C ASE S TUDIES IN N EUROPATHOLOGY

1. CASE STUDIES IN NEUROPATHOLOGY Kenneth Clark, MD Neuropathology Fellow, UPMC

2. CLINICAL HISTORY • 56-year-old man with severe Crohn’s disease  short gut syndrome  small intestinal transplant • Immunosuppressants – prednisone, tacrolimus • Multiple episodes of rejection and recurrent infections – • EBV enteritis • Pneumonia • Staphylococcal sepsis (line)

3. Clinical Course • 14 days prior to death presents with cough, fever, malaise  CT scan of the chest reveals a consolidation of right lower lobe • Empiric antibiotics (including antifungals and antivirals) • Blood cultures were negative • Admitted • Conditioned remained unchanged for the next 12 days

4. Clinical Course • 3 days prior to death he developed tachycardia and episodic hypotension (70/20) • At the same time began showing indications of delirium

5. Delirium (small groups) • Typically caused by processes inside or outside the brain? • What are the causes? • Manifestations?

6. Summary • Delirium in an immunosuppressed patient with fever, hemodynamic instability and right lower lobe mass • What is the differential diagnosis in this patient?

7. Clinical Course • Intubated and BAL performed  numerous WBC and no organisms on gram stain  sent for culture • 36 hours prior to death sustained a tonic-clonic seizure • Unresponsive off sedation, no gag or corneal relfexes • EEG  generalized slowing • Multi organ system failure  died

8. Differential Diagnosis

34. Cause of Death Disseminated Aspergillosis

35. MECHANISMOF DEATH