodium-128 ARF-Creatinine-600 APTT-189 INR >9 (july 12) Fibrinogen-1.0 D- dimmer >4000 Hepatitis-AST 1000, ALT 5573, GGT 66, BR 666(total)) Blood smear-schistocytes, burr cells

6. Translation DIC Hepatitis ARF

7. Course in Hospital Treated presumptively as sepsis nyd- piptazo, flagyl Negative workups – no identifiable septic or obstetrical causes for DIC. July 23-24- Patient briefly extubated before re- intubation and markedly decreased LOC and brain death. Comfort care initiated July 24 th, patient deceased within the hour. Autopsy- Non-contributory to date

8. Imaging CT head- July 24th There is severe compression of structures in the fourth ventricle. Fluid around the brainstem has been effaced and the fourth ventricle is compressed. The patient is at risk for developing transtentorial or tonsillar herniation. Severe cerebral edema.