The patient is a 46 year old
male who presented on 12-7-02 with a painful purple big toe. He also
has pain in his right forearm and hand in an ulnar distribution, and notes that
his fingers, turn white in the cold. They became very
numb and then improve on rewarming.
His past medical history is
significant for a two year history of abdominal pain which was believed to be
caused by his gall bladder but after cholecystectomy the symptoms persisted.
The pain was constant, dull and made worse with eating. He was diagnosed with
ischemic bowel disease and referred to surgery. A 12" segment of small
bowel was resected with placement of a gastrojejunostomy tube. Pathology of the
bowel could not determine the etiology of the ischemia. A biopsy of his kidney
showed arteriosclerosis and glomerulosclerosis with no immunologic staining
The patient was subsequently diagnosed with
vasculitis by muscle biopsy on 12-12-02 and continued to have worsening problems with patchy ischemia.† Testing was negative for ANA, ANCA, RF and he
was presumed to have poly arteritis nodosa (PAN). He was started on steroids
and Cytoxan therapy for immunosuppression, but he continued to lose weight.
Additional studies for vascular disease found that the patient was heterozygous
for Factor V Leiden. He was admitted to the hospital on 8-16-03 with dry gangrene of the left great toe and severe
2. What additional risks does Factor V Leiden impose on
3. Review the EKG from this admission; are there any
signs of cardiac ischemia?
4. An x-ray of the foot was performed to rule out
osteomyelitis of the great toe, do you see any bone loss?
His clinical labs
on admission were consistent with his state of immunosuppression and
infection. The patient was treated with surgical resection of
ischemic bowel on 8-18-03 when free air was found on abdominal films.† Pathologic review of
the surgical material did not find evidence for active PAN.† The patient developed fevers on the second
postoperative day and it was thought that he had developed an anastomotic leak
in the bowel and sepsis.† He was given
comfort measures and died on 8-21-03. An Autopsy
1. What do the CBC and smear
findings have to do with the diagnosis of vasculitis?
2. What changes are seen on CXR?
The autopsy revealed that
the patient had developed pneumonia as the immediate cause of death despite
negative pre-mortem cultures.† Two
additional areas of ulceration in the bowel were found and the surgical
anastomotic site in the bowel was intact.†
Using all of the information you
have gathered from the chart, prepare a presentation about this case as you
would for attending rounds with a concise summary of the history, physical
findings, labs and x-rays. Your presentation should be about 5 minutes long. A
copy of your presentation needs to be handed in to your facilitator by the end
of the lab on 12/11/03.
Incorporate the following into your report:
1. Describe polyarteritis nodosa, its diagnosis and
2. Is atherosclerosis associated with vascular damage?
3. How does Factor V Leiden affect
4. Describe the etiology of ischemic infarcts of the
tissues in this case
5. How does immunosuppression increase the risk of
HPI: This 46 year old
male presents today with a painful purple left big toe present for the past 2
- 3 weeks. He has a history beginning about two years ago of some type of
vascular problem. He began to have abdominal pain which was believed to be
caused by his gall bladder since US showed some stones. It was resected but
the patients symptoms still remained. The pain was constant and dull but was
made much worse with eating or drinking. He suffered with this problem for
several months and finally he was discovered to have ischemic bowel
incidentally. He was immediately referred to surgery and had a 12"
section of bowel surgically resected with placement of a GJ tube. The patient
has never used the tube and tolerates his PO intake. At this time he was
diagnosed with a vascular disease of unknown etiology. He went to numerous
physicians in an attempt to figure out what may be causing this problem. He
was sent to a rheumatologist who after significant testing decided that his
problem was probably of a vascular not rheumatologic origin. He had a recent
biopsy of his kidney done which showed arteriosclerosis and
glomerulosclerosis but no immunologic staining patterns. He also continues to
have attacks of abdominal pain the last of which was about one month ago and
caused him to lose 10 pounds. The toe pain began about three weeks ago. The
patient set up an appointment with a vascular surgeon for next Monday but
could not tolerate the pain any longer when he reported to the emergency room
this am. The patient describes getting pain as severe as a 10/10. He also
reports that this intense pain causes purple blotches to appear and march up
his legs but not to his buttocks. It blanches on pressing. The toe had caused
some throbbing episodes occasionally in the past but nothing to this degree.
In addition, the pt.
has this pain in his right forearm and hand in his ulnar distribution. He
notes that his hand, mostly his fingers, turn white in the cold and become
very numb but it improves when warming up. The pain is constant regardless of
the temperature. The patient has had an extensive work-up for many different
potential problems, but none of the results have been rewarding. The patient
does report a history of livedo reticularis and possible palpable purpura.
The patient had vascular surgery see him today but they decided that his toe
problem was more of a vasculitis type problem and so rheumatology was
consulted and has added a great deal to the assessment and plan of how we
should treat and attempt to diagnose a problem in this
PMH: Pain in Ulnar
nerve distribution in R arm from elbow to fingers - Past 1-2 wks
HTN - Well controlled (120's to 130's ) with medication
History of constipation causing rectal tears
PSH: 12" of small
bowel (not duodenum) resected
Kidney biopsy 10 years and 3 wks previous
Cholecystectomy - 99
FH: A brother has HTN
Mother has hyperlipidemia, some kind of arthritis
Sister may possibly have Raynaudís syndrome
SH: Married with one daughter who is in good health. Works
as an airline mechanic. He has been exposed to all of the solvents and
hazardous materials associated with that job. Pt. has had no history of
smoking and has a distant history of alcohol use. He served in Desert Storm.
HEENT: Denies SOB, mouth ulcerations, pain in the neck and
nosebleeds as well. The pt. is bald but wears a hairpiece.
CV: The pt. denies CP, heart palpitations or racing. Pulm: Denies lung problems or respiratory
infections. Abd: Has pain off an on. Currently is symptom free.
No blood in stool.
GU: Has difficulty starting and stopping his urine stream. Extrem: Pt. denies stiffness in joints or back
pain. He has generalized full-body muscle aches.
Neuro: Denies loss of balance, vision, or memory
Vitals: T:36.3, HR:108 BP:115/80, RR:18 SpO2:99% on RA
General: Tired, cachectic man in noticeable discomfort
HEENT: TM's clear, PEERLA, EOMI, OP pink and moist, no hemorrhage or
ulcerations, no lymphadenopathy, no thyromegaly, no carotid bruits, no JVD
PULM: Normal lung excursion, lungs CTA
CV: No heaves or thrills, nl
S1/S2 no M/R/G detected Abd: No masses, +BS, soft & non-tender, spleen
tip palpated, hepatic border 2 cm below the costal ridge, no CVA tenderness.
A GJ tube is present on his left side.
Extremities: no pulses palpated in DT or DP in either foot. Left big toe is
exquisitely tender and purple on the medial side. The toe is also cold. There
is pain in the ulnar distribution on his R. arm below the elbow. No petechia,
ulcerations, or splinter hemorrhages detected.
Neuro: CN II-XII grossly intact, UES & LES 4/5, all reflexes intact, feet
hypersensitive to stimuli, diminished vibratory sensation in LE.
A/P: 46 y/o male with
ischemic bowel problems and thrombosis of his left big toe.
1. Painful toe - The
pt. is obviously suffering greatly from the entity causing the problem with
his toe. He needs pain control and an aggressive work-up to determine the
best way to treat this problem. This problem is most likely related to the
problem causing his bowel ischemia, overall myalgias, and neuropathic pain.
He best fits into the category of a medium vessel vasculitis with PAN topping
the list. He demonstrates a chronic anemia, bowel ischemia, weight loss,
myalgias, and signs of mononeuritis multiplex all of which fit with PAN.
Hypertension, renal involvement, abdominal problems, cholecystitis, livedo
reticularis, and palpable purpura are also features of this problem and this
patient manifests them all. However, most of the time if PAN is untreated
within 2 years it is fatal and this pt. has had problems for about this
period of time.
Less likely moderate
vessel vasculitides are Takayasu's or Viral induced infections.
Cryoglobulinemia almost always occurs in conjunction with Hepatitis C and
Hepatitis B will manifest itself much like PAN. Takayasu's is also possible
except that there should be major aortic involvement and this has not been
demonstrated. The pt. has never smoked and has had unilateral extremity
involvement and began in the belly so Buerger's vasculitis is also unlikely.
The small vessel
vasculitides are also a possibility for this man's problems. Wegner's, HSP,
and mixed cryoglobulin vasculitis secondary to Hep B. or C are a possibility.
His clinical picture does not fit this group as well as the medium vessel
vascular inflammatory disorders, especially since this man has few cutaneous
antibody syndrome may also be to blame for these problems. To be diagnosed
with one of these syndromes there must be an actual event like thrombosis and
either a positive anticardiolipin or lupus anti-coagulation test. Since the
pt. has had a possible thrombotic event, these other two tests should be
looked for to determine if he may have one of these conditions. The heparin
drip he is on should protect him if he does have this condition. However, his
clinical picture does not fit the signs and symptoms of these disorders very
well but these causes must remain on the differential until some lab results
can help rule in or out the specific problem. An elevated PTT is frequently
found in pt's with either SLE or RA most often caused by lupus
The plan is to order a
huge spectrum of labs to try and figure out what is going on in this man. The
justification for this is that he may have a life-threatening condition and
delaying work-up could be dangerous for him.
- draw lupus anti-coagulant and anti-cardiolipin antibody levels
- draw Protein C, S, Factor V, and anti-thrombin levels
- draw homocysteine levels
- draw B2 glycoprotein abs.
- draw P-ANCA, C-ANCA
- draw cryoglobulins, CPK, and recheck RF and ANA
- CXR for poss granulomatous disease
- draw Hep. B and C serologies and draw LFT's
- Heparin to relieve symptoms
- PCA to help control the pain
2. CRI - The pt. has
had a baseline creatinine of about 2 due to glomerulosclerosis. He is
spilling some protein in his urine. It would be good to quantify exactly how
much protein he is losing to help determine his specific problem. He does
have a calculated anion gap, but this is likely due to his failing renal
function not a true metabolic acidosis
- 24 hour urine for protein
3. Increased SED rate
- This is a very non-specific test but it has remained elevated for a long
time. It certainly leads down the road to considering a connective tissue
cause of vasculitis.
4. Ischemic Bowel - As
mentioned above, this is most likely due to the same cause as the pt.'s toe
pain. He continues to have pain on and off and products with wheat flour
appear to make this worse. He is tolerating po
intake just fine at this time. Therefore, we will give him a wheat free diet
- Wheat free diet
5. Wt. loss - This has
occurred secondary to times when #4 above has been a problem. The pt. has
been recently gaining weight since he has felt like eating. We will feed him
whatever he can tolerate.
6. Anemia - It is
unclear at this point why this pt. had this microcytic anemia. Some of the
vasculitic syndromes are associated with anemia. His failing kidney function
may also have something to do with this. We will get some labs to see where
the etiology of this problem may be.
- Fe studies including total iron, ferritin, TIBC, etc.
- reticulocyte count
- peripheral smear
7. Elevated PTT - As
mentioned in #1, an elevated PTT not related to being anticoagulated may be
related to some rheumatologic conditions. The patient has had and elevated
PTT before starting heparin therefore using PTT to determine heparin dosing
is difficult. However, heparin levels themselves can be measured and should
be done in this case. The normal range is 0.35-0.75.
- d/c PTT for following heparin
- begin using serum heparin levels to follow anticoagulation
8. Neuropathy - The
pt. complains of neuropathies in his feet and his right hand. He is
hypersensitive to stimulation on the bottom of his feet and complains of
intermittent tingling and pain. He should have nerve conduction studies done
to locate the best location to obtain a biopsy. Vessels where the neuropathy
is a problem will most likely have the pathology that will be diagnostic.
- Nerve conduction studies
9. Cardiac - This is
probably not a cardiac problem but there may be some endocarditis that is
causing this. The BP has been well controlled on his current medications and
those should be continued. Homocysteine can cause heart problems and it
should be rechecked to make sure it isn't involved in this problem. It is
still not clear and in fact it is unlikely that he actually has
atherosclerosis. However, if he does cholesterol emboli could cause this
problem. His previous records indicate a very good LDL and cholesterol level
and that he was put on a statin more for hope it would have some effect than
for a clinical need.
- continue Lotensin
- EHCO to check for endocarditis
- draw homocysteine levels
- continue Zocor 20 mg po q.h.s. for now
10. Rectal tears - The
pt. states that he has had recent tears in his rectum since having some
increased hardness of his stools. He is very afraid to have narcotic
treatment without keeping his stools soft. We will give him an aggressive
regimen with his PCA.
- docusate 100 mg po bid
- Senna 17.2 mg po bid
11. Prophylaxis - The
pt. is anticoagulated with his heparin so DVT's are
not a concern, but the pt. does have a history of esophagitis so he should
get an H2 blocker while an inpatient to avoid reflux.
- Ranitidine 300 mg po qd
afebrile, 97-110, 18, 103-140/70's
HEENT: white sclera, no oral lesions
CV: Regular, no murmurs/gallops Abd: BS+, soft, mildly tender with light touch of
skin, J tube in place
Ext: no pitting
MS: hands/wrists/elbows/knees/ankles/mtp's -- no
SKIN: + lower extremity livido today, left toe is warmer, +ecchymotic/mottled
changes medially - unchanged, spooning of nails
Neuro: dysesthesia -- right ulnar forearm and 4th and 5th digits, motor
grossly normal in this distribution, nl light touch
of lower extremity
over past 1.5 years: nl porphyria evaluation, sl elevated homocysteine,
negative Celiac sprue eval, neg
Whipple's bx, ANCA negative, RF neg, ANA neg, persistently elevated ESR's
Kidney Bx 11/01 -- arteriosclerosis/glomerulosclerosis
on admit wbc 7500, hct
30, plt 483
creatinine 2.4 (up from 1.8 last)
U/A -- no protein, no blood ††† PTT 49
ESR 50 ††† ANCA negative
labs: nl liver tests, nl
CK, RF neg, hep B neg
46 yo male with the following problem list:
*Ischemic digit -- plethysmography showing diffuse bilateral small vessel
diminished blood flow.
*Elevated PTT -- no 1:1 or Lupus AC has been done yet!
*Suggestion of inflammation --
high ESR (but renal insufficiency may falsely elevate)
*Anemia - low Fe, low Transferrin, Ferritin 218, reticulocytes 1.1%
consistent with AOCD, no Fe deficiency with ferritin >
*Renal insufficiency - bland U/A with recent bx showing arteriosclerosis only
*Ulnar Dysesthesias/Paresthesias with apparent motor abnormality
*Hx Ischemic Bowel - bx in 2001 showing no active
We do not have the mesenteric angiogram which was
apparently done then.
the two most concerning diagnoses include systemic vasculitis, particularly
PAN, and antiphospholipid antibody syndrome (APS). Since admit, we still do
not have a better handle on the diagnosis, awaiting multiple labs, an ECHO,
and nerve conduction studies. Fortunately, his condition remains stable with
his toe perhaps even mildly improved. I am not convinced that we currently
have proof of active inflammation and
vasculitis -clearly compelling clinical picture--however, ESR and Plt elevation alone, especially with renal insufficiency,
will not be sufficient to warrant therapy. Hence, we need to continue to look
for other vasculitis mimics and look for a good source of tissue to document
active inflammation. He has had at least 1.5 years of sx's
without prednisone or cytotoxic treatment. This alone speaks against active
vasculitis throughout this time. Alternatively, he may have had active
inflammation in the past and be suffering now from complications of chronic
endothelial damage/repair -- atherosclerotic-like changes and endothelial
are unchanged from 12/7 consult.
Lupus Anticoagulant Panel
Hypercoagulable eval -- Pro C/S,
Please get "CBC with manual diff" to look
at RBC morphology and to look for eosinophilia as seen in cholesterol emboli,
get daily HCT on Heparin too
ECHO -- looking for vegetations/atrial myxoma
24 hour urine -- creatinine and protein and SPEP/UPEP
Nerve conduction studies for ulnar dysesthesias
Please obtain old mesenteric angiogram. May consider repeat mesenteric
angiogram here if no apparent bx site.
chem 7 -- ? acute change in renal function
Check Lactate (sl elevated AG on admit, hx ischemic bowel, cold toe)
Continue Heparin (no enoxaparin due to renal insufficiency)
Would hold off on Coumadin until we know if bx or arterial stick for
angiogram may be pursued.
With hx of "Raynaud's" and abnl plethysmography, could add Nifedipine for improved
Container one labeled "ileum" contains a
segment of small intestine, 18.5 cm in length x 2.0 to 3.0 cm in diameter. Much of
the central 12.0 cm is covered with thick, geographic, purulent, yellow-white exudate,
with focal hemorrhage and patchy, more fibrinous or fibrous serosal adhesions.
There is a modest wedge of mesentery, variable smooth and glistening, but on
one side also showing fairly extensive geographic exudate. A fresh silk suture
marks a transmural perforation measuring 5 x 2 mm, that on opening the duct is
at the base of a sharply punched out mucosal ulcer, 1.0 x 0.7 cm. The mucosa
otherwise is mostly relatively normal in appearance with a just a very vague,
inconspicuous, pink to light violaceous mottling. Scattered about the mucosa
are multiple small inconspicuous shallow erosions or ulcers measuring 1-5 mm.
5.0 cm from one end either is a 2.5 cm segment of slight serosal thickening and
luminal narrowing. 1A-1B - surgical margins, inked, each including punctate and
slightly larger but small shallow mucosal erosions; 1C - sections of the
largest mucosal ulcer with sutured transmural perforation; 1D-1E - random
sections including small and punctate mucosal erosions; 1F-1L -generous
sections of mesentery with major mesenteric blood vessels. Container two labeled
"jejunum" contains a segment of small gut measuring 45.0cm in length
x up to approximately 3.3 cm in general average diameter. The serosal
appearance is variable, from smooth to shiny to dull and slightly granular, to
showing geographic areas of layered, thick, yellowish, gray-white exudate, and
scattered areas of serosal hemorrhage and fairly delicate serosal adhesions.
Approximately 12.0 cm from one surgical margin, there is a 5.0 cm segment of
slightly bulbous dilatation and thinning of the wall, associated with a small,
slight, band-like stricture and contracture of the mesentery and slightly onto
the adjacent gut wall. There are two freshly sutured, transmural perforations,
one 3.5 cm from one surgical margin, the second 2.5 cm from the opposite
surgical margin, both associated with either geographic exudate on the serosal
surface or a surrounding rim of gray-green apparent necrosis of the serosa and
muscular wall. The opened segment shows a variable mucosa, in some areas
normal, larger areas showing a slight darker, violaceous to red maroon
discoloration. In the dilated thin-walled area, the mucosa shows a variable
appearance with some flattening and granularity, surrounding very irregular,
somewhat serpiginous areas of shallow mucosal ulceration measuring up to 3.0 x
1.0 cm, generally somewhat linear. Several small scattered superficial mucosal
erosions from punctate up to 5 mm are identified. Both transmural perforations
are associated with punched out, full thickness mucosal ulcers measuring up to
5-7 x 2-4 mm. 2A - one surgical margin; 2B - perforation near the surgical
margin; 2C - opposite surgical margin; 2D - perforation near this margin; 2E-2F
- sections of the dilated area with the large mucosal ulcers; 2G-2H - random
mucosal sections trying to demonstrate the punctate and small mucosal erosions;
2I-2L - sections from mesentery.
SP MICROSCOPIC EXAMINATION
of the ileum show small intestine with mucosal ulceration andperforations.
The margins show mesenteric inflammation but viable tissue. Sections of the
jejunum also show small bowel with areas of ischemic necrosis and perforation.
The surgical margins show mesenteric acute and chronic inflammation but show
viable tissue. Sections of the mesentery of both specimens show numerous
vessels with evidence of old vasculitis. This includes disruption of the
internal elastic lamina, mural fibrosis and thrombosis with recanalization. We
do not see evidence of acute vasculitis and these changes would be that of
healed polyarteritis nodosa. These changes occur in multiple medium-sized vessels.
ILEUM, PARTIAL EXCISION - -
MUCOSAL ULCERATION AND PERFORATION. -
MESENTERIC VESSELS WITH EVIDENCE OF OLD VASCULITIS.
PARTIAL EXCISION - -
ISCHEMIC NECROSIS. -
MESENTERIC VESSELS WITH EVIDENCE OF OLD VASCULITIS.
Received labeled with the patient's name, medical record number and "muscle"is fresh tissue measuring
1.5 x 1.0 x 0.3 cm. The specimen is divided into four portions. One piece of tissue is placed in glutaraldehyde
and saved for possible electron microscopy. Two pieces of tissue are frozen and submitted for histochemical
staining. One piece of tissue is placed in formalin and submitted for light microscopy. The formalin fixed
tissue consists of a 2.1 x 0.7 x 0.5 cm, tan-brown, ragged, fibrous soft tissue.
Received labeled with the patient's name, medical record number and "nerve" is fresh tissue that measures
2.0 x 0.2 x 0.2 cm. The specimen is divided into two portions. One piece of tissue is placed in glutaraldehyde
and sent for plastic embedding and thick sections. One piece of tissue is placed in formalin and submitted
for light microscopy. The formalin fixed tissue consists of a single tan-white, smooth, fibrous soft
tissue measuring 1.4 x 0.2 x 0.2 cm. Toto 1A with instructions to histology for cross and longitudinal sections.
SP MICROSCOPIC EXAMINATION
histochemical stains on the frozen tissue demonstrate skeletal muscle with
scattered atrophic fibers. There is no inflammation. There is no degeneration or
regeneration in the fibers. The vessels appear normal. The ATPase pH 9.4 shows
that the atrophic fibers are Type II fibers. The normal mosaic pattern of Type
I and Type II fibers is seen. There is no evidence for a neurogenic atrophy.
The modified Gomori trichrome shows the normal fiber architecture. The NADH
shows the normal inter myofibrillar architecture. The PAS shows no excessive
glycogen. The paraffin embedded section of muscle demonstrates two arterioles
with chronic inflammatory cells infiltrating the walls. There is eccentric
involvement of the vessel wall in one of the vessels. There is no necrosis of
the vessel walls. The inflammation is primarily composed of lymphocytes. The
paraffin embedded section of nerve demonstrates several arterioles with
perivascular cuffing by lymphocytes and involvement of the vessel walls by the
inflammation. There is no overt necrosis of the vessel walls.
GASTROCNEMIUS MUSCLE, BIOPSY, SKELETAL MUSCLE WITH VASCULITIS
NERVE, BIOPSY, PERIPHERAL NERVE WITH VASCULITIS AND FOCAL LOSS OF MYELINATED
HPI: This is a 46 yo
white male with PAN (negative HBV and HCV studies, + mesenteric angiogram, mononeuritis
+ bx, ischemic toes, ischemic bowel/resection) dx
12/01, has been on steroids and Cytoxan subsequently with persistent active
inflammation. He has necrotic toes which require amputation, and he has
malabsorption issues with + fecal fat studies, in need of subsequent GI
seen by rheumatology, who noted persistent evidence of inflammation with ESR
82 and new vasculitic-appearing leg ulcer as well as persistent wt loss. Due
to concerns of malabsorption, plans for high dose Solu-Medrol X 2 days with
increase of prednisone to 100 mg qd were made.
while pt was here to receive his 2nd Solu-Medrol infusion, pt complained of
severe abdominal pain that started that am, which he describes as a cramping
feeling. He says this pain varies in intensity from 10/10 at its worst to a
4/10 at its best. Despite this pain he sates his appetite is okay. He denies
any nausea or vomiting. 2 year history of chronic diarrhea, with no recent
change in its character. Denies any BRBPR or melena. He states he has
episodes similar to this about one time a month, with resolution after
1) PAD dx 12/01. Course as outlined above
2) ischemic bowel with resection of small bowel 12/00
3) Dry gangrene of L great and second toe.
5) jejunostomy tube
Cytoxan 150 mg qd
Prednisone 40 mg qd
Neurontin 300 mg bid-tid
Lotensin 10 mg bid
Fentanyl patch 50 mcg
Elavil 50 mg bid
Nifedipine 30 mg qd
Pancrease 3 cap tid, and amylase and lipase
Zantac 150 mg bid prn
Coumadin 3 mg qd
Zocor 20 mg qd--last lipids very low so he is holding
Actonel 30 mg q week
Bactrim DS 1 po q mwf
Percocet 7.5 mg qd to bid
NKDA, Wheat intolerance
Mother has hypercholesterolemia and arthritis. Sister has Raynaud's
He is married with one daughter. No tobacco. No alcohol. No IVDA.
No fevers, + chills, + weight loss, no change in appetite, o rash, no
bruising, no HA, no dizziness, no syncope, no vertigo, no tinnitus no cough,
no dyspnea, + palpitations, no CP, + difficulty swallowing ("food gets
stuck"), no heartburn, no N/v, no dysuria, nocturia (1x per hour), +
numbness. + body aches.
93 140/82 16 35.4
HEENT: PERRLA, EOMI, no icterus noted. OP clear. Eschar present over L eye.
Neck: No TM, ? of supraclavicular lymph node on L vs vessel.
CV: rrr, no mrg Abd: Soft, non distended, bilateral lower abdomen
tenderness. Tender to percussion. No masses, no HSM. BS+.
Ext: Left great and second toe necrotic. L lat
malleolus with ulcer. L should with black eschar. L elbow with eschar. R
Achilles with eschar. R heal with eschar.
Musculoskeletal: hands/wrists/elbows/knees/ankles - no synovitis, nlrom, nontender bilaterally
WBC 5.1 (72% PMN, Band 25, 2% lymph) HCT 25.3 Plt 379
Na 133 K 3.3 Cl 95 CO2
28 BUN 21 Cr 1.5 Glu 117
AST 12 ALT 15 Alk
Phos 59 Alb 2.7 T bili 0.3
PT 28.5 INR 2.7 Lactate
5.9 Lipase 41 Amylase 36
ESR 82 (8/15/02)
x-ray: Large amount of stool, no free air.
1) Abdominal Pain: With past hx of mesenteric
ischemia and elevated Lactate, concern for recurrent ischemia. However, pt
reports exact same pain multiple times in past, resolves with hydration.
Surgery consulted, not an acute abdomen. Constipation visible on KUB. Will use
enema per surgery recommendations. Will follow lactates, exam.
2) Elevated lactate-- suggestive of ischemia. Pt with necrotic toe. This
could be a possible other source of ischemia.
3) necrotic toe-- will consult vascular surgery regarding would care.
4) PAN -- marked systemic inflammation and constitutional sx's
persist; Will continue Cytoxan, Solu-Medrol x 1 day, then prednisone 100 mg
qd. Risedronate Q week for bone protection.
4) Anemia-- recent guaiac negative. Will obtain peripheral smear, retic count, B 12, folate, ferritin, TIBC. Secondary to
chronic dz vs. renal insufficiency, vs loss.
5) will obtain foot x-ray, look for osteomyelitis in light of elevated ESR.
Blood cx x 2.
6) Skin lesions-- will consult derm to see if they feel consistent with
vasculitis. However, in light of pt poor healing, do not desire biopsy at
7) Malabsorption-- study showed 11.9 g fat excreted over 24 hours, with 2-7
normal. Unsure of etiology-- bacterial overgrowth, secondary to dysmotility?
Will consult GI for their input.
8) Pt is full code.
OPERATION PERFORMED: Segmental resection
of small bowel with †††††††††† primary anastomosis.
ANESTHESIA: †††† General endotracheal. † OPERATIVE DETAIL AND FINDINGS: The patient is a 47-year-old gentleman
with polyarteritis nodosa whom we were consulted on this morning for
abdominal pain and free air. He has been undergoing a steroid pulse for
flare-up of his vasculitis and this complication has happened after a couple
of days in the hospital.
After getting informed
consent he was brought to the Operating Room where he underwent general
endotracheal anesthesia. A Foley catheter was placed. Central line was placed
in the right internal jugular vein and our resuscitation was continued with a
central line as opposed to the peripheral line which was running more slowly.
A left femoral arterial line was placed by anesthesia as he had no radial
artery pulses that were palpable. He was then finally placed supine and
prepped and draped in the usual manner. He had had a previous midline
incision from a small bowel resection from a couple of years ago. It was
unclear whether he had perforated or just strictured. In any event, his
midline was opened. We gained access to his abdomen without any difficulty.
There was really very little in the way of adhesions. There was some free air
and there was some dirty dish brown-colored free peritoneal fluid with some
odor to it in the abdominal cavity.
getting the omentum off of his midline and freeing up a couple of colon that
were stuck to some small bowel, we began to run his small bowel. From his
ligament of Treitz it was about 8 inches down to an old jejunostomy feeding
tube site. This was not obstructed. Then between the jejunostomy feeding tube
site and the ileocecal valve there were two stapled side-to-side function
end-to-end anastomoses indicating prior resections and there were four bowel
perforations. There were two perforations such that it appeared that we could
just resect two small segmental resections. The most distal one in the ileum
amounted to about 8 inches of intestine and the more proximal one in the
jejunum would require the removal of about 18 inches of intestine.
intervening bowel between the two perforations was very mottled and
hemorrhagic and it looked very compromised. The area around the punctate
perforations was very mottled as well and it did not appear that it was a
very safe thing just to oversew them. So we fired the GIA stapler across the
bowel above and below the perforation in the areas of good bowel and we
resected the mesentery in between 6-inch clamps and tied the stumps with 3-0
silk ties. We then did a functional end-to-end anastomosis with the GIA
stapler and the TA-60 stapler. There were good staple line crossings and the
bowel did not look compromised in the area that was reanastomosed.
closed the mesenteric defects with running 3-0 Vicryl. At the end we ran the
bowel again and there were not any other areas of compromise or perforation.
We had resected about 24-inches of bowel and she had about 48 inches of bowel
left in measuring it with an 18-inch free silk tie and measuring it across
the antimesenteric border of the bowel and his ileocecal valve was intact.
The stomach looked fine. Duodenum looked fine. Pancreas, liver and colon
looked fine. His transverse colon was a little thin and dilated. The rectum
washed the abdomen out with about 6 liters of warm saline and aspirated all
of the fluid. The feeding tube was then exchanged for a 12-French red rubber
catheter. This feeding tube had been placed two years ago. It had never been
used. The plastic was brown and discolored and partially filled with
concretions, so it was simply removed in the Operating Room and then a new
red rubber catheter placed in there and secured with a 2-0 silk stitch. The red
rubber catheter was placed downstream of the insertion point. The original
catheter had worked its way upstream.
abdomen was then closed with running 1-0 Surgipro. The subcutaneous space was
irrigated and the skin was closed with staples. He tolerated the procedure
reasonably well. With the 4 liters of crystalloid he received during the
two-hour operation his heart rate came down and his blood pressure stabilized
and he made about 400 cc of urine. The blood loss was about 100 cc. He also
received the beginning of what was going to be a 2-unit packed cell infusion
for a HCT of about 27 at the beginning of the procedure. All sponge counts,
needle counts and instrument counts were correct. He was taken to the ICU
intubated following the procedure, having tolerated it reasonably well.
Comments: DIFFERENTIAL: Segs 85, bands 13, monos 1, lymphs 1. MORPHOLOGY: Erythrocytes are normochromic and macrocytic and exhibit moderate
anisopoikilocytosis. Macrocytes and burr cells are readily identified.
Myeloid forms comprise the predominant leukocyte population and demonstrate a
shift to immaturity, with increased numbers of bands identified. Lymphocytes
are markedly reduced in number. Platelets are adequate in number and
unremarkable in morphology. PERIPHERAL BLOOD: - NORMOCHROMIC, MACROCYTIC ANEMIA WITH MODERATE ANISOPOIKILOCYTOSIS.
- RELATIVE NEUTROPHILIA WITH SHIFT TO IMMATURITY IN MYELOID SERIES.
- ABSOLUTE LYMPHOPENIA. †
FINDINGS : AP view of the
chest is obtained. This is a technically limited study
with exclusion of the bases. CHEST TUBES AND CATHETERS:
There is a right IJ catheter with tip in the SVC. The endotracheal
tube is 6 cm above the carina. The nasogastric tube extends
below the margins of the study. LUNG INFLATION: Lung
inflation is normal. PULMONARY PARENCHYMA: There
is increased opacity of the right hemithorax and the left
lower lobe. There is increased left retrocardiac opacity,
consistent with effusion, atelectasis or consolidation. Kerley B
lines are present. PLEURAL SPACE: There is
increased bilateral pleural effusion. There is no pleural
thickening or pneumothorax. CARDIAC AND MEDIASTINAL CONTOURS : The cardiac and mediastinal silhouettes are unchanged. PULMONARY VESSELS: Pulmonary
vasculature is indistinct. CHEST WALL AND SOFT TISSUE:
There are no osseous or soft tissue lesions.
IMPRESSION: 1. INCREASED
PULMONARY EDEMA. 2. INCREASED BILATERAL PLEURAL EFFUSION.
3. TECHNICALLY LIMITED STUDY WITH EXCLUSION OF THE LEFT BASE.
CHEST XRAY 1V
Atelectasis, vasculitis, abdominal pain.
FINDINGS: Comparison with
1990s- 2002 at 0547 hours.
silhouette is unchanged. There is increasing vascular
enlargement and indistinctness with interval development of Kerley B
lines and increasing diffuse hazy opacity throughout the lungs
bilaterally. Left retrocardiac consolidative opacity is unchanged. No
other change in the pulmonary parenchymal or vascular
markings seen. The endotracheal tube, NG tube, and right internal
jugular central venous sheath are unchanged. No other definite
interval changes are seen.
IMPRESSION:Increasing changes of pulmonary edema as
described. Increased diffuse density
has configuration suggesting posterior layering pleural effusions
bilaterally. Left basilar consolidation
may represent atelectasis, aspiration, or infiltrate. Correlation with
clinical findings recommended.
CHEST XRAY 1V
Findings: Comparison study
is dated 8/18/02. The tubes and lines are unchanged in appearance.
Increasing opacity within the left lower lobe is seen resulting
in obscuration of the left hemidiaphragm. No pleural
effusions are identified. There is no evidence of pulmonary edema.
The osseous structures are stable in appearance.
Impression: New ill-defined
opacity seen within the left lower lobe with obscuration of the
left hemidiaphragm. Differential considerations include
atelectasis versus pneumonia.
CHEST XRAY 1V
Suspected free air under the
FINDINGS Lungs are clear with no
evidence of consolidation or pulmonary edema. Normal size and
configuration of the cardiomediastinal silhouette. The costophrenic recesses
are clear bilaterally with no evidence of pleural effusions or
pneumothorax. There is evidence of free
air under the right hemidiaphragm.
IMPRESSION: NO EVIDENCE OF
ACUTE CARDIOPULMONARY PROCESS. FREE AIR UNDER THE RIGHT
ABDOMEN 1 VIEW
Abdomen single view
REASON FOR EXAM: Abdominal
intra-abdominal air seen suggesting bowel perforation. Large amount of
fecal material seen in the colon. No abnormal calcifications
seen or evidence of organomegaly. Left sided tube seen ending in
the abdominal cavity. Status post cholecystectomy with
surgical clips in the right hypochondrium.
intraperitoneal air suggesting bowel perforation.
FOOT 2 VIEW
LEFT FOOT: 08/16/2002.
HISTORY: Evaluate for osteomyelitis.
FINDINGS: There is a bipartite lateral sesamoid. This is of no clinical significance. There are no areas of rarefaction to suggest osteomyelitis.
IMPRESSION: NO EVIDENCE OF RAREFACTION TO SUGGEST OSTEOMYELITIS. †
ADMISSION DIAGNOSIS: Abdominal pain and polyarteritis nodosa.
OTHER DIAGNOSES: 1. Hypertension. 2. Raynaud's. 3. Status post small-bowel resection and jejunostomy tube placement. 4. Renal insufficiency. 5. Gangrene of left first and second toes.
PROCEDURE: SURGICAL: Small-bowel resection with primary anastomosis on 08/18/2002.
HISTORY: Patient was a 46-year-old male with a diagnosis of
polyarteritis nodosa diagnosed in December 2001 who had been on treatment
regimens of steroids and Cytoxan with persistent and active inflammation. He
had had necrotic toes which required amputation; malabsorption issues and
positive fecal fat studies. He was seen by Rheumatology who noted the
persistent inflammation and new vasculitic appearing leg ulcers. He had
persistent weight loss due to malabsorption. High dose Solu-Medrol was given
for two days with increases of his prednisone to 100 mg q.d. On the second
day of Solu-Medrol infusion he had severe abdominal pain.
PAST MEDICAL HISTORY: As above. In addition, he had ischemic bowel with
resection of small bowel back in December 2002 and then dry gangrene of great
and second toes, hypertension, J-tube placement, and a cholecystectomy.
PHYSICAL EXAMINATION: VITAL SIGNS: He was febrile, pulse 93, blood
Soft, nondistended, with bilateral lower abdominal tenderness.
LABORATORY DATA: Total white count of 5.1 with 70% polys, bands 25, 2%
lymphs, hematocrit at 25, lactate of 5.9, and an INR of 2.7.
Abdominal films at that time showed a large amount of colonic fecal
material with no evidence of intestinal obstruction or free intra-abdominal
HOSPITAL COURSE: The initial assessment was abdominal pain with a
further plan to obtain a Surgery consult and elevated lactate which was felt
to be due to the patient's necrotic toe. Polyarteritis nodosa treated with
Cytoxan, Solu-Medrol, and prednisone. Anemia was being worked up.
Late on the first hospital day, Surgery consult was obtained which at that
time the patient had no evidence of an acute abdomen and the initial
assessment was thought to be due to constipation/dehydration. However, early
on the third hospital day, the Surgery Team was called to see the patient in
regards to increasing abdominal distention and free air on the chest x-ray
and the patient had a lactate of 4.6 at that time and was taken to the
operating room emergently for an exploratory laparotomy. For details, please
see operative report, but during the exploratory laparotomy they found two
perforations repaired by two small segmental resections with primary
Postoperatively the patient was not doing well and by the second
postoperative day he became increasingly unstable with increasing tachypnea
and tachycardia with fevers to 40 degrees Celsius. His abdomen was increased
in distention and his lactate was starting to rise. At this time, concern
regarding an intra-abdominal process with perforation or anastomotic leak was
discussed with the family and a grave prognosis was shared with them who at
this time wished to only continue supportive measures and did not wish to
continue any aggressive care. The patient was made DNR with no further
operations. He was maintained on supportive care with IV antibiotics and fluids
and pain control.
The patient was managed with palliative care until 08/21/2002 where he continued to deteriorate and
the family elected to withdraw support and the patient did expire one hour
AUTOPSY CAUSE OF DEATH: Pneumonia DUE TO: Sepsis DUE TO: Perforated bowel DUE TO: Polyarteritis nodosa. ------------------------
AU CASE SUMMARY
CLINICAL HISTORY: The patient was a
46-year-old male, veteran of the Gulf war. His past medical history was
significant for hypertension, mononeuritis multiplex, Raynaud's
phenomenon, chronic renal insufficiency, macrocytic anemia, and
polyarteritis nodosa with complications including ischemic bowel (status
post two small bowel resections and jejunostomy tube placement) dry
gangrenous left big toe and left second toe, renal insufficiency and
livedo reticularis. He was also a heterozygote for factor V Leiden. He
has a sister with history of Raynaud's syndrome. The patient had been on
steroids and Cytoxan due to concerns of malabsorption and persistent
evidence of inflammation (ESR 82). He was to receive Solu-Medrol for two
days and prednisone, 100 mg qd. The patient was receiving his second high
dose of Solu-Medrol when he developed abdominal pain. The patient was
admitted. Abdominal x-rays at that time demonstrated a large amount of
stool without free air. No acute surgical intervention was taken and the
patient was given IV fluids, an enema and magnesium citrate without
results. Labs on admission were: Sodium 133, potassium 3.3, chloride 95,
C02 28, urea nitrogen 21, serum creatinine 1.5, glucose 117; the white
blood cell count was 5.1, hematocrit 25.3, platelets 379; AST 12, ALT 15,
alkaline phosphatase 59, albumin 2.7, total bilirubin 0.3, PT
28.5, INR 2.7, lactate 5.9, lipase 41, amylase 56. The patient's stool
was guaiac negative. During the next 24 hours the radiology report was
revised to read "questionable sub-diaphragmatic lucency on the left
which may represent free air". The patient was taken to surgery,
where four perforations were noted between the jejunostomy site and the
ileocecal valve. Two sections of small intestine were removed, the proximal
portion measuring 18 inches and the distal portion measuring 8 inches. An
end-to-end anastomosis was performed. The patient was intubated and
sedated. He did relatively well the first 12 hours status post surgery.
However, his pH continued to drop, he was dependent on the ventilator,
and became hemodynamically unstable. Chest x-ray on 8-20-02 suggested
posterior pleural effusions bilaterally. Labs on 8-21-02 were as follows:
WBC 7.5, hematocrit 27.2, platelets 24, potassium 4.1, urea nitrogen 37,
serum creatinine 2.4, ABG's
7.49\28.4\73.3\21.6. The family decided not to continue aggressive care
and support was withdrawn. The patient expired on August 21st, 2002,
† At autopsy, numerous skin lesions were present (ulcerations and
eschar). The left great toe and left second toe were necrotic. Several
areas of necrosis were found in the stomach, duodenum and colon. There
was evidence of peritonitis, gastrohepatic adhesions, and 100 cc of
ascites (serous). Multiple infarcts were seen in the kidneys, adrenals, and
testicles. Microscopically, scarring and recanalization of medium-sized
vessels was noted in the mesentery, stomach, spleen, liver, and kidneys.
The lungs demonstrated mild bronchopneumonia and early diffuse alveolar
damage. A 675 cc right serous pleural effusion, and 1000 cc left serous
pleural effusions were present. The bone marrow as hypocellular (40%),
consistent with the patient's use of Cytoxan. Overall, the findings are
suggestive of classic polyarteritis nodosa. Typical features of this
disease include livedo reticularis, necrotic lesions, infarcts of the
digits, and mononeuritis multiplex. Involvement of the medium-sized
arteries in the skin, gastrointestinal tract, and kidneys, is also
consistent with PAN. ANCA tests are often negative.
Immediate cause of death was
pneumonia, due to sepsis after perforation of the small bowel. The small
bowel perforations were likely a complication from PAN. Being
heterozygous for Factor V Leiden also increased this patient's risk for
AU FINAL DIAGNOSIS
CLINICAL DIAGNOSES: 1. Heterozygous for factor V Leiden. 2. Polyarteritis nodosa †† A) Small bowel ischemia
status post two small bowel resections †† B) Dry gangrenous left
great toe and left second toe. †† C) Renal insufficiency. †† D) Livedo reticularis. 3. Macrocytic anemia. 4. Hypertension. 5. Raynaud's syndrome. 6. Mononeuritis multiplex.
FINAL ANATOMIC DIAGNOSES: I. Early diffuse alveolar damage and bronchopneumonia. †† A) Right pleural serous
effusion 675 cc. †† B) Left pleural serous
effusion 1,000 cc. II. Serous pericardial effusion 30 cc. III. Polyarteritis nodosa (12/01) (SP-01-12921). ††† A) Areas of necrosis in
colon, duodenum and stomach with gastrohepatic †††††† adhesions. †††††† 1) Peritonitis. †††††† 2) Ascites 100 cc
serous fluid. †††††† 3) Status post small
bowel excision 96.5 cm (SP-02-8250). †††††† 4) Jejunostomy site
patent. †††††† 5) Midline incision
with staples clean and healing. †† B) Skin lesions. †††††† 1) Ulcer - left
lateral malleolus. †††††† 2) Black eschar - left
shoulder. †††††† 3) Eschar left elbow. †††††† 4) Eschar/ulcer right
Achilles 2.4 x 2.7 cm. †††††† 5) Ulcer right heel
6.2 x 5.7 cm. †††††† 6) Necrotic great left
toe and left 2nd toe. †† C) Multiple old infarcts of
kidneys. †† D) Focal testicular
infarcts. IV. Incidental findings: †† A) Surgically absent
gallbladder. †† B) Scrotal edema. †† C) Diffuse hair loss. †† D) Mild scoliosis. V. Neuropathology report to follow. ------------------------ †
AU GROSS DESCRIPTION
EXTERNAL EXAMINATION: A duly
executed permit for autopsy is received from the wife. The body length is
185 cm crown-to-heel and 79 cm crown-to-rump. The body is estimated to
weigh 77.3 kg. The body is that of a normally developed Caucasian male
who appears much older than the stated age of 46 years. His body habitus
is cachectic. The head circumference is 56 cm, the head is normal in size
and the shape is symmetric. The hair distribution is normal and the
texture is fine. The scalp hair is light brown to gray and medium length
(7 cm) and shows baldness over the frontal and vertex area. The face is
not remarkable. The eyes are normal and blue in color. The right pupil measures
4.0 mm and the left pupil measures 5.0 mm. The ears are normal. The nose,
mouth and neck are normal. There is 4+ dependent livor of the posterior
and 0 rigor mortis. A 3.8 x 1.2 cm scar is present over the left
shoulder. A 1.2 cm area of ulceration is present on the mid-back, and a
3.4 cm ulceration is present on the right buttocks. The right medial
malleolus has a 2.4 x 2.7 ulcer. The right Achilles has a 6.2 x 5.7 cm
ulcer and the right arch of the foot has a 1.0 cm ulcer. A 7.8 cm scar is
present on the anterior right leg, and a 1.0 cm scar is present on the
medial aspect of the left knee. The lower extremity calf muscles are thin
and the legs are hairless. A 24 cm abdominal incision is present, held
together with staples. An old jejunostomy sitemeasuring 3.0
cm is present in the left lower quadrant. Intravenous access lines are
found on both forearms bilaterally. The chest circumference is 89 cm and
the chest is symmetric. The breasts are normal and the chest hair is
scanty. The abdominal circumference is 78 cm and the abdomen is flat. The
back shows minimal scoliosis with a major curve to the right. The
external genitalia are normal for male sex. The penis is circumcised and
the scrotum is edematous. The extremities show no clubbing. However, the
left great toe and left second toe show dry gangrene. CENTRAL NERVOUS SYSTEM: A bitemporal incision is performed and the
calvarium is removed. The scalp is normal. The skull is of average
thickness. The middle ears are not examined. The dura is normal. The
meninges are normal. The cerebral vessels show no atherosclerosis. The
brain weighs 1,410 grams. The brain and spinal cord are saved for further
neuropathologic examination. THORACIC CAVITY: A "Y" incision is made. The subcutaneous
fat measures 0.7 cm at the level of the nipples. Organ situs in the
thorax is normal. The pleural surfaces are smooth and glistening. The
pleural cavities contain 675 cc on the right and 1,000 cc on the left of
serous fluid. A pneumothorax is not found. The mediastinum is without
lesions. ABDOMINAL CAVITY: A midline incision is made. The fat measures 1.2
cm at the level of the liver. Organ situs in the abdomen is normal. The
diaphragmatic dome heights are at the level of the sixth rib on the right
and sixth rib on the left. The liver is 2.5 cm below the right costal
margin at the midclavicular line. The peritoneal surfaces show fibrous
adhesions and purulent exudate. The peritoneal cavities contain 100 cc of
serous fluid. The retroperitoneum is without lesions. The stomach
contains dark brown fluid. There appears to be an area of retrogastric
hemorrhage. CARDIOVASCULAR SYSTEM: The heart weighs 352 grams. The pericardial
cavity contains 30 cc of serous fluid. The epicardium is smooth and
glistening and the epicardial fat is of the usual amount. The heart
chambers are not dilated. The right ventricular thickness is 0.5 cm and
the length is 8.4 cm. The left ventricular thickness is 1.5 cm and the
length is 8.1 cm. The atrial appendages are free of thrombi. The foramen
ovale is closed. The myocardium is firm and brown, with no fibrosis. The
endocardium is thin and translucent. The trabeculae carneae and papillary
muscles are normal. The chordae tendineae are normal. The heart valves are thin and pliable. The heart valve
ring circumferences are: 13.0 cm tricuspid; 7.0 cm pulmonic; 10.2 cm
mitral; 6.5 cm aortic. The coronary arteries show right dominance with
minimal atherosclerosis and no narrowing of all branches. Thrombosis of
no vessels is found. The aorta is elastic and shows no atherosclerosis.
The major branches are all patent. The vena cava are patent. RESPIRATORY TRACT: The pharynx, larynx, trachea and mainstem
bronchi are without lesions. The right lung weighs 870 grams and the left
lung weighs 700 grams. The pleural surfaces are smooth. The lungs are
inflated with formalin prior to sectioning. The pulmonary parenchyma
shows posterior congestion. On sectioning, the parenchyma shows areas of
patchy consolidation in the upper lobes. Tumor masses and granulomas are
not seen. The cut surfaces of the lungs are pink and exude no fluid.
Anthracotic pigmentation is not marked. The bronchi are normal. The
pulmonary arteries do not have premortem
thromboemboli. The pulmonary arteries have no atherosclerosis. The
pulmonary veins are clear. GASTROINTESTINAL TRACT: The tongue is normal. The submandibular
salivary glands are not examined. The esophagus is without lesions. The
stomach contains dark brown fluid. The gastric mucosa shows several areas
of erosion. The esophagus is without lesions and the stomach contains
dark brown fluid. The gastric mucosa shows several areas of erosion. The
rugal pattern is normal. The pylorus is patent and the duodenum shows
several areas of necrosis. The remaining small intestine (approximately 4
feet) is patent at the area of the old jejunostomy site. The mucosa is
velvety and the folds are normal. The appendix is normal. The large
intestine is normal. The mucosa is velvety and the mucosal folds are
normal. The bowel contents consist of a moderate amount of soft green
stool. The mesenteric arteries and veins appear grossly normal. PANCREAS: The pancreas measures 15.2 x 2.5 x 1.6 cm and is the
usual size, firm, with normal architecture. Fat necrosis is not present.
The pancreatic duct is patent with no stones and enters the duodenum at
the ampulla of Vater. HEPATOBILIARY SYSTEM: The liver weighs 2,050 grams. The liver
capsule is smooth and glistening. The liver edge is sharp. The hepatic
parenchyma is firm and brown. Cirrhosis is not present and a lobular
pattern is not visible. Tumor masses are not seen. The portal vein,
hepatic artery and hepatic veins are patent. The gallbladder is absent.
The cystic duct, extrahepatic ducts,and
intrahepatic ducts are patent. The ampulla of Vater is normal.
SPLEEN AND LYMPHATIC SYSTEM: The
spleen weighs 200 grams. The splenic capsule is smooth and translucent
with no lesions. The splenic parenchyma is dark red and soft. The
follicular and trabecular pattern is not visible. There are no accessory
spleens found. The splenic artery and splenic vein are patent. URINARY SYSTEM: The right kidney weighs 82 grams and the left
kidney weighs 90 grams. The capsules strip with ease. The cortical
surfaces of the kidneys are pale red, smooth, and nodular, with many
V-shaped scars. The cut surfaces are pale red. The right cortical
thickness ranges from 0.3 cm to 0.9 cm. The left cortical thickness
ranges from 0.5 cm to 1.0 cm. The corticomedullary demarcations are good.
The medullae are red. There are no cysts present. The pyramids are
normal. The calyces and pelves are normal. The uterus are normal and
enter the bladder at the trigone. The bladder is the usual size with a
thin wall and smooth mucosa throughout. A catheter is not present. The
bladder contains a small amount of yellow urine and no calculi. The urethra
is patent. The renal arteries show no atherosclerosis. The renal veins are
clear. MALE GENITAL SYSTEM: The prostate is normal in size and firm with
the usual appearance. The seminal vesicles are normal. The testicles are
normal. On sectioning they are pale brown and soft in consistency. The
tubules string poorly. The epididymides are normal. ENDOCRINE GLANDS: The pituitary is the usual size, shape, and
color. The thyroid weighs 28.1 grams and is the usual size. The thyroid
has the usual shape, color and consistency. On sectioning the parenchyma
is red-brown and firm with no nodules. No parathyroid glands are found.
The right adrenal gland weighs 8.5 grams and the left adrenal gland
weighs 8.3 grams. The adrenals are normal in size with the usual shape,
color, and consistency. Their cortices have the usual appearance. The
medullae are normal. MUSCULOSKELETAL SYSTEM: The body and extremities are symmetric with
no malformations. Skeletal muscles are red-brown. There is evidence
for muscle wasting in the lower†
extremities bilaterally. Bone deformities are not present.
Cardiopulmonary resuscitation was not performed. The joints are not
examined. The vertebral bone marrow is red and the vertebral bone is
normal in consistency. CASSETTE SUBMISSION: A - Bone marrow (rib). B - Left and right adrenal. C - Pituitary. D - Septum, left anterior descending coronary artery, and left
ventricle. E - Right ventricle and right circumflex artery. F - Base of first and second left toes. G - Spleen with vessels. H - Diaphragm. I - Mesentery. J - Stomach and pancreas. K - Retrogastric hemorrhage. L - Liver. M - Lung - right upper lobe. N - Lung - right middle lobe. O - Lung - right lower lobe. P - Bone. Q - Lung - left upper lobe. R - Lung - left lower lobe. S - Thyroid. T - Testes. U - Right kidney. V - Left kidney. W - Bladder and prostate. X - Colon - cecal area. Y - Diaphragm ------------------------
AU MICROSCOPIC DESCRIPTION
Bone Marrow: Sections of bone marrow
from the rib (cassette A) demonstrate hypocellularity, estimated at 40%. All three cell lines are identified
with a myeloid to erythroid ratio of 3:1. Mesentery: Sections of the mesentery (cassette I) demonstrate
scarring and recanalization of the medium sized arteries. The larger vessels
demonstrate no abnormalities. Elastin stain demonstrates intact elastic lamina. Diaphragm: A section of diaphragm (cassette H and Y) demonstrates
muscle loss and acute inflammation. Pancreas: A section of pancreas (cassette J) demonstrates no
abnormalities. Stomach: A section of stomach (cassette J) demonstrates areas of
vascular destruction. Sections of the posterior stomach (cassette K) show
fat necrosis and recanalized vessels. There is also acute inflammation. Elastin
stain demonstrates intact elastic lamina. Spleen: Sections of the spleen (cassette G) demonstrate amorphous
material surrounding the lumens of medium to small sized vessels. The larger
vessels demonstrate no abnormalities. Trichrome stains show occlusion and
fibrin deposition in the walls of medium to small sized vessels. Congo Red
stain is negative for amyloid. Liver: Sections of the liver (cassette L) demonstrate some bile
stasis. There is minimal steatosis and the medium sized arteries have thickened
walls. Iron stain is negative. Lung: Sections of the lung (cassettes M, O, Q, R) demonstrate
patchy bronchopneumonia and early diffuse alveolar damage. Note: There is
a floater in cassette M. Heart: Sections of the left anterior descending coronary artery
(cassette D) demonstrate a thickened wall with medial hypertrophy and fibrosis.
The left ventricle and septum demonstrate no abnormalities. The right
ventricle (cassette E) demonstrates no abnormalities. The right coronary
artery (cassette E) shows eccentric scarring and fibrosis. There is
evidence of old vascular disease and calcifications in several of the vessels. Adrenals (cassette B): The adrenals show several nodules of
hyperplasia in the cortex and also demonstrate several areas of infarct. Kidney: Sections of kidney (cassettes U and V) demonstrate
thyroidization of the kidney. There are vessels that have been completely occluded
and recanalized, and evidence of old scarring and infarcts. Some
vessels are suspicious for thrombotic disease. There is a loss of glomeruli.
Elastin stain shows damaged elastic lamina in several vessels. Prostate: A section of prostate (cassette W) demonstrates no
abnormalities. Note: There is a floater in cassette W. Bladder: A section of bladder (cassette W) demonstrates no
abnormalities. Colon (cecal area): Sections of the large
intestine (cassette X) demonstrates necrosis and peritonitis. Testes: Sections of the testicle (cassette T) demonstrate infarcted
areas of the seminiferous tubules. There is no evidence of sperm production. Pituitary: A section of the pituitary (cassette C) shows no
abnormalities. Thyroid: A section of thyroid (cassette S) demonstrates no
abnormalities. Base of first and second left toes: Sections of the base of the
first and second left toes (cassette F) demonstrate areas of ulceration and
scarred vessels. Elastin stain demonstrates one vessel with destroyed
elastic lamina. There is no evidence of active polyarteritis nodosa. Bone: A section of bone demonstrates hypocellular marrow and
osteopenic bone. ------------------------