Morbidity and Mortality Conference

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Morbidity and Mortality Conference

• Dimitrios Tzachanis
• June, 12th 2002

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Presentation

• 69 yo M with CLL s/p mini-allo BMT
• L flank pain x 7 months
• First noticed it during exercise
• Started progressing 2 months ago to the point of
  being present all the time
• ROS negative for fevers, dysuria, polyuria

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Past Medical History

• CLL
• Dx 9y PTP
• Tx with chlorambucil, prednisone, fludarabin
  and rituxan
• S/p mini-allo BMT 12mos PTP
• H/o recurrent fevers, infections and Coombs
  anemia prior to BMT

• Chronic GVHD
• Dx 7mos PTP
• Skin rash bx c/w GVHD
• Protracted N/V stomach bx c/w GVHD
• Also liver involvement suspected
• Tx with Cyclosporine and Steroids

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Past Medical History

• Cardiomyopathy
• Dx 8mos PTP, EF 30 with global hypokinesis
• S/p endomyocardial biopsy chronic
  inflammation with necrotizing granulomata
• Started on carvedilol, ACE-I, digoxin,
  furosemide and spironolactone
• Improved - last EF 65 (4 mos PTP)
• Also h/o AR and MR

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Past Medical History Continued

• H/o VZV on chronic suppression
• T3 fx s/p MVA 10mos PTP

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• Medications
• Cyclosporine 125mg bid
• Dexamethasone 1mg bid
• Lorazepam 0.5-1mg prn nausea
• Omeprazole 20mg qd
• Acyclovir 200mg tid
• Trimethoprim/Sulfamethoxazole 1 DS tab qM-W-F
• Fluconazole 100mg bid
• Carvedilol 6.25mg bid
• Folic Acid 1mg qd
• Multivitamins 1 tab qd
• Temazepam 30mg qPM
• Docusate 100mg bid
• TUMS prn

• Allergies
• - Nitrofurantoin

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Social and Family History

• Social History
• Married, lived in Chester, VT
• Tobacco none
• EtOH none
• Retired pedopsychologist

• Family History
• Mother died from aneurysm
• Father died from prostate Ca
• Sister (his HLA-matched donor) alive, well

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Physical Exam
Gen Thin, cachectic in NAD VS 36.5 120/70
70 18 95RA HEENT PERRL, EOMI, OP clear,
JVP6cm Card RRR, no m/r/g Resp Clear Abd
Soft, mild LLQ tenderness, ND, BS, no
HSM Back Mild left CVAT Extr No edema Skin No
rash, no petechiae or ecchymoses LN No
lymphadenopathy appreciated Neuro Nonfocal
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Laboratory Data
Ca 9.5 CsA 143 (100-300) UA wnl
11.0 MCV 99.9 16.5
274 N85 B3 L8 M4
137 101 33
161 5.0 23 1.3
EKG NSR
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CT abdomen and pelvis
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AP

• CT chest/abd/pelvis
• Delayed left nephrogram with dilatation of the
  left renal collecting system, replacement of the
  collecting system by numerous fluid-containing
  areas and thinning of the renal cortex this was
  present on a prior CT 7mos PTP and has progressed
• Decrease in para-aortic LAD
• Thought to have ureter stricture due to lymphnode
  shrinkage and fibrosis
• Scheduled for IVP and ureteral stent as an outpt
• Started on oxycodone/acetaminophen for pain
  control

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IVP

• Good flow of contrast up to the kidney
• Irregularly marginated collection of contrast in
  the renal collecting system, suggesting a filling
  defect either tumor or clot, or extravasation of
  the contrast
• Pt admitted for pain control and further w/up

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HD1- Laboratory Data
Ca, Mg, Phos wnl LDH 173 TP 6.1 Alb 2.4 TB 0.3 DB
0.1 AST 17 ALT 54 Alk Phos 399 CsA 311
(100-300) coags wnl UA wnl
8.7 MCV 96.8 11.9
261 N66 B21 L9 M3 Myelocyte1
137 101 36
4.4 24 1.3
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AP

• ? Renal mass - PTLD vs RCC vs CLL progression
• continue Oxycodone/Acetaminophen for pain
  control
• repeat CT chest/abd/pelvis for restaging
• U/S guided biopsy

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HD2

• Pt felt the same
• VSS, and PE unchanged
• WBC returned to normal

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Repeat CT scan
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HD2

• CT chest/abd/pelvis large L renal polycystic
  mass c/w RCC unchanged from previous
• U/S guided biopsy

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S-02-8048 Kidney biopsy
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HD3

• Urology consult
• Nephrectomy recommended, pt agreed
• Bowel prep with clears fleet enemas, anesthesia
  pre-op consult

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HD4

• Pt stable
• Seen by anesthesiology
• Made NPO after midnight for surgery

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HD5
Preop labs
145 103 31
3.2 25 1.4
8.7 9.7
278
Calcium 8.3 Phos
10.0 Mg 0.67

• D/w Renal high Phos 2 to fleet enemas in the
  face of abn kidney fx
• Calcium gluconate and dextrose given
• Pt taken to the OR

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OR

• OR mass replacing most of the left kidney
  resected
• Pt tolerated the procedure well, no complaints
  post-op

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S-02-8243 Left kidney, resection
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S-02-8243 Whole mount of sections of kidney
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S-02-8243 Microscopic Images
Necrosis and inflammation extending up the pyramid
Necrosis and inflammation in cortex
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S-02-8243 Aspergillus sp.
GMS
HE
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HD6- POD2

• Started on liposomal amphotericin B
• Had rigors to that
• Also transfusion of PRBCs started
• C/o not feeling well - Ativan given
• Shortly thereafter found unresponsive by his
  nurse
• Code Blue was called

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Code Blue

• Initial rhythm PEA, given Epi and Atropine
• Went into Vtach, shocked repeatedly
• Remained in junctional rhythm with palpable pulse
  on epi gtt
• Code labs WBC 11.2 (13 B) Hgb 7.1 (8.7), Plt 30
  (287)
• PT 34.2 INR 5.3 PTT gt130
• Na 147 K 7.1 Chl 119 CO2 13 BUN 25 Creat
  1.2
• ABG 7.33/33/91
• Ca 10.3 Mg 0.61 Phos 10.8
• Given Calcium, bicarb, insulin dextrose
• Finally asystolic
• Code called after 2hrs of resuscitative efforts
• An autopsy was performed

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A-02-44 Heart
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A-02-44 Right kidney
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A-02-44 Lymph nodes
Periaortic node, HE
Periaortic node, B-L26
Periaortic node, CD3
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A-02-44 Final Anatomic diagnosis
I. Chronic lymphocytic leukemia (CLL) for nine
years A. Generalized lymphadenopathy with
residual CD5-negative CLL B. Status post
allogeneic bone marrow transplant 3/01 1.
Graft vs. host disease 2. Immunosuppressive
therapy II. Status post left nephrectomy A.
Renal fungal abscess with Aspergillus sp.
positive culture B. No post-operative
retroperitoneal or abdominal bleeding III.
Disseminated intravascular coagulation A.
Dermal petechiae B. Microthrombi in small
arterioles of the myocardium C. Clinical
history of coagulopathy IV. Incidental
findings A. Fused aortic valves B. Benign
prostatic hyperplasia with bladder hypertrophy
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Cumulative Incidence of Invasive Mold Infections
after Allogeneic BMT
Median 102 days
Incidence 16
Baddley et al. CID 2001 32, 1319 1324.
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Case Fatality Rate Among Patients with
Aspergillosis
CFR 86.7
Overall CFR 58
Lin et al. CID 2001 31 358 -366
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Potential Sites of Aspergillus Infection


Lin et al. CID 2001 31 358 -366
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Total Medical Costs 212, 000

• 7/13/01 8/18/01
• CHF secondary to myocarditis
• Total charges 56,000
• 8/20/01 9/21/01
• GVHD
• Total charges 71, 000
• 4/05/02 4/09/02
• Renal Aspergilloma, nephrectomy, and CODE
• Total Charges 45, 000
• Clinic charges from 1/1/01
• 40, 000