1 / 36

Morbidity and Mortality Conference

Morbidity and Mortality Conference. Dimitrios Tzachanis June, 12th 2002. 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

azia
Download Presentation

Morbidity and Mortality Conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Morbidity and Mortality Conference Dimitrios Tzachanis June, 12th 2002

  2. 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

  3. 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

  4. 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

  5. Past Medical History Continued • H/o VZV on chronic suppression • T3 fx s/p MVA 10mos PTP

  6. 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

  7. 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 Social and Family History

  8. Physical Exam Gen: Thin, cachectic in NAD VS: 36.5 120/70 70 18 95%RA HEENT: PERRL, EOMI, OP: clear, JVP~6cm 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

  9. 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

  10. CT abdomen and pelvis

  11. A&P: • 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

  12. 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

  13. HD#1- 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

  14. A&P • ? 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

  15. HD#2 • Pt felt the same • VSS, and PE unchanged • WBC returned to normal

  16. Repeat CT scan

  17. HD#2 • CT chest/abd/pelvis: large L renal polycystic mass c/w RCC unchanged from previous • U/S guided biopsy

  18. S-02-8048 Kidney biopsy

  19. HD#3 • Urology consult: • Nephrectomy recommended, pt agreed • Bowel prep with clears & fleet enemas, anesthesia pre-op consult

  20. Pt stable Seen by anesthesiology Made NPO after midnight for surgery HD#4

  21. HD#5 Preop labs: 8.7 9.7 278 145 103 31 3.2 25 1.4 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

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

  23. S-02-8243 Left kidney, resection

  24. S-02-8243 Whole mount of sections of kidney

  25. S-02-8243 Microscopic Images Necrosis and inflammation extending up the pyramid Necrosis and inflammation in cortex

  26. S-02-8243 Aspergillus sp. GMS H&E

  27. HD#6- POD#2 • 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

  28. 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 >130 • 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

  29. A-02-44 Heart

  30. A-02-44 Right kidney

  31. A-02-44 Lymph nodes Periaortic node, H&E Periaortic node, B-L26 Periaortic node, CD3

  32. 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

  33. Cumulative Incidence of Invasive Mold Infections after Allogeneic BMT Median 102 days Incidence 16% Baddley et al. CID 2001: 32, 1319 –1324.

  34. Case Fatality Rate Among Patients with Aspergillosis CFR 86.7% Overall CFR 58% Lin et al. CID 2001: 31 358 -366

  35. Potential Sites of Aspergillus Infection * * Lin et al. CID 2001: 31 358 -366

  36. 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

More Related