Case Presentation

1
Case Presentation

• Intern ???

2
General Data

• Name ?X?
• Age 41 y/o
• Date of admission 930312

3
Chief complaint

• Left leg numbness, weakness and general malaise
  for several days

4
Present illness

• This 41 y/o man has past history of liver
  cirrhosis and type 2 DM. This time he complained
  of left leg weakness, numbness and general
  malaise for several days. There was no fever,
  abdominal pain, tarry stool, change of bowel
  habit, edema, or change of consciousness. He went
  to our ER, and lab data showed Glu 606 mg/dl
  T. bili 5.42 mg/dl GPT 48 U/l NH3 199 Alb
  2.5 g/dl Na/K 119/4.7 mEq/dl WBC 5100/cc Hb
  12.7 g/dl INR 1.28R. Hepatic encephalopathy or
  DM neuropathy was first suspected. He was
  admitted to GI ward for further evaluation.

5
Past history

• HTN (-)
• Alcohol and HBV related liver cirrhosis, child
  class C noted for two months
• HBV carrier noted for 10 yrs
• Poor controlled type 2 DM with insulin SC
  injection
• Right thigh pyomyositis, K. pneumonia and
  enterococcus induced, s/p debridement 8 months ago

6
Personal and family history

• Smoking 0.3PPD for 20 yrs
• Drinking ?? one bottle (300cc) per day for 15
  yrs, quitted for 2 months
• Allergy NKA
• Family history non-contributory

7
Physical examination

• General clear consciousness, moderately
  development, GCS E4V5M6
• Vital Signs BP 110/66mmHg , RR 20/min , PR
  96/min, BT 36.1?
• Skin no rash, no vesicle, no scar, no tattoo, no
  moles, normal skin texture and turgor
• Head symmetric head and face, no trauma lesion,
  no bruit
• Eyes no pale conjunctiva, icteric sclera, lids
  no lesion, pupil sizes 3mm with normal shape and
  normal reflex, normal eyes position/movement,

8
Physical examination

• Ears no discharge, normal external canal, and
  intact tympanic membrane
• Nose symmetric, intact palate, no polyp, and no
  nasal deviation
• Throat lips, teeth, gums, tongue, pharynx all
  normal
• Neck normal ROM, no LAP
• Chest symmetric expansion of respiration, clear
  BS
• Heart regular heart beat, no murmur
• Abdomen flat, no scar, spider angioma (), liver
  span 7cm, no hepatosplenomegaly, normoactive
  bowel sounds, no rebound pain, no muscle
  guarding, and no inguinal mass

9
Physical examination

• Musculoskeletal normal ROM, no obvious
  deformity, palmar erythema ()
• Neurology
• Consciousness E4V5M6
• Activity good
• Motor function normal
• Sensory function left hypoesthesia
• Muscle strength R 5 / L 4

10
Hepatic encephalopathy
11
Child-Pugh classification
12
Diagnostic impression

• R/o hepatic encephalopathy, Gr I
• R/o DM neuropathy
• Liver cirrhosis, HBV and alcohol related, Child
  class C
• HBV carrier
• Type 2 DM with poor insulin control

13
Plans to do

• Consult META for controlling blood glucose
• Evaluating DM complication
• Keep defecation 2-3 times per day
• Watch for consciousness level
• Watch for focal neurological signs

14
Hospital course

• 0313
• Consult META for controlling blood glucose and
  evaluating complication
• HbA1c 11.5
• 0316
• NCV compatible with sensorimotor
  polyradiculoneuropathy, demyelination
  predominantly entrapment neuropathy of bil.
  ulnar n. watch for coexisted bil. lumbosacral
  radiculopathy

15
Hospital course (contd)

• 0317
• Left side limb weakness, left facial palsy
  central type, blood glucose 193 (3/16 5pm) ? 229
  (3/16 10pm) ? 270 (3/17 3am) ? 268 (3/17 6am)
• R/o CVA, r/o organic brain lesion ? arrange brain
  CT

16
Hospital course (contd)
17
Hospital course (contd)

• Brain CT right thalamus lesion, r/o cardiogenic
  emboli related infarct, consider arrange cardiac
  echo and carotid doppler, check coagulation
  function
• Cardiac echo normal LV wall motion and systolic
  function, trivial MR, LA enlargement
• Carotid doppler no carotid atherosclerosis,
  normal perfusion and laminar flow
• Consider arrange MRI
• 0318
• Consult INF for r/o brain abscess ? administrate
  Flomoxef 1500mg q6h IV for empiric therapy

18
Hospital course (contd)
T2W
19
Hospital course (contd)
T1W
20
Hospital course (contd)
FLAIR
21
Hospital course (contd)
DWI
22
Hospital course (contd)
ADC
23
Hospital course (contd)

• 0319
• N/E pupil 3, / 3, Babinskis sign ?/?
  sensory left hypoesthesia muscle power
• 5 3
• 5- 4

MRI suggest brain abscess, functional MRI also
support the hypothesis, consider stereostatic
biopsy
24
Hospital course (contd)

• 0322
• Consult NS for biopsy
• 0323
• Antithrombin III 34.9?, protein C 37.6?,
  protein S 40.9?, C3 58.8, C4 13.0, B2GPI
  0.431, ANA (-)
• 0324
• Biopsy no growth of bacteria, no malignant cell,
  PAS (), AFS (-), gliosis, NOS ? suggest brain
  abscess, cause indeterminate

25
Hospital course (contd)

• 0326
• N/E pupil 3, / 3, Babinskis sign ?/?
  sensory left hypoesthesia muscle power 5- / 3
• 0327
• Fever up to 38.9? ? administrate Rocephin and
  metronidazole, check blood culture ? no bacterial
  growth

26
Hospital course (contd)

• 0330
• Fall down from bed with left body contussion,
  left wrist swelling and left shoulder pain ?
  wrist and shoulder X-rays distal radius fracture
  with volar angulation of distal fragment, on long
  arm splint
• 0402
• N/E pupil 3, / 3, Babinskis sign ?/?
  sensory function left hypoesthesia muscle
  power 5- / 3

27
Hospital course (contd)
28
Hospital course (contd)
29
Hospital course (contd)
30
Hospital course (contd)
31
Hospital course (contd)
32
Brain abscess and DM

• Defects in immune function in diabetics include
  depressed neutrophil and T cell function.
• The association between DM and increased
  susceptibility to infection is not supported by
  strong evidence.
• Some specific infections are more common in
  diabetic patients, even occur exclusively in
  them.

33
Brain abscess and DM

• Joshi, N, Caputo, GM, Weitekamp, MR, et al.
  Infections in patients with diabetes mellitus. N
  Engl J Med 1999 341 1906

34
Brain abscess and DM
35
Brain abscess and DM

• Invasive otitis externa
• P. aeruginosa
• Unrelenting pain, otorrhea, hearing loss without
  fever, intense cellulitis, polypoid granulation
  tissue of external ear canal
• Cranial osteomyelitis and intracranial
  involvement
• Debridement, Grams stain, tissue culture,
  tissue biopsy
• MRI, SPECT

36
Brain abscess and DM

• Rhinocerebral mucormycosis
• 50 in diabetic patient
• Risk factor ketoacidosis, resistance to
  Rhizopus oryzae
• Facial ocular pain and nasal stuffiness, with or
  without discharge ? proptosis, chemosis, and
  necrotic lesions on palate or nasal mucosa
  black eschar on nasal turbinate
• Headache, fever, ophthalmoplegia, visual loss,
  cavernous sinus, int. jugular v., int. carotid a.
  thrombosis

37
Brain abscess and DM

• Biopsy and tissue culture
• Histologic finding of broad, nonseptate,
  haphazardly branching hyphae invading tissue
• Cultures are often negative.
• MRI
• Cure surgical debridement and drainage
• Imidazole or amphotericin B?

38
Brain abscess and DM
39
Brain abscess and DM

• Magee CC. Halligan RD. Milford EL. Sayegh MH.
  Nocardial infection in a renal transplant
  recipient on tacrolimus and mycophenolate
  mofetil. Clinical Nephrology. 52(1)44-6, 1999
  Jul.
• Samra Y. Hertz M. Altmann G. Adult listeriosis--a
  review of 18 cases. Postgraduate Medical Journal.
  60(702)267-9, 1984 Apr.

40
Brain abscess and DM

• Amonn F. Muller U. Brain abscess--a possible
  complication of cerebral infarction?.
  Schweizerische Medizinische Wochenschrift.
  Journal Suisse de Medecine. 114(2)58-62, 1984
  Jan 14.
• Tanaka M. Matsumoto S. Tuberculous brain
  abscess. A case report. Neurologia
  Medico-Chirurgica. 22(3)235-40, 1982 Mar.

41
Specific pathogens and DM

• Group B streptococcus
• Klebsiella pneumoniae
• Salmonella enteritidis.
• Mycobacterium tuberculosis
• Staphylococcus aureus (?)

42
Case study

• Negative culture and biopsy, positive PAS,
  negative AFS ? cannot fully r/o fungal or viral
  infection, compare with CT findings, consider
  change drugs or arrange second operation and
  drainage?

43
Thanks for your attention
44
Coagulation dysfunction

• Antithrombin III
• Synthesized in liver and  endothelial cells
• Acts as an anticoagulant by directly binding and
  inactivating the serine proteases (factors XIa,
  IXa, Xa, and thrombin
• The presence of heparin increases the activity
  of AT by 104 - 105
• Normal value 5-15 mg/L (50-150 activity)

45
Coagulation dysfunction

• Protein C
• Vitamin K-dependent protein synthesized in the
  liver and is an inhibitor of the procoagulant
  system.
• Synthesized as an inactive form. Activated
  Protein C is a serine protease which functions to
  inactivate Factors Va and VIIIa.
• Protein C is activated to Protein Ca when
  thrombin binds to thrombomodulin. This binding
  alters the conformation of thrombin to a form
  that readily activates Protein C.
• The activity of Protein C is markedly enhanced
  by its cofactor Protein S.

46
Coagulation dysfunction

• Protein S
• Vitamin K-dependent factor synthesized in the
  liver.
• Cofactor to Protein C in the inactivation of
  Factors Va and VIIIa.
• In the circulation, Protein S exists in two
  forms a free form and a form bound to complement
  protein C4b. Total and free protein S should be
  obtained to have more accuracy in evaluation.

47
Coagulation dysfunction