Pulmonary Pathology Case 6

 

1. The patient is a 63-year-old Caucasian woman with a history of alpha-1 antitrypsin deficiency diagnosed in 1986. She underwent a right lung transplant in 1996. In April of 2003, she was diagnosed with post transplant lymphoma of the jejunum with nodules in the right transplanted lung. Her past medical history is also significant for chronic renal insufficiency, diabetes mellitus type II, hypertension and diverticulitis. She presents on 10-22 with hypotension. Her hospital course was complicated by sepsis, atrial fibrillation with a rapid ventricular response and perforated bowel. The patient underwent two surgical procedures for resection of bowel and exploration.   Despite aggressive medical therapy, the patient remained dependent on mechanical ventilation and total parenteral nutrition until her death.

 

Admission H&P            10-23-03

MICU Note                    10-27-03

Surgical H&P                 10-30-03

Surgical Pathology Reports

Operative note               10-30-03

Operative note               11-10-03

Laboratory Summary

Microbiology Report

Death Summary             11-13-03

Autopsy Report             11-14-03

Autopsy Gross Images

Autopsy Microscopic Images

 

Radiology Reports        X-ray Images

                                      CXR 5-11-99 (baseline)

          CXR 10-7-03       CXR 10-7-03

          CXR 10-9-03       CXR 10-9-03

          CT 10-23-03        CT 10-23-03

          CXR 10-25-03     CXR 10-25-03

          CXR 11-13-03     CXR 11-13-03

 

 

2. Review the case in order to answer the following questions:

 

1. What is the pertinent Clinical History?

2. What is her underlying lung disease?

3. What treatment did she receive for this disease and how did it predispose her for the acute     disease?

4. What are the pertinent Laboratory findings to her lung disease and cause of death?

5. What was his hospital course?

6. Why did she die?

7. Give an academic review of:        

Alpha-1 antitrypsin deficiency

          Panlobular emphysema

 

3. Prepare a power point presentation including the above material to present to the entire class.  Make this a formal presentation as if you were presenting at a major conference.  You will have ten minutes to present and 5 minutes for questions.  Be prepared to answer questions about the case from the clinical faculty.

 

 

Radiology

CXR 5-11-99 Post transplant film for baseline

 

CXR 10-7-03 PA and Lateral           report

 

CXR 10-9-03                 report

 

CT 10-23-03                  report

 

CXR 10-25-03               report

 

CXR 11-13-03               report

 

Autopsy Gross Images

Lungs in-situ

 

Lungs inflated with formalin

 

Cross section of native lung with alpha-1 anti-trypsin deficiency

 

Autopsy Microscopic Images

Sections of native lung

 

 

 

Sections of transplanted lung with nodule of lymphoma

 

High power of lung nodule of lymphoma

 

Liver low power, H&E

 

Liver low power, PAS with diastase

 

High power liver with PAS/D stain showing pink globules

 

 

Admission HP  10-23-03


63yo woman w/ h/o lung transplant and B-cell lymphoma admitted yesterday for hypotension in clinic. Overnight pt received IVF and had normalization of blood pressure but then was found to be in A-flutter at a 2:1 to 3:1 rate. She has had chest pressure off and on over the last several days. She has mild SOB at rest. She is mildly sleepy but otherwise mentating normally. She has diffuse body pain including pleuritic chest pain and lower abdominal pain. No diarrhea.

PMH:
1.   Alpha-1-antitrypsin deficiency diagnosed 1986
2.   Right lung transplant 8/8/95
3.   Diffuse large B cell lymphoma 6/21/03
4.   Chronic Renal insufficiency
5.   Sleep Apnea
6.   DM Type II
7.   HTN
8.   Diverticulitis
9.   Gallbladder remove in 1980
10. Appendix removed in 1980
11. Nephrolithiasis Stones removed in 1980
12. Blood Clots in legs in 1959 and 1960
13. Tonsillectomy in childhood

ALLERGIES: Codeine, Phenergan, No ASA products, Avoids narcotics

Meds:
Bactrim 420 mg P.O. q M&H
Cardizem 240 q pm
Lasix 80 mg BID
Mag Oxide 400 mg P.O. q day (noon)
Prednisone 1 mg P.O. q am
Prilosec 20 mg P.O. q am
Prograf 3 mg P.O. q am and 2 mg P.O. q hs
Rocaltrol (Vit D) P.O. q M,W,F
Zestril 20 mg P.O. q am
Insulin NPH 36 U S.Q. q am
Insulin NPH 10 U S.Q. q pm
Humalog sliding scale 1 U per 25 points over 150
Epogen q Fri
Senna 2 tabs PO qd

PE: 130/70 130 20 Tm 36.7
CV: no JVD, irreg/irreg, no murmur
lungs: decreased BS on left, crackles at R base
Ab: +BS, mild obese, ND, mild diffuse tenderness
ext: 2+ B LE edema, no rash

A/P
1) A-flutter
-currently w/ good BP, normal mentation and no ischemic changes on EKG

-pt has had chest pressure for last several days, raising question of whether A-flutter has been going on for > 48 hours

-will see whether EKG was done in clinic or on admit for comparison
-rate control w/ diltiazem gtt
-correct metabolic derangement as below
-serial trop I

2) Renal
-worsening of CRI since D/C w/ urine Na that is not interpretable due to Lasix
-UA benign without casts
-likely prerenal etiology due to aggressive diuresis
-non-gap metabolic acidosis on admit without diarrhea likely indicates
   underlying renal tubular acidosis that has been worsened by inappropriate
   delivery of chloride containing IVF over night
-hyperkalemia c/w type 4 RTA
-start bicarb gtt D5 w/ 3 amps bicarb at 100 cc/hr to correct non-gap acidosis
   and hypovolemia
-Kayexalate for hyperkalemia

3) abdominal pain
-pain itself is not very severe but could represent underlying significant pathology
-principle worries are diverticulitis, ischemic colitis/pancreatitis/hepatitis
   due to hypotension and tachyarrhythmia and SBP if ascites present
-once rate controlled, will get abdominal CT scan
-if ascites present it should be tapped under U/S if small
-cont antibiotics for now to cover for diverticulitis
-follow pancreatic and liver enzymes

4) heme
-pancytopenia w/ neutropenia
-no fever since admit
-will investigate whether pt was febrile at home or in clinic, if no fever
   or identified source of infection then will stop antibiotics

 

MICU  10-27-03


R2 MICU Accept Floor-MICU Service Transfer Note
Much of the history obtained from the last admission note.

HPI: The Patient is a 63 yo female with a history of alpha-1-antitrypsin deficiency first diagnosed in 1986; right lung transplant was performed in 1996. Mild post transplant rejection. Was diagnosed with B-cell lymphoma in the jejunum in April of this year after several months of abdominal pain and melena. Of note, staging workup showed multiple lung nodules in transplanted lung, pericardial effusion. Failed Rituxan; started CHOP therapy 9/4/03, just finished 3rd round. 9/12/03 admitted with neutropenic fever; treated with meropenem for two days and then switched to Tequin for diverticulitis. Several weeks ago her abdominal pain returned and she has developed progressive fatigue, SOB and lower extremity edema. She was admitted again 10/7 for aggressive diuresis and treatment for diverticulitis (meropenem, then gatifloxacin). Returned home on 10/15.

Pt was admitted to the oncology service again on approximately 10/22 with hypotension. She developed A-fib with RVR and was transferred to the MICU service (10/23), where she was observed to have MAT. The patient's hypotension and acute-on-chronic renal insufficiency responded well to hydration; however, the patient had persistent MAT and was cardioverted electively. Then the patient was transferred back to heme/ oncology (10/25). On the night after transfer, the patient reverted to Atrial fibrillation with RVR and was transferred to 4N. The patient was amiodarone loaded, continued on an amiodarone oral dose, and started on a diltiazem gtt. On the night of 10/26-10/27, the patient became tachypneic and hypotensive. This was after starting on oral diltiazem, with the gtt still going after starting PO diltiazem. The tachypnea improved with BiPAP; a CXR revealed a growing left plural effusion.

PMH:
Alpha-1-antitrypsin deficiency diagnosed 1986
    --Right lung transplant 8/8/96
Diffuse large B cell lymphoma 6/21/03
Chronic Renal insufficiency
Sleep Apnea
DM Type II
HTN
Diverticulitis
DVT 1959, 1960

PSurgHx:
Right lung transplant 1986
Gallbladder remove in 1980
Appendix removed in 1980
Nephrolithiasis; stones removed in 1980
Tonsillectomy in childhood

ALLERGIES: Codeine, Phenergan, ASA products, Avoids narcotics

Outpatient Meds:
Bactrim 420 mg P.O. q M&H
Cardizem 240 q pm
Lasix 80 mg BID
Mag Oxide 400 mg P.O. q day (noon)
Prednisone 5 mg P.O. q am
Prilosec 20 mg P.O. q am
Prograf 3 mg P.O. q am and 2 mg P.O. q hs
Rocaltrol (Vit D) P.O. q M,W,F
Zestril 20 mg P.O. q am
Insulin NPH 36 U S.Q. q am
Insulin NPH 10-12 U S.Q. q pm
Humalog sliding scale 1 U per 25 points over 150
Epogen q Fri
Senna 2 tabs PO qd

FH:
Father died at 72 of MI, alcoholism
Mother died at age 56 of heart problems secondary to alcoholism and diet pills
Maternal aunt died at age 60 of gastric cancer
Siblings have tested NEG for A-1-antitrypsin

SH:
The Patient has been on disability since 1986 from her job as a computer programmer. She has never been married and has no children. She lives with a friend who helps take care of her.  She has a 20 pack year history of smoking but quit in 1986. Social ETOH, no elicit drugs.

ROS:
Feels thirsty, dyspnea improved on BiPAP, abdominal pain.

PE:
VS: T 38 P 115 R 44 before BiPAP, now 30; BP 88/50 manual each arm, 88% on 15L Mask
GEN- obese woman with chronic steroid stigmata
HEENT- conjugate gaze, pupils 2-3mm bilaterally.
NECK- no goiter
CHEST- markedly diminished breath sounds on the left. Right sided crackles clear with moving around.
ABD- soft, tender to palpation in upper abdomen, both sides. Bowel tones are present.
EXTR- tender, trace pitting edema bilaterally over shins, feet are warm.
NEURO- oriented to month, circumstances, person

LABS:
TSH 0.38
WBC 0.490, HCT 24.7%, Plt 35,000
Chem 8 143/3.9//110/26//119/2.8 Glc 100 Ca 8.1
7.35/39.6/59.9/21/88.5 on 15L mask
PTT 43
Tacrolimus 12.7, 10.2

CXR: L lung with bullous emphysema and a pleural effusion. Right lung with vascular congestion.

A: 63 YOF s/p Right lung transplant for A1AT deficiency, with lymphoma, in the midst of CHOP, with neutropenia and recurrent a-fib, hypotension, and an increasing left pleural effusion.

Problem List:
1. Lymphoma-
   Neutropenia
   Anemia
   Thrombocytopenia

2. A-fib with RVR

3. Hypotension: DDX= hypothyroid, adrenal failure, diltiazem, sepsis (early), hemorrhage, PTX, MI, PE, arrhythmia, acute valvular failure, MI. Most likely is an effect of diltiazem combined with intravascular hypovolemia.

4. Tachypnea
   Possibilities are pneumonia, mass effect of the pleural effusion, and many of the diagnoses in 3.

5. S/P Lung txp

6. CRI

7. DM2, slightly suppressed TSH.

Plan by problem:
1. Oncology following pt Follow CBC. Treat neutropenic fever, but not starting antibiotics with a stronger alternative possibility for hypotension.  G-CSF.  Transfuse to keep HCT>20%.

2. Continue amiodarone orally; cardiovert if pt becomes unstable. Keep electrolytes optimized.  Continue heparin gtt. Not starting Coumadin in case pt will have effusion tapped soon.

3. Fluid bolus challenge. If T>38.3, start neutropenic coverage. Stop diltiazem gtt. Reduce oral diltiazem if BP remains low. Check EKG, troponin, FT4. Recheck HCT.

4. BiPAP at night, consider diagnostic AND therapeutic pleural tap.

5. Continue prednisone and tacrolimus, followed by lung transplant service.

6. CRI- renal dose medications

7. NPH when eating, FSBG, SSI

HOUSEKEEPING
SCD's
Heparin gtt
Lansoprazole.
Full Code.

ADDENDUM:
Pt continued to have hypotension (MAPS into 40's). Hence, consent was obtained for elective cardioversion. After etomidate administered by anesthesia, pt was successfully cardioverted with 150 J biphasic current, into NSR, with prompt improvement of BP.

Plan for today:
-STOP all diltiazem
-Re bolus with 300mg amiodarone IV, then 0.5mg/mL gtt
-CT or US-guided pleurocentesis, send for culture, cytology. Intent both diagnostic and therapeutic tap.

 

History and Physical  10-30-03

Surgical H&P:

cc: abdominal pain/acute abdomen

HPI: The Patient is a 63 yo female with a history of alpha-1-antitrypsin deficiency diagnosed 1986; s/p r lung transplant 1996, recently diagnosed with B-cell lymphoma involving jejunum in April of this year after several months of abdominal pain and melena. Staging w/u showed multiple lung nodules in transplanted lung, pericardial effusion. Pt had 2 recent flare ups of diverticulitis early September and again 10/7. Pt admitted on 10/22 for hypotension, acute/chronic renal failure. Transferred to MICU for A-fib with RVR and again for tachypnea and hypotension. She has had abdominal pain for about 6 or 7 days, which has become progressively worse over this time. She has been constipated since her last CT on 10/23 (passing only small amount of liquid stool yesterday.) She states the pain is both sharp and dull, is worse in her mid epigastrium but diffusely involves entire abdomen. No melena, BRBPR. Pt has had an elevated WBC since 10/28 but was profoundly neutropenic previously. She also c/o F/C, denies n/v.

PMH:
Alpha-1-antitrypsin deficiency diagnosed 1986
Diffuse large B cell lymphoma 6/21/03
R SF vein thrombosis 10/28/03
Chronic Renal insufficiency
Sleep Apnea
DM Type II
HTN
Diverticulitis
DVT 1959, 1960

PSurgHx:
Right lung transplant 1986
Gallbladder remove in 1980
Appendix removed in 1980
Nephrolithiasis; stones removed in 1980
Tonsillectomy in childhood

ALLERGIES: Codeine, Phenergan, ASA products, Avoids narcotics

Meds:
HEPARIN DRIP 25000 UNITS IV   CONT 10/25/03 23:00 --
IMIPENEM/CILASTATIN (PRIMAXIN) 500 MG IV   12H 10/29/03 04:00 --
INSULIN NPH HUMAN (On Hold) 20 UNITS SQ   AMI 10/25/03 08:00 --
INSULIN NPH HUMAN (On Hold) 10 UNITS SQ   PMI 10/24/03 17:00 --
INSULIN REGULAR HUMAN 100 UNIT IV   TRT 10/29/03 15:00 --
INSULIN-R SLIDING SCALE (On Hold) 1 DOSE SQ   Q6 10/29/03 12:00 --
TACROLIMUS 0.5 MG IV   Q12 10/28/03 21:00 --
AMIODARONE 200 MG DHT   TIDWM 10/29/03 17:00 --
EUCERIN 2 OZ TOP   ATBED 10/24/03 22:00 --
LANSOPRAZOLE SOLUTION 30 MG DHT   QDAM 10/29/03 09:00 --
PREDNISONE 5 MG DHT   QDAM 10/29/03 09:00 --
SENNA CONCENTRATE EXTRACT 17.6 MG DHT   HS 10/29/03 21:00 --
SULFAMETH/TRIMETH 200/40 80 MG DHT   QMTH 10/31/03 09:00 --
TACROLIMUS 2 MG DHT   HS 10/29/03 21:00 --
TACROLIMUS   3 MG DHT   QDAM 10/29/03 09:00 --

FH:
Father died at 72 of MI, alcoholism
Mother died at age 56 of heart problems secondary to alcoholism and diet pills
Maternal aunt died at age 60 of gastric cancer
Siblings have tested NEG for A-1-antitrypsin

SH:
The Patient has been on disability since 1986 from her job as a computer tech/programmer. She has never been married and has no children. She lives with a friend "sister" who helps take care of her. She has a 20 pack year history of smoking but quit in 1986. Social ETOH, no illicit drugs.

ROS:
Feels thirsty, dyspnea improved on BiPAP, abdominal pain, constitutional symptoms as above, c/o bilateral leg pain (has thrombosis of superficial femoral vein, no endocrine symptoms.   

PE:
VS: T 38.4, 10-113, 92-120/37-83, 30-33, 92-100% BiPAP 20/5
GEN- obese woman, on nasal BiPAP, resting comfortably
HEENT- ATNC, EOMI, PERRL, sclera anicteric, DHT R nares
NECK- supple, no lad
CHEST- diminished breath sounds on the left. Right sided CTA
ABD- soft, diffusely tender to palpation-exquisitely tender in mid epigastrium, tympanic, diminished bowel sounds, no rebound, no peritoneal signs, some involuntary guarding c deep palp of mid epigastrium.
EXTR- 2+ pitting edema bilateral lower extremities, no c/c.
NEURO- intact, non focal.

LABS:
AMY/LIP/LACTATE/LFT's pending
            WBC RBC Hgb HCT MCV Plt
10/30/03 03:00 27.27 3.06 9.0 26.7 87.4 315 --
10/30/03 03:00 137 4.3 110 20 115 3.5 103 7.7 -- 5.9

CXR--r sided consolidation, IMPROVED LUNG OPACITIES, MOST LIKELY PNEUMONIA WITHIN THE PATIENT'S TRANSPLANTED RIGHT LUNG.

A/P: 63 YOF s/p Right lung transplant with history of diverticulitis and abdominal pain x 6-7days. Pt is febrile and has an elevated WBC--27. DDx include: PUD, perforated ulcer, perforated small bowel from lymphoma/mesenteric ischemia/pancreatitis/ gastritis
1) Abd series to r/o free air
2) D/C Dobbhoff tube feeds
3) Abd/pelvis CT to r/o pancreatitis

 

Surgical Pathology Report

10/30/03

SP FINAL REPORT Sigmoid Colon

SP SUBMITTING PHYSICIAN

Dr. General Surgery

SP CLINICAL HISTORY

Free air in abdomen. Ruptured sigmoid diverticulum.

SP GROSS DESCRIPTION

Received in two parts. Part number one sent to microbiology for culture and sensitivity. Part two is received in formalin in a single container labeled with the patient's name, medical record number and "sigmoid colon" and consists of an unopened segment of colon stapled closed at one end, measuring 15.0 cm in length by up to 3.3 cm in diameter, showing a modest wedge of mesocolon and patches of thin opaque serosal adhesions and focal serosal hemorrhage in the central portion of the specimen. There is some firm induration of the mesentery. On opening, there is a 6.5 cm segment of muscular thickening and mucosal hyperemia and coarsely gathered mucosal folds that obscure the serosal adhesions within the BI mesenteric fat there is a small apparent abscess cavity 1.0 cm in diameter just external to the thickened muscularis. On sectioning, no direct diverticular communication to the mucosa is identified. There is focal circumscribed yellowish apparent fat necrosis near the abscess. Cassette code: 1A-1B - the sections of the surgical margins, inked black; 1C-1D - sections of the mesenteric abscess beneath the muscularis with adjacent fat necrosis; 1E - sections of a grossly uncomplicated diverticulum.

 

SP DIAGNOSIS

1. SPECIMEN SENT TO MICROBIOLOGY LABORATORY

2. SIGMOID COLON; RESECTION:
- DIVERTICULOSIS
- SUBSEROSAL ABSCESS, SEROSAL FAT NECROSIS AND SEROSAL ADHESIONS, CONSISTENT WITH RUPTURED DIVERTICULUM
- SURGICAL MARGINS FREE OF INFLAMMATION
- NO EVIDENCE OF MALIGNANCY

 

 

08/03/03

SP FINAL REPORT  Stomach Nodule

SP SUBMITTING PHYSICIAN

Dr /Pulmonary

SP CLINICAL HISTORY

Epigastric abdominal distress/pain

SP GROSS DESCRIPTION

Received are three containers with formalin labeled with the patient's name and medical record number. Container one labeled "stomach nodule" contains two tan-pink, irregular, firm, smooth soft tissue fragments measuring 0.7 x 0.4 x 0.3 cm and a 0.4 x 0.3 x 0.2 cm. The tissue is wrapped and submitted in toto in 1A. Container two labeled "distal stomach" contains six tan-pink, translucent, tissue is wrapped and submitted in toto in 2A-2B.  Container three labeled "jejunal stenosis" contains twelve tan-pink,
irregular, hemorrhagic, crumbling soft tissue fragments ranging in size from  0.7 cm in greatest length x 0.5 cm in greatest width. The tissue is wrapped and submitted in toto in 3A-3D. VA/ch 8/2/03
------------------------

SP MICROSCOPIC EXAMINATION

Sections of the jejunal stenosis biopsies (specimen 3) show a focally dense lymphoplasmacytic infiltrate composed of pleomorphic medium-to-large lymphocytes and many plasma cells. The infiltrate fills the lamina propria and focally extends into the jejunal epithelium. Scattered small lymphocytes and eosinophils are also noted in the lamina propria and epithelium. Immunohistochemical staining performed on specimen 3 demonstrates positivity of the large lymphocytes and plasma cells for CD79a. CD3 positivity is identified in scattered small lymphocytes. The bcl-2 stained section demonstrates no significant reactivity. In-situ hybridization reveals scattered positive signals for Epstein-Barr
virus (EBV) encoded RNA within large lymphocytes in the lymphoplasmacytic infiltrate.

SP DIAGNOSIS

1,2. STOMACH, BIOPSY NODULE AND DISTAL STOMACH: FINDINGS CONSISTENT WITH HYPERPLASTIC/INFLAMMATORY GASTRIC POLYPS.
\
3. JEJUNUM, BIOPSY STENOSIS: POLYMORPHIC POST-TRANSPLANT LYMPHOPROLIFERATIVE DISEASE. SEE COMMENT.
------------------------

SP COMMENTS

Taken together, the histologic and molecular data fit with a diagnosis of polymorphic post-transplant lymphoproliferative disease.


Operative Report

Operation Report         Proc Date: 10/30/03
 
PREOPERATIVE DIAGNOSIS:       Perforated viscus.
POSTOPERATIVE DIAGNOSIS:      Perforated sigmoid colon from
                              diverticulitis.

OPERATION PERFORMED:

INDICATIONS: Patient is a 63-year-old female whom we were asked to consult in the Medical Intensive Care Unit. It appeared that she had an approximately three to five day history of worsening abdominal pain, followed by worsening clinical deterioration. At the time of my evaluation, she had physical exam concerning for peritonitis. This was confirmed by a lateral decubitus film showing a suggestion of free air, which was confirmed by a CT scan showing definitive extraluminal gas.  She also had a white count, tachycardia, and fever. Based on this, we discussed her grave prognosis, and she wished full treatment options, including exploratory laparotomy.

PROCEDURE: After informed consent was obtained, the patient was taken to the operating room, placed supine on the operating room table, and had the uneventful induction of generalized anesthesia and endotracheal intubation.

A sterile prep and drape of the abdomen was performed, and an upper midline incision from approximately 6 cm above the umbilicus down to below the umbilicus was made sharply. Bovie cautery was used to divide down through the skin and subcutaneous tissues down to the level of the fascia. The peritoneum was entered sharply under direct vision using Metzenbaum scissors and scalpel. Once we entered the abdomen, we were able to protect the bowel, while the remainder of the incision was opened down to the level of approximately a few fingerbreadths above the pubis. We were able to explore the abdomen.

There were lymphomatous changes of the patient's bowel consistent with her B-cell lymphoma from her posttransplant lymphoma. She had a lung transplant in 1996 and had developed B-cell lymphoma for which she was currently receiving CHOP therapy. Other than the lymphomatous bowel and a mat of bowel proximally up not too far beyond the level of the ligament of Treitz, we found murky fluid throughout the abdomen and a perforated sigmoid colon. We performed a sigmoid colectomy in the standard fashion. A GIA stapler was used to fire across the sigmoid colon at approximately the pelvic inlet.

We then dissected down using a combination of Bovie cautery and taking larger vessels between clamps and securing them with silk ties. We did this down for a quite a low resection, as the inflamed bowel extended quite distally. A TA staple line was fired across the bowel a few centimeters above the dentate line. We were then able to imbricate the distal staple line and tag it with Prolene stitches. We divided the mesentery, and the specimen was removed. We copiously irrigated the abdomen and suctioned all the irrigant.

At this point, because of the involvement of the descending colon in the left upper quadrant lymphomatous mass, we opted to perform a loop ileostomy approximately 40 to 50 cm proximal in normal healthy-appearing small bowel. This was done in the standard fashion by creating a right-sided circumferential incision in the right lower to mid quadrant. Bovie cautery was used to divide down through the skin and subcutaneous tissues, and 6-inch clamps were then used to expose the fascia, which was opened in the cruciate fashion.

We then, after creating a window in the mesentery of the small bowel at the appropriately placed position, placed a Penrose through the window in the mesentery and pulled this up through the newly created stoma site. This was not under tension, and the bowel looked viable. We then copiously irrigated the abdomen, continued exploration, and found no other evidence of intra-abdominal pathology. There was, however, extensive adhesive disease from her prior upper midline incision. This precluded thorough inspection of the liver, stomach, and duodenum. There was, however, no purulent, murky fluid coming from this area. It all had come from the lower abdomen apparently.

We then closed the abdomen after approximately 6 liters of irrigation was used, and this had all been suctioned out. We then closed with #2 Prolene stitches in interrupted figure-of-eight style stitches.

We then matured the stoma by creating an enterotomy in the small bowel, imbricating the superior margin, and placing simple interrupted sutures in the inferior aspect. This was done with #4-0 Vicryl stitches. The stoma appliance was placed. Sterile bandage was placed over the wound after it had been packed with Kerlix. Sponge and needle counts were okay.
The patient was taken back to the Medical Intensive Care Unit in critical condition for further care.

 

Operative Report

Operation Report         Proc Date: 11/10/03
PREOPERATIVE DIAGNOSIS:       Abdominal sepsis.
POSTOPERATIVE DIAGNOSIS:      Same.

OPERATION PERFORMED:     1.   Exploratory laparotomy.
                         2.   Placement of drains.

ANESTHESIA:              General endotracheal.

COMPLICATIONS: None.

INDICATIONS: This is a 63-year-old woman with multiple medical problems including being status post single lung transplant. In addition, she has wide-spread lymphoma. She recently underwent a sigmoid colectomy with diverting loop ileostomy for perforated diverticulitis. She had done poorly over the last several days, prompting a CT scan yesterday that revealed free air and free fluid in the abdomen. We were taking her back to the operating room for exploration for presumed bowel perforation.

FINDINGS: There was a large amount of mildly cloudy free fluid in the abdomen. We performed a thorough exploration, including exploration of the ileostomy at both the proximal and distal colonic staple lines, as well as the entire small bowel. There was no identified bowel perforation. There was a large mass of lymphoma in the left upper quadrant with a small amount running through the mass.

It was presumed that this was the site of her perforation, although there was no active evidence of regressive small bowel contents at this time. We also examined the stomach and duodenum in detail with no evidence of perforation. We therefore copiously irrigated the abdominal cavity, placed drains, and closed.

PROCEDURE: After obtaining informed consent, the patient was brought to the operating room and placed in the supine position on the operating table. After the uncomplicated induction of general endotracheal
anesthesia, the abdomen was prepped and draped in sterile fashion. The stoma was prepped out of the field.

We opened her midline incision by cutting her fascial stitches. We then performed manual exploration of the abdominal cavity. There were essentially no adhesions, which was quite surprising given her being ten days status post her prior surgery. In addition, she had no granulation tissue over her wound and really no evidence of tissue healing.

We initially examined the proximal and distal staple lines of the colon. Each of these was probed and squeezed looking for any evidence of anastomotic leakage and found none. We then ran the small bowel in its entirety, looking carefully for evidence of perforation or injury and there was none.

There was a large lymphoma mass in the left upper quadrant with multiple loops of small bowel incorporated into it. There was no evidence of bowel perforation, although, given this was the only area that we could not examine in detail and which was not amenable to resection, we presumed that her microperforation occurred in this area. There was no evidence of ongoing contamination of the abdomen.

We then turned our attention to the stomach and duodenum. We entered the lesser sac between the gastrocolic omentum. We were able to get several fingers into the lesser sac and palpate the anterior and posterior aspects of the stomach. There were no masses and no evidence of perforation. Likewise, there was no succus or free fluid in the lesser sac.

With careful mobilization of some adhesions to the right upper quadrant, we were able to visualize the first and second portions, as well as the third portion of the duodenum. This was grossly normal with no evidence of injury or perforation.

We then copiously irrigated and the abdominal cavity and drained it of irrigant fluid. We then repeated all of these maneuvers looking for evidence of bowel injury or perforation and found none. After repeating these maneuvers a third time, we concluded that her microperforation had likely sealed, this likely from the area of the lymphoma as there were some inflammatory changes in this region. This was not amenable to further surgical therapy.

We therefore left the drain by the rectal stump and drain in the left upper quadrant by the lymphoma mass. We again copiously irrigating the abdomen, drained the irrigant fluid, and began our closure.

The midline fascia was closed with interrupted figure-of-eight #2 Prolene stitches. The fascia came together without difficulty. The wound was packed open.

The patient was then brought to the medical intensive care unit hemodynamically stable, but requiring significant ventilatory support in critical condition. At the end of the case, all sponge and needle counts were correct.

 

 

            Laboratory Summary

 

Collected D/T

WBC

RBC

Hgb

Hct

MCV

Plt

%P

%Bd

%L

%M

%E

%BA

ANC

#P

#L

#M

#E

#BA

11/13/03 04:00

58.57

3.44

10.0

32.3

93.7

229

--

--

--

--

--

--

--

--

--

--

--

--

11/12/03 03:00

58.37

3.47

10.2

31.0

89.3

247

--

--

--

--

--

--

--

--

--

--

--

--

11/11/03 04:00

72.91

3.43

10.0

30.7

89.5

286

93

5

1

1

--

--

71.5

--

--

--

--

--

11/10/03 09:00

68.38

3.56

10.5

33.2

93.1

271

--

--

--

--

--

--

--

--

--

--

--

--

11/10/03 03:05

62.73

2.40

7.1

22.2

92.5

333

--

--

--

--

--

--

--

--

--

--

--

--

11/09/03 04:36

67.91

3.56

10.5

32.1

90.1

483

--

--

--

--

--

--

--

--

--

--

--

--

11/08/03 04:00

56.25

3.37

9.6

29.6

87.9

453

--

--

--

--

--

--

--

--

--

--

--

--

11/07/03 04:10

53.35

3.48

9.9

30.6

87.9

428

--

--

--

--

--

--

--

--

--

--

--

--

11/06/03 04:45

60.08

3.74

10.6

32.8

87.7

506

--

--

--

--

--

--

--

--

--

--

--

--

11/05/03 17:45

66.77

3.98

11.4

36.2

90.8

567

--

--

--

--

--

--

--

--

--

--

--

--

11/05/03 04:10

58.11

3.90

11.2

34.9

89.4

436

86.3 

--

11.9 

1.5 

0.0 

0.4 

--

50.1 

6.9 

0.9 

0.0

0.2

11/04/03 05:15

53.46

4.12

11.9

36.8

89.5

460

88

3

3

6

--

--

48.6

--

--

--

--

--

11/03/03 04:20

39.53

3.86

11.1

34.0

88.2

221

95

--

1

4

--

--

--

--

--

--

--

--

11/01/03 04:00

38.41

4.04

11.5

35.3

87.4

263

--

--

--

--

--

--

--

--

--

--

--

--

10/31/03 04:00

--

--

--

--

--

--

78

16

3

1

--

--

--

--

--

--

--

--

10/31/03 04:00

44.94

4.25

12.6

38.1

89.8

454

--

--

--

--

--

--

--

--

--

--

--

--

10/30/03 21:50

34.32

3.88

11.6

35.1

90.3

318

--

--

--

--

--

--

--

--

--

--

--

--

10/30/03 03:00

27.27

3.06

9.0

26.7

87.4

315

--

--

--

--

--

--

--

--

--

--

--

--

10/29/03 03:15

--

--

--

--

--

--

53

36

6

5

--

--

--

--

--

--

--

--

10/29/03 03:15

23.34

3.12

8.9

27.6

88.4

236

--

--

--

--

--

--

--

--

--

--

--

--

10/28/03 03:45

12.58

3.14

9.0

27.6

87.8

156

--

--

--

--

--

--

--

--

--

--

--

--

10/27/03 03:44

--

--

--

--

--

--

36

45

4

11

--

--

--

--

--

--

--

--

10/27/03 03:44

3.15

3.36

9.7

29.3

87.2

95

--

--

--

--

--

--

--

--

--

--

--

--

10/26/03 05:45

0.49

2.87

8.4

24.7

85.8

35

--

--

--

--

--

--

--

--

--

--

--

--

10/25/03 04:00

0.14

3.15

9.1

27.3

86.7

28

--

--

--

--

--

--

--

--

--

--

--

--

10/24/03 05:05

0.14

3.58

10.3

30.7

85.9

41

--

--

--

--

--

--

--

--

--

--

--

--

10/23/03 06:15

0.13

3.27

9.4

29.0

88.5

61

60

--

40

--

--

--

--

--

--

--

--

--

10/22/03 23:45

0.15

3.18

9.4

27.6

86.8

76

55

--

45

--

--

--

--

--

--

--

--

--

10/22/03 14:55

0.7

3.44

10.2

28.8

84.0

101

68

 

24

2

--

--

--

--

--

--

--

--

10/18/03 11:06

34.6

3.81

11.2

32.1

84.0

503

96

--

2

2

--

--

--

--

--

--

--

--

10/15/03 07:15

33.73

4.23

12.3

37.6

88.9

815

87.7 

--

8.1 

3.1 

0.3 

0.8 

--

29.6 

2.7

1.1 

0.1 

0.3 

10/14/03 05:45

35.34

4.08

11.9

36.2

88.8

798

--

--

--

--

--

--

--

--

--

--

--

--

10/13/03 06:00

31.30

3.98

11.2

35.3

88.8

847

--

--

--

--

--

--

--

--

--

--

--

--

10/12/03 07:00

26.19

3.97

11.4

34.0

85.8

830

--

--

--

--

--

--

--

--

--

--

--

--

10/11/03 06:30

26.54

4.21

12.2

35.8

85.1

888

--

--

--

--

--

--

--

--

--

--

--

--

10/09/03 20:07

23.99

4.58

13.0

38.1

83.1

--

--

--

--

--

--

--

--

--

--

--

--

--

10/09/03 10:20

23.95

4.40

12.2

36.7

83.3

800

87.2 

--

9.3 

3.2 

0.1 

0.3 

--

20.9 

2.2 

0.8 

0.0 

0.1 

10/08/03 08:23

22.32

4.52

12.8

37.8

83.7

660

--

--

--

--

--

--

--

--

--

--

--

--

10/07/03 18:00

22.03

3.50

9.3

28.7

82.0

689

85.0 

--

12.0 

2.8 

0.1 

0.3 

--

18.7 

2.6 A

0.6 

0.0 

0.1 

10/04/03 14:45

11.3

3.24

9.0

25.8

80.0

132

--

--

--

--

--

--

--

--

--

--

--

--

09/24/03 08:20

20.6

3.97

11.2

32.8

83.0

543

76

6

9

7

--

1

16.9

--

--

--

--

--

09/20/03 15:27

20.0

4.00

11.3

33.0

83.0

536

83

5

5

6

1

--

17.6

--

--

--

--

--

 

 

Collected Date/Time

Na

K

Cl

CO2

BUN

SCr

Glc

Ca

TP

PO4

Mg

11/13/03 04:00

136

3.7

104

22

113

3.0

348

8.9

--

7.7

--

11/12/03 03:00

138

3.3

103

26

108

3.1

106

8.3

4.2

--

--

11/11/03 04:00

137

4.0

99

29

109

3.2

106

8.7

--

--

--

11/10/03 09:00

136

4.4

99

26

103

3.1

180

8.4

--

--

--

11/10/03 03:05

137

4.3

95

25

100

3.2

151

8.4

--

10.2

--

11/09/03 04:36

134

3.7

95

28

111

3.1

65

7.7

4.0

--

--

11/08/03 04:00

134

3.0

95

28

114

3.3

67

7.3

--

9.6

--

11/07/03 04:10

134

4.3

103

20

116

3.3

90

8.1

--

10.7

--

11/06/03 21:00

135

4.0

103

22

117

3.3

90

8.1

--

--

--

11/06/03 04:45

135

3.9

104

20

110

3.3

125

7.7

--

--

--

11/05/03 17:45

136

3.9

106

16

114

3.4

119

7.9

--

--

--

11/05/03 04:10

136

4.3

112

14

114

3.3

74

8.4

--

9.7

--

11/04/03 05:15

137

4.2

111

16

116

3.5

130

8.7

--

9.8

2.2

11/03/03 04:20

135

4.7

113

14

113

3.3

107

7.8

--

9.2

--

11/03/03 04:00

137

4.7

113

15

107

3.4

79

8.1

--

9.0

--

11/01/03 04:00

139

4.8

114

17

101

3.2

103

7.9

--

7.8

--

10/31/03 17:48

135

5.0

112

17

100

3.2

123

8.1

--

--

--

10/31/03 04:00

138

4.8

113

16

96

3.1

274

7.5

4.7

6.9

2.1

10/30/03 21:50

136

5.1

112

18

95

2.9

289

6.8

--

--

--

10/30/03 03:00

137

4.3

110

20

115

3.5

103

7.7

4.7

5.9

--

10/29/03 03:15

139

4.3

111

20

107

3.4

125

7.9

--

--

--

10/28/03 03:45

140

3.9

110

22

105

3.3

75

8.2

--

--

--

10/27/03 14:22

--

--

--

--

--

--

--

--

4.4

--

--

10/27/03 03:44

140

4.3

107

24

114

3.1

213

8.0

4.8

--

--

10/26/03 05:45

143

3.9

110

26

119

2.8

100

8.1

--

--

--

10/25/03 04:00

146

3.3

114

23

141

2.9

96

7.8

--

--

--

10/24/03 14:48

142

4.9

113

18

145

3.1

297

7.9

--

--

--

10/24/03 05:05

144

4.6

112

20

154

3.6

131

8.8

5.0

--

2.4

10/23/03 20:53

138

5.6

111

15

157

3.7

200

9.3

--

--

--

10/23/03 16:24

139

5.3

111

16

149

3.8

280

9.0

5.3

--

--

10/23/03 06:15

139

5.3

114

15

148

3.8

275

8.5

--

--

--

10/22/03 23:45

137

4.5

111

16

140

3.7

274

7.6

--

8.2

2.1

10/22/03 21:45

--

--

--

--

--

--

--

--

4.8

8.3

--

10/22/03 14:55

134

5.0

104

18

153

4.2

318

8.4

--

--

--

10/18/03 11:06

131

5.5

100

19

110

4.3

483

8.3

--

--

--

10/15/03 07:15

138

5.6

104

27

57

2.7

209

9.4

--

--

1.4

10/14/03 05:45

135

5.1

103

27

58

2.4

218

8.9

5.6

--

--

10/13/03 06:00

139

5.0

104

29

60

2.6

178

9.0

--

--

--

10/12/03 07:00

138

4.7

105

28

57

2.4

175

8.9

5.6

--

--

10/11/03 06:30

140

4.4

103

29

53

2.6

159

8.7

--

--

--

10/09/03 20:07

140

4.6

105

26

54

2.6

174

8.5

--

--

--

10/09/03 10:20

138

3.4

103

28

50

2.5

149

7.8

5.9

--

--

10/08/03 08:23

139

3.5

105

25

55

2.6

121

8.1

6.0

--

--

10/07/03 18:00

136

3.2

103

26

59

2.5

68

8.1

5.6

--

--

09/24/03 08:20

141

4.5

113

24

23

2.0

73

8.9

5.7

--

--

09/20/03 15:27

139

5.2

114

21

32

2.1

172

8.0

--

--

--

 

 

Collected Date/Time

ABO RH

Antibody Screen

Direct Coombs

11/10/03 00:40

A POS

NEG

--

11/07/03 11:40

A POS

NEG

--

10/30/03 14:35

A POS

NEG

--

10/26/03 09:30

A POS

NEG

--

10/07/03 23:00

A POS

NEG

 

 

 

Collected Date/Time

AST

ALT

AlPh

Alb

TBil

DBil

11/12/03 03:00

45

33

388

1.7

2.2

2.2

11/09/03 04:36

40

23

323

1.7

0.6

--

10/31/03 04:00

35

28

523

1.9

0.4

0.4

10/30/03 03:00

52

33

624

2.0

0.4

0.4

10/27/03 03:44

45

39

531

2.1

0.8

--

10/24/03 05:05

15

24

211

2.5

0.6

0.4

10/23/03 16:24

16

27

256

2.7

0.6

--

10/22/03 21:45

19

24

173

2.3

0.6

0.5

10/14/03 05:45

29

20

215

2.6

0.3

--

10/13/03 06:00

--

--

--

2.4

--

--

10/12/03 07:00

34

29

240

2.5

0.3

0.3

10/09/03 10:20

46

58

330

2.6

0.4

--

10/08/03 08:23

51

47

362

2.8

0.6

--

10/07/03 18:00

141

67

388

2.7

0.4

0.4

09/24/03 08:20

20

27

192

2.5

0.5

--

 

 

Collected Date/Time

SG

WBC

Prot

Bld

Bact

Nit

#WBC

#RBC

11/11/03 12:20

1.016

SMALL

NEG

NEG

--

NEG

16

--

11/05/03 21:30

1.019

SMALL

NEG

NEG

--

NEG

16

--

11/03/03 10:45

1.013

TRACE

30

NEG

--

NEG

21

12

11/03/03 18:50

1.011

NEG

NEG

NEG

--

NEG

--

--

10/31/03 04:00

1.012

NEG

100

SMALL

--

NEG

30

7

10/28/03 15:25

1.009

NEG

NEG

SMALL

--

NEG

--

12

10/27/03 10:54

1.012

NEG

NEG

NEG

--

NEG

4

3

10/22/03 19:15

1.011

NEG

NEG

NEG

RARE

NEG

--

1

10/07/03 22:45

1.008

NEG

NEG

NEG

--

NEG

--

--

 

 

Date/Time

pH

PaCO2

PaO2

O2Hb

HCO3

BE

FiO2

Na+

K+

Ca++

Lact

11/12/03 03:06

7.458

37

73.3*

92.4

25.9

2.5

40

142

3.3

1.22

1.3

11/11/03 23:14

7.484

35.4

60.2*

90

26.3

3.2

40

141

3.4

1.23

1.3

11/11/03 11:26

7.453

38.2

65.7*

92

26.4

2.8

50

--

--

--

--

11/10/03 16:32

7.258

56

59.4*

88.9

24.2

-2.8

90

139

4.3

1.27

1.9

11/10/03 14:51

7.275

52.6

62.9*

90.5

23.7

-2.9

80

139

4.3

1.26

2.1

11/10/03 11:20

7.274

53.1

64.6*

91.3

23.8

-2.8

90

--

--

--

--

11/10/03 09:00

7.193

65.4

70.4*

89.7

24.2

-4.2

90

135

4.4

1.16

2.7

11/10/03 06:15

7.204

66.3

64.3*

87.3

25.2

-2.3

100

136

4.3

1.16

3.5

11/09/03 19:45

7.411

33.1

77.9*

91.9

20.6

-2.9

50

137

4.4

1.16

5.4

11/06/03 05:40

7.429

27.1

60.9*

90.8

17.6

-5.3

30

--

--

--

1.7

11/05/03 20:07

7.33

26.7

75.3*

92.9

13.7

-10.6

40

139

3.9

1.18

2.8

11/05/03 16:54

7.256

29.5

87.1*

92.4

12.7

-13

40

136

4.1

1.14

2.5

11/04/03 13:03

7.264

26.2

73*

92.3

11.5

-14

30

137

5

1.28

1.7

11/03/03 11:58

7.343

22.5

79.7*

93.1

11.9

-12.1

30

138

4.8

1.25

1.6

10/31/03 13:40

7.327

29.5

86.8*

94.3

15

-9.4

60

--

--

--

--

10/31/03 03:50

7.268

31.3

112.1*

96

13.9

-11.7

80

137

4.8

1.11

3

10/31/03 01:30

7.259

30.9

137.3*

96.6

13.4

-12.3

100

136

4.9

1.11

2.3

10/30/03 23:43

7.246

33.7

111

96.2

14.1

-11.9

100

--

--

--

2

10/30/03 21:45

7.213

42.8

131.8*

96.2

16.6

-10.4

100

--

--

--

1.7

10/30/03 19:00

7.167

44

81.3

92.3

15.3

-12.4

75

137

5

1.16

1.6

10/30/03 18:10

7.108

53.3

88.2*

92.2

16.1

-13.1

83

139

5.2

1.18

1.3

10/30/03 17:06

7.095

57.4

117*

94.3

16.8

-12.1

100

138

4.7

1.25

1.9

10/30/03 14:30

7.355

30.8

74.9*

91.9

16.7

-7.5

45

--

--

--

--

10/28/03 16:03

7.327

36.2

64.4

89.3

18.4

-6.4

45

139

4.5

1.24

1.9

10/28/03 10:35

7.315

38.4

67.3

89.9

19

-6.1

45

--

--

--

--

10/27/03 01:15

7.352

39.6

61.2*

87

21.4

-3.3

15

140

4.2

1.24

1.8

10/23/03 16:35

7.314

26.2

90.4*

94.4

12.9

-11.8

4

--

--

--

--

10/22/03 17:42

7.33

27.1

88.6*

94.2

13.9

-10.5

3

133

4.6

1.16

0.6

10/09/03 19:55

7.469

37.6

68.2*

91.7

26.9

3.6

3

140

4.5

1.16

0.8

10/07/03 18:03

7.437

36.3

51.5

86.2

24.1

0.5

3

--

--

--

--

 

 

Collected Date/Time

PT

PTT

INR

11/13/03 04:00

19.2

59

1.6

11/12/03 03:00

--

57

--

11/11/03 21:15

--

62

--

11/11/03 11:25

--

79

--

11/11/03 04:00

27.6

86

--

11/10/03 20:15

--

> 150

--

11/10/03 12:15

20.6

37

--

11/10/03 03:05

19.2

45

1.6

11/10/03 00:40

35.0

124

3.4

11/09/03 04:36

--

78

--

11/08/03 04:00

--

71

--

11/07/03 04:10

--

68

--

11/06/03 21:00

--

58

--

11/06/03 15:18

--

64

--

11/06/03 04:45

--

148

--

11/05/03 12:30

--

75

--

11/05/03 04:10

--

65

--

11/04/03 14:45

--

42

--

11/04/03 08:00

--

67

--

11/04/03 00:15

--

91

--

11/03/03 15:00

--

73

--

11/03/03 07:15

--

56

--

11/03/03 22:30

--

45

--

11/03/03 16:35

--

61

--

11/03/03 08:00

--

98

--

11/03/03 01:00

--

97

--

11/01/03 19:10

--

84

--

10/29/03 18:45

--

78

--

10/29/03 03:15

--

50

--

10/28/03 18:15

--

67

--

10/28/03 12:00

--

66

--

10/28/03 03:45

16.0

72

1.2

10/27/03 16:00

--

53

--

10/27/03 10:20

--

57

--

10/27/03 03:44

15.5

50

1.2

10/26/03 21:49

--

43

--

10/26/03 15:00

--

51

--

10/26/03 05:45

16.6

95

1.3

10/23/03 16:24

15.9

32

1.2

10/14/03 05:45

16.3

--

1.3

10/09/03 10:20

16.4

--

1.3

10/08/03 08:23

16.9

--

1.3

10/07/03 18:00

17.3

41

1.4

10/04/03 14:45

17.5

--

1.4

 

 

Collected Date/Time

Lab Description

Result/Unit

H/L

Ref Interval

11/12/03 14:50

VANCOMYCIN, RANDOM LEVEL

30.9 ug/mL

 

 

11/07/03 10:00

VANCOMYCIN, TROUGH LEVEL

15.6 ug/mL

H

5.0-10.0

11/07/03 08:30

TACROLIMUS

9.6 ng/mL

 

 

11/06/03 21:00

VANCOMYCIN, RANDOM LEVEL

17.5 ug/mL

 

 

11/06/03 08:48

VANCOMYCIN, RANDOM LEVEL

19.8 ug/mL

 

 

11/06/03 08:48

TACROLIMUS

9.4 ng/mL

 

 

11/04/03 08:00

TACROLIMUS

10.1 ng/mL

 

 

11/01/03 04:00

VANCOMYCIN, RANDOM LEVEL

18.2 ug/mL

 

 

10/31/03 18:00

VANCOMYCIN, TROUGH LEVEL

18.9 ug/mL

H

5.0-10.0

10/31/03 04:00

TACROLIMUS

12.1 ng/mL

 

 

10/30/03 23:30

VANCOMYCIN, TROUGH LEVEL

19.7 ug/mL

H

5.0-10.0

10/30/03 03:00

TACROLIMUS

11.2 ng/mL

 

 

10/29/03 14:15

TACROLIMUS

12.0 ng/mL

 

 

10/29/03 03:15

VANCOMYCIN, TROUGH LEVEL

18.1 ug/mL

H

5.0-10.0

10/27/03 20:15

TACROLIMUS

21.9 ng/mL

 

 

10/26/03 21:49

TACROLIMUS

15.7 ng/mL

 

 

10/25/03 04:00

TACROLIMUS

10.2 ng/mL

 

 

10/24/03 20:00

TACROLIMUS

12.7 ng/mL

 

 

10/24/03 08:00

TACROLIMUS

14.4 ng/mL

 

 

10/23/03 16:24

VANCOMYCIN, TROUGH LEVEL

13.7 ug/mL

H

5.0-10.0

10/23/03 12:35

CYCLOSPORINE A

<25 ng/mL

 

 

 

 

Collected Date/Time

Lab Description

Result/Unit

H/L

Ref Interval

11/13/03 04:00

LIPASE, SERUM or PLASMA

115 U/L

 

30-190

11/11/03 12:20

CREATININE, URINE - mg/dL

37 mg/dL

 

 

11/11/03 12:20

CREATININE, URINE - mg/day

NOT APPL mg/d

 

800-1800

11/11/03 12:20

TIME

RANDOM hr

 

 

11/11/03 12:20

TOTAL VOLUME

RANDOM mL

 

 

11/11/03 12:20

SODIUM, URINE mmol/L

< 5 mmol/L

 

 

11/11/03 12:20

SODIUM, URINE mmol/day

NOT APPL mmol/d

 

51-286

11/11/03 12:20

TIME

RANDOM hr

 

 

11/11/03 12:20

TOTAL VOLUME

RANDOM mL

 

 

11/11/03 04:00

TROPONIN I

1.6 ng/mL

H

0.0-0.4

11/11/03 04:00

FIBRINOGEN

508 mg/dL

H

150-430

11/11/03 04:00

D-DIMER

7.8 ug/mL

H

0.0-0.5

11/11/03 04:00

NUCLEATED RED BLOOD CELL

2 %

H

< 0

11/11/03 04:00

POLYCHROMASIA

1+

A

 

11/11/03 04:00

TARGET CELLS

1+

A

 

11/11/03 04:00

HAPTOGLOBIN

96 mg/dL

 

30-200

11/10/03 12:15

FIBRINOGEN

479 mg/dL

H

150-430

11/10/03 12:15

D-DIMER

4.0 ug/mL

H

0.0-0.5

11/10/03 12:15

HAPTOGLOBIN

98 mg/dL

 

30-200

11/10/03 09:00

TROPONIN I

1.4 ng/mL

H

0.0-0.4

11/10/03 07:00

GRAM STAIN SOURCE

ABD FLD

 

 

11/10/03 07:00

GRAM STAIN WHITE BLOOD CELLS

1+

 

 

11/10/03 07:00

GRAM STAIN ORGANISMS

NONE

 

 

11/10/03 07:00

PLEASE NOTE:

SEEBELOW

 

 

11/09/03 20:30

TROPONIN I

1.0 ng/mL

H

0.0-0.4

11/09/03 20:10

C.DIFFICILE TOXINS (A

NEGATIVE

 

NEGATIVE

11/05/03 18:00

C.DIFFICILE TOXINS (A

NEGATIVE

 

NEGATIVE

11/03/03 10:45

OSMOLALITY, URINE

358 mOs/kg

 

50-800

11/03/03 10:45

CREATININE, URINE - mg/dL

48 mg/dL

 

 

11/03/03 10:45

TIME

RANDOM hr

 

 

11/03/03 10:45

CREATININE, URINE - mg/day

NOT APPL mg/d

 

800-1800

11/03/03 10:45

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 10:45

URINE UREA NITROGEN - g/dL

0.533 g/dL

 

 

11/03/03 10:45

TIME

RANDOM hr

 

 

11/03/03 10:45

URINE UREA NITROGEN - g/day

NOT APPL g/d

 

12.0-20.0

11/03/03 10:45

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 10:45

POTASSIUM, URINE mmol/L

48.1 mmol/L

 

 

11/03/03 10:45

TIME

RANDOM hr

 

 

11/03/03 10:45

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 10:45

POTASSIUM, URINE mmol/day

NOT APPL mmol/d

 

40-80

11/03/03 10:45

CHLORIDE, URINE mmol/L

12 mmol/L

 

 

11/03/03 10:45

CHLORIDE, URINE mmol/day

NOT APPL mmol/d

 

140-250

11/03/03 10:45

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 10:45

TIME

RANDOM hr

 

 

11/03/03 10:45

SODIUM, URINE mmol/L

< 5 mmol/L

 

 

11/03/03 10:45

SODIUM, URINE mmol/day

NOT APPL mmol/d

 

51-286

11/03/03 10:45

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 10:45

TIME

RANDOM hr

 

 

11/03/03 10:00

OSMOLALITY, SERUM or PLASMA

324 mOs/kg

H

280-303

11/03/03 18:50

POTASSIUM, URINE mmol/L

47.9 mmol/L

 

 

11/03/03 18:50

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 18:50

TIME

RANDOM hr

 

 

11/03/03 18:50

POTASSIUM, URINE mmol/day

NOT APPL mmol/d

 

40-80

11/03/03 18:50

CHLORIDE, URINE mmol/L

17 mmol/L

 

 

11/03/03 18:50

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 18:50

CHLORIDE, URINE mmol/day

NOT APPL mmol/d

 

140-250

11/03/03 18:50

TIME

RANDOM hr

 

 

11/03/03 18:50

SODIUM, URINE mmol/L

7 mmol/L

 

 

11/03/03 18:50

SODIUM, URINE mmol/day

NOT APPL mmol/d

 

51-286

11/03/03 18:50

TOTAL VOLUME

RANDOM mL

 

 

11/03/03 18:50

TIME

RANDOM hr

 

 

11/03/03 18:13

C.DIFFICILE TOXINS (A

NEGATIVE

 

NEGATIVE

10/30/03 03:00

LIPASE, SERUM or PLASMA

51 U/L

 

30-190

10/30/03 03:00

AMYLASE, SERUM - U/L

< 30 U/L

 

30-110

10/27/03 16:00

TROPONIN I

0.7 ng/mL

H

0.0-0.4

10/27/03 14:00

LD, BODY FLUID

379 IU/L

 

 

10/27/03 14:00

GRAM STAIN SOURCE

EFFUSION

 

 

10/27/03 14:00

GRAM STAIN PMN'S

1+

 

 

10/27/03 14:00

GRAM STAIN ORGANISMS

NONE

 

 

10/27/03 14:00

GRAM STAIN WHITE BLOOD CELLS

1+

 

 

10/27/03 14:00

TOTAL PROTEIN, BODY FLUID

< 2.0 gm/dL

A

 

10/27/03 14:00

AMYLASE, BODY FLUID

< 30 IU/L

 

 

10/27/03 14:00

SR SOURCE

EFFUSION

 

 

10/27/03 14:00

CRYSTALS

NOT APPL

 

NEGATIVE

10/27/03 14:00

BODY FLUID SOURCE

SEE NOTE

 

 

10/27/03 14:00

APPEARANCE

CLEAR

 

 

10/27/03 14:00

RED BLOOD CELLS, FLUID

666 /uL

 

 

10/27/03 14:00

% LYMPHOCYTES FLUID

57 %

 

 

10/27/03 14:00

% MONONUCLEAR CELLS FLUID

33 %

 

 

10/27/03 14:00

TOTAL NUCLEATED CELL FLUID

154 /uL

 

 

10/27/03 14:00

COLOR

YELLOW

 

 

10/27/03 14:00

% PMN FLUIDS

10 %

 

 

10/27/03 14:00

DIFFERENTIAL TOTAL CELL COUNT

100

 

 

10/27/03 14:00

CLOTS

NONE

 

NONE

10/27/03 10:54

CREATININE, URINE - mg/dL

66 mg/dL

 

 

10/27/03 10:54

TIME

RANDOM hr

 

 

10/27/03 10:54

CREATININE, URINE - mg/day

NOT APPL mg/d

 

800-1800

10/27/03 10:54

TOTAL VOLUME

RANDOM mL

 

 

10/27/03 10:54

SODIUM, URINE mmol/L

17 mmol/L

 

 

10/27/03 10:54

TIME

RANDOM hr

 

 

10/27/03 10:54

TOTAL VOLUME

RANDOM mL

 

 

10/27/03 10:54

SODIUM, URINE mmol/day

NOT APPL mmol/d

 

51-286

10/27/03 03:44

LACTATE DEHYDROGENASE

519 U/L

 

300-600

10/27/03 03:44

TROPONIN I

< 0.4 ng/mL

 

0.0-0.4

10/27/03 03:44

THYROXINE, FREE

1.2 ng/dL

 

0.8-1.5

10/25/03 21:40

CREATINE KINASE, ISOENZYME MB

1.3 ug/L

 

0.0-5.0

10/25/03 21:40

TROPONIN I

0.7 ng/mL

H

0.0-0.4

10/25/03 21:40

CREATINE KINASE, TOTAL

< 20 U/L

 

20-180

10/25/03 18:30

C.DIFFICILE TOXINS (A

NEGATIVE

 

NEGATIVE

10/25/03 04:00

THYROXINE, FREE

0.7 ng/dL

L

0.8-1.5

10/24/03 19:40

TROPONIN I

0.7 ng/mL

H

0.0-0.4

10/24/03 05:05

LIPASE, SERUM or PLASMA

22 U/L

L

30-190

10/24/03 05:05

AMYLASE, SERUM - U/L

< 30 U/L

 

30-110

10/24/03 05:05

THYROID STIMULATING HORMONE

0.38 mU/L

L

0.40-5.00

10/23/03 20:53

TROPONIN I

0.6 ng/mL

H

0.0-0.4

10/23/03 06:15

LIPASE, SERUM or PLASMA

550 U/L

H

30-190

10/23/03 06:15

GAMMA GLUTAMYL TRANSFERASE

877 U/L

H

10-55

10/23/03 06:15

TROPONIN I

0.6 ng/mL

H

0.0-0.4

10/22/03 21:45

LIPASE, SERUM or PLASMA

28 U/L

L

30-190

10/22/03 21:45

GAMMA GLUTAMYL TRANSFERASE

490 U/L

H

10-55

10/22/03 19:15

CREATININE, URINE - mg/dL

46 mg/dL

 

 

10/22/03 19:15

CREATININE, URINE - mg/day

NOT APPL mg/d

 

800-1800

10/22/03 19:15

TOTAL VOLUME

RANDOM mL

 

 

10/22/03 19:15

TIME

RANDOM hr

 

 

10/22/03 19:15

POTASSIUM, URINE mmol/L

26.9 mmol/L

 

 

10/22/03 19:15

TOTAL VOLUME

RANDOM mL

 

 

10/22/03 19:15

TIME

RANDOM hr

 

 

10/22/03 19:15

POTASSIUM, URINE mmol/day

NOT APPL mmol/d

 

40-80

10/22/03 19:15

CHLORIDE, URINE mmol/L

25 mmol/L

 

 

10/22/03 19:15

TIME

RANDOM hr

 

 

10/22/03 19:15

TOTAL VOLUME

RANDOM mL

 

 

10/22/03 19:15

CHLORIDE, URINE mmol/day

NOT APPL mmol/d

 

140-250

10/22/03 19:15

SODIUM, URINE mmol/L

30 mmol/L

 

 

10/22/03 19:15

SODIUM, URINE mmol/day

NOT APPL mmol/d

 

51-286

10/22/03 19:15

TIME

RANDOM hr

 

 

10/22/03 19:15

TOTAL VOLUME

RANDOM mL

 

 

10/12/03 19:04

OCCULT BLOOD, FECAL

POSITIVE

A

NEGATIVE

10/12/03 18:15

OCCULT BLOOD, FECAL 1

POSITIVE

A

NEGATIVE

10/12/03 18:15

OCCULT BLOOD, FECAL 3

NOT APPL

 

NEGATIVE

10/12/03 18:15

OCCULT BLOOD, FECAL 2

NOT APPL

 

NEGATIVE

10/12/03 13:00

OCCULT BLOOD, FECAL 1

POSITIVE

A

NEGATIVE

10/12/03 13:00

OCCULT BLOOD, FECAL 3

NOT APPL

 

NEGATIVE

10/12/03 13:00

OCCULT BLOOD, FECAL 2

NOT APPL

 

NEGATIVE

10/12/03 07:00

GAMMA GLUTAMYL TRANSFERASE

253 U/L

H

10-55

10/11/03 06:30

C-REACTIVE PROTEIN

17.9 mg/dL

H

0.0-0.8

10/10/03 09:45

C.DIFFICILE TOXINS (A

NEGATIVE

 

NEGATIVE

10/10/03 07:32

TROPONIN I

0.6 ng/mL

H

0.0-0.4

10/10/03 07:32

GAMMA GLUTAMYL TRANSFERASE

349 U/L

H

10-55

10/09/03 20:07

TROPONIN I

0.6 ng/mL

H

0.0-0.4

10/09/03 10:20

GAMMA GLUTAMYL TRANSFERASE

365 U/L

H

10-55

10/08/03 19:15

CYTOMEGALOVIRUS DETECTION, PCR

NEGATIVE

 

 

10/08/03 19:15

SR SOURCE

BUFFY

 

 

10/08/03 06:00

TROPONIN I

0.5 ng/mL

H

0.0-0.4

10/07/03 23:00

TROPONIN I

0.5 ng/mL

H

0.0-0.4

10/07/03 18:00

CHOLESTEROL

184 mg/dL

 

 

10/07/03 18:00

LIPASE, SERUM or PLASMA

63 U/L

 

30-190

10/07/03 18:00

AMYLASE, SERUM - U/L

31 U/L

 

30-110

10/07/03 18:00

THYROID STIMULATING HORMONE

1.18 mU/L

 

0.40-5.00

10/07/03 18:00

HEMOGLOBIN A1C

7.1 %

H

4.0-6.0

09/24/03 08:20

LACTATE DEHYDROGENASE

587 U/L

 

300-600

 

Microbiology Report

11/14/03

WOUND CULTURE, BOIL, RIGHT LEG

Name

Result

GRAM STAIN

NO ORGANISMS SEEN

GRAM STAIN

NO PMNS SEEN

FINAL REPORT

1+ COAGULASE NEGATIVE STAPHYLOCOCCUS SPECIES (CoNS)

 

11/10/03

WOUND CULTURE, ABDOMEN

 

Name

Result

GRAM STAIN

NO ORGANISMS SEEN

GRAM STAIN

NO PMNS SEEN

FINAL REPORT

See Comments

 

Comments:
VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) , RECOVERED IN BROTH ------------------------

FINAL REPORT

See Comments

 

Comments:
CANDIDA GLABRATA (TORULOPSIS GLABRATA) , RECOVERED IN BROTH ------------------------

 

10/30/03

WOUND CULTURE, PERITONEAL FLUID

Name

Result

GRAM STAIN

NO ORGANISMS SEEN

GRAM STAIN

2+ PMNS

FINAL REPORT

1+ CANDIDA GLABRATA (TORULOPSIS GLABRATA)



 

Radiology Report

11/13/2003

CHEST XRAY 1V

History: Right lung transplant and sepsis

Findings: A single view the chest was obtained compared to radiographic previous day. Endotracheal tube, nasogastric tube, and central venous catheter remain in place.

Diffuse opacities in the transplanted right lung are again seen.
Perihilar opacity in the emphysematous left lung is unchanged.

IMPRESSION: NO SIGNIFICANT CHANGE

IMAGE

10/25/2003

CHEST XRAY 1V

PORTABLE CHEST 10/25/03 COMPARISON: 10/22/03

HISTORY: Effusion, lymphoma.

FINDINGS: Artifacts secondary to overlying defibrillator pads are superimposed in the left chest region. An indwelling left sided internal jugular central venous catheter remains in place and unchanged.

The cardiac silhouette appears slightly more prominent than on the previous exam. focal hyperinflation of the left lung, particularly involving the apex, is re demonstrated. There is mediastinal shift, left to right, with compression of the right lung. A left sided effusion has developed, obscuring the left hemidiaphragm.

IMPRESSION:

INTERVAL DEVELOPMENT OF LEFT SIDED EFFUSION, MODERATE.




IMAGE

10/23/2003

THORAX CT WO

History: Lymphoma

Technique: Five millimeter images were obtained through the chest without contrast.

Findings: Comparison is made with a study performed in August 28, 2003.

There has been interval development of a moderate to large left-sided pleural effusion. Bullous emphysematous changes are seen involving the native left lung with the presence of a 5.5 x 3.4 cm area of atelectatic lung to in the region of left hilum, which appears to have increased in size compared to the prior exam. The transplanted right lung again demonstrates volume loss with subsegmental areas of atelectasis. The multiple previously described nodules in the right lung are again noted; although some of the nodules have decreased in size or are now absent, Other nodules appear to be increased to in size. At the confluence of the right sided inferior pulmonary veins, there is a soft tissue mass seen in the peribronchial location, which appears to have increased in size from the previous study. This is consistent with peribronchial lymph node enlargement.

Mediastinal structures are otherwise unchanged.

The regional osseous structures appear unremarkable.

Please refer to the dictation of the abdomen for further information.

Impression:

INTERVAL DEVELOPMENT OF LEFT-SIDED PLEURAL EFFUSION WITH PROGRESSION OF THE PREVIOUSLY DESCRIBED LEFT HILAR OPACITY TO IN THE NATIVE EMPHYSEMATOUS LUNG.

MULTIPLE RIGHT-SIDED PULMONARY NODULES, WITH THE INTERVAL DEVELOPMENT OF A SOFT TISSUE MASS IN A PARABRONCHIAL DISTRIBUTION IN THE REGION OF THE CONFLUENCE OF THE INFERIOR PULMONARY VEINS. THIS IS MOST LIKELY A CONGLOMERATE OF LYMPH NODES.

NO OTHER SIGNIFICANT CHANGES. PLEASE SEE DICTATION OF THE ABDOMEN FOR FURTHER DESCRIPTION.


IMAGE

 

Radiology Report

10/09/2003

CHEST XRAY 1V

SINGLE PORTABLE VIEW OF THE CHEST: 10/09/2003.

HISTORY: Lymphoma and CHF.

FINDINGS: Single portable view of the chest was obtained. Port-A- Cath is unchanged in appearance and positioning. Cardiac silhouette remains stable in size. Extensive emphysematous changes involving the entire left lung again noted with mild shift of the mediastinal structures to the right which is unchanged. Degree of retrocardiac opacity is stable. When compared to the prior exam, there is increased patchy ill-defined opacity within the right lung, most notable at the right lung base. This may be secondary to increasing consolidation in mainly the right lower lobe. There is blunting of the bilateral costophrenic angles which is stable in appearance likely due to bilateral pleural effusions. There is no
definite evidence for pulmonary edema.

IMPRESSION:

1. STABLE SEVERE EMPHYSEMATOUS CHANGES OF THE LEFT LUNG.

2. INCREASED PATCHY ILL-DEFINED OPACITY IN THE RIGHT LUNG, MOST NOTABLE IN THE RIGHT LUNG BASE. THIS MAY BE SECONDARY TO INCREASING CONSOLIDATION. MULTIPLE PULMONARY NODULES WERE SEEN ON PRIOR CHEST CT IN THIS REGION.

3. PERSISTENT RETROCARDIAC OPACITIES STABLE IN APPEARANCE.

4. SMALL BILATERAL PLEURAL EFFUSIONS UNCHANGED.

 

IMAGE

 

 

10/07/2003

CHEST XRAY 2VWS

History: Non-Hodgkin's lymphoma.

Findings: Comparison study is dated 10/4/03. The porta cath is unchanged in appearance. The cardiomediastinal silhouette is stable. Again noted is extensive an emphysematous changes involving the entire left lung. Persistent increased retrocardiac opacity is again identified, without significant change. Mild vascular distinctness is seen within the right lung. There is also are small right pleural effusion and ill-defined increased opacity involving the right lung base, without significant change. Osseous structures are stable in appearance. There are small bilateral pleural effusions, unchanged

Impression:
1. Persistent increased opacity within the right lower lobe, without significant change.
2. Stable retrocardiac opacity.
3. Mild vascular distinctness involving the right hemithorax likely secondary to increased fluid status.
4. Stable appearance of small bilateral pleural effusions.

IMAGE

 

Death Summary

Death Summary         Adm Date: 10/22/03
                     Disc Date: 11/13/03
 DEATH DIAGNOSES:
1. Septic shock.
2. Alpha-1 antitrypsin deficiency causing bullous emphysema in the residual left native lung.
3. Status post right lung transplant secondary to No. 2 performed in 1996.
4. Respiratory failure due to acute respiratory distress syndrome due to overwhelming infection.
5. Acute-on-chronic renal insufficiency with hyperphosphatemia.
6. Perforated diverticulum.
7. Neutropenia secondary to chemotherapy.
8. Large B-cell lymphoma arising out of post-transplant lymphoproliferative disorder.
9. Obstructive sleep apnea.
10. Diabetes type 2.
11. Right lower extremity deep venous thrombosis.
12. Fungemia.
13. Atrial flutter with rapid ventricular response.
14. Possible microperforation of bowel in the area of bulky lymphoma.
15. Left pleural effusion.
16. Renal tubular acidosis.

ADMISSION DIAGNOSIS:
Hypotension.

SERVICE: Medical ICU.

CONSULTS:
1. General Surgery.
2. Nephrology.
3. Lung Transplant Service.

PROCEDURES:
1. On 10/30/2003, the patient underwent exploratory laparotomy with partial sigmoid resection and loop ileostomy.
2. On 11/10/2003, the patient underwent repeat exploratory laparotomy to evaluate free air which brought up a suspicion of microperforation of the lymphomatous bowel. 

The Patient was a 63-year-old female with a history of alpha-1 antitrypsin deficiency first diagnosed in 1986 who underwent right lung transplant in 1996. The patient was diagnosed with B-cell lymphoma of the jejunum in April 2003 after several months of abdominal pain and melena. Staging workup showed lung nodules in the transplanted lung, pericardial effusion. The patient failed Rituxan and started on CHOP therapy September 2003 and had just finished the third round when she was admitted to the hospital 09/12/2003 with neutropenic fever. The patient had progressive fatigue, shortness of breath, and lower extremity edema.

At the beginning of October, the patient was admitted for aggressive diuresis and treatment for diverticulitis. The patient then returned home 10/15/2003. The patient was admitted to the Oncology Service again on 10/22/2003 with hypotension. She developed atrial fibrillation with rapid ventricular response and was transferred to the MICU 10/23/2003 where she was observed to have multifocal atrial tachycardia. The patient's hypotension and acute-on-chronic renal insufficiency responded well to hydration. However, the patient had persistent multifocal atrial tachycardia and was electively cardioverted.

Then the patient was transferred back to the Hematology Oncology Service on 10/25/2003. On the night after transfer, the patient reverted to atrial fibrillation with rapid ventricular response and was transferred to telemetry. The patient was loaded with amiodarone and started on a diltiazem drip.

On the night of 10/26/2003 through 10/27/2003, the patient became tachypneic and hypotensive. This was after starting on oral diltiazem with the intravenous diltiazem still running. The tachypnea improved with BiPAP. A chest x-ray revealed a growing left pleural effusion.

PAST MEDICAL HISTORY: Alpha-1 antitrypsin deficiency diagnosed in 1986 with right lung transplant 1996, diffuse large B-cell lymphoma diagnosed 06/21/2003, chronic renal insufficiency, sleep apnea, diabetes type 2, hypertension, diverticulitis, DVT in 1959 and 1960.

 

PAST SURGICAL HISTORY: Right lung transplant, gallbladder removal, appendectomy, and tonsillectomy.

HOSPITAL COURSE: The patient was readmitted to the Intensive Care Unit. For hypotension, the patient had empiric treatment with imipenem and vancomycin. Later, Flagyl was added because of the concern that the patient had developed C-difficile colitis because of multiple antibiotics. The patient required pressors for hypotension not responsive to fluids and also was given stress-dosed corticosteroids. Because she was a post-lung-transplant patient, the patient was continued on her tacrolimus and corticosteroids to avoid rejection.

For her acute-on-chronic renal insufficiency, nephrology was consulted. The patient took phosphate binders for hypophosphatemia. The patient had a trial of dobutamine which did not significantly increase urine output but did cause significant hypotension, and therefore, the dobutamine was discontinued.

For perforation of a diverticulum diagnosed at the end of October when the patient developed increasing abdominal pain and free air on CT scan, the patient underwent laparotomy, partial sigmoid resection, and loop ileostomy.

The patient was re-explored on 11/10/2003 when she had increased abdominal pain and new free air because of a suspicion of repeat perforated viscus. No definite source of new infection or perforation was found. However, there was a strong concern that the patient had microperforation of the area of her bowel which was involved with bulky lymphoma.

For her neutropenia, the patient was treated with G-CSF and erythropoietin.

For sleep apnea, the patient was first treated with BiPAP, and after her first procedure on 10/30/2003, remained on mechanical ventilation via endotracheal tube until the time of her death. For her diabetes, the patient was treated with an insulin drip.

For a right lower extremity DVT discovered by Doppler lower extremity ultrasound on 11/29/2003, the patient was treated with the heparin drip.

For fungemia, the patient was treated with caspofungin for a flutter with rapid ventricular response. The patient was cardioverted several times and treated with IV and then oral amiodarone.

For possible microperforation of her bowel with an area of bulky lymphoma, the patient was continued on empiric antibiotics.

For her renal tubular acidosis. The patient was treated with bicarbonate.

Despite aggressive medical therapy including mechanical ventilation, broad-spectrum antibiotics, total parenteral nutrition, surgical and nephrology consultations, pressor support and transient inotrope support, the patient was not able to get off mechanical ventilation after an extended period of several weeks in the intensive care unit.

After discussing her situation and prognosis multiple times with her family and with the transplant attending, the patient asked for support to be withdrawn.

DISPOSITION: On 11/13/2003, the patient was extubated and started on a morphine drip. The patient's friends and family were at the bedside. The patient became hypotensive, bradycardic, and then expired just before 5 p.m. The patient's eyes were donated for eye research, and the patient is having a postmortem examination.

           

            AUTOPSY REPORT

 

11/14/03

AUTOPSY FINAL REPORT

 

AU CASE INFORMATION

SEX: F AGE: 63

DATE ADMITTED: 10/22/03
DATE OF DEATH: 11/13/03
DATE OF AUTOPSY: 11/14/03
RESTRICTIONS: No restrictions
CONSENT: Consent obtained from sister


AUTOPSY CAUSE OF DEATH: Diffuse alveolar damage
DUE TO: Sepsis
DUE TO: Ruptured diverticulum
OTHER CONDITIONS: Large B-cell lymphoma, alpha-1 antitrypsin deficiency
status post right lung transplant (1996).
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AU CLINICAL DIAGNOSIS

CLINICAL DIAGNOSES:
1. Alpha-1 antitrypsin deficiency.
A. Bullous emphysema, severe.
a. Right lung transplant (1996).
i. Tacrolimus and corticosteroids.
ii. Post-transplant large B-cell lymphoma (2003) of jejunum
I. Chemotherapy with CHOP, Rituxan.
a. Neutropenic fever.
II. Nodules in transplanted lung.
2. Diverticulitis
A. Ruptured diverticulum
a. Emergent partial colectomy with diverting ileostomy (10/31/03).
b. Re-exploration (11/10/03).
i. Presumed microperforation in small bowel lymphoma.
B. Positive blood cultures for Candida glabrata.
3. Atrial fibrillation with rapid ventricular response.
4. Diabetes mellitus.
5. Chronic renal insufficiency.
A. Acute renal insufficiency.
6. Left pleural effusion.
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AU FINAL DIAGNOSIS

I. Alpha-1 antitrypsin deficiency.
   A. Severe panlobular emphysema of the left lung.
   B. PAS positive hepatic globules and mild fibrosis.
   C. Status post right lung transplant.
      1. Lymphoma (7 x 4 x 4 cm) in wall of duodenum/jejunum.
         a. Multiple small nodules of lymphoma in mesenteric fat.
         b. No evidence of bowel disruption.
         c. Nodules of lymphoma in the right lung (up to 4 cm).
II. Sepsis, peritonitis (acute).
   A. Liquified spleen.
   B. Diffuse alveolar damage.
   C. Acute interstitial nephritis.
      1. Acute tubular necrosis.
III. Atherosclerosis.
    A. Systemic.
       1. Moderate to severe calcific atherosclerosis of aorta.
      2. Arterionephrosclerosis.
         a. Severe diabetic nephropathy.
           1) Parathyroid adenoma.
           2) Osteitis fibrosa cystica.
         b. Cortical thickness of 0.4 cm.
   B. Coronary.
      1. Mild atherosclerosis of all branches with minimal to no occlusion.
IV. Incidental findings
   A. Focal follicular hyperplasia of left thyroid lobe.
   B. Surgically absent gallbladder.
   C. Congested, steatotic liver.
   D. Vesicles right lower leg, largest 4 x 3 cm.
   E. Hemorrhagic gastritis.
   F. Uterine fibroids (x2).
   G. Diverticulosis.
      1. Status post bowel resection and diverting ileostomy for
      perforation.
   H. Multiple renal cysts, largest measuring 3.5 x 2.5 x 2.0 cm.
   I. Soft, thinned myocardium.
   J. Small, remote infarct of right caudate.
------------------------

AU CASE SUMMARY

CLINICAL SUMMARY: The patient is a 63-year-old Caucasian woman who was admitted to the hospital on October 22, 2003. The patient had a history of alpha-1 antitrypsin deficiency which was diagnosed in 1986. She underwent a right lung transplant in 1996. In April of 2003, she was diagnosed with a large B-cell lymphoma of the jejunum with nodules in the right transplanted lung. Her past medical history is also significant for chronic renal insufficiency, diabetes mellitus type II, hypertension and diverticulitis. The patient had been admitted to the hospital at the beginning of October for aggressive diuresis and diverticulitis. However, she returned home on October 15, only to be readmitted on October 22 with hypotension. She was treated with antibiotics for suspected sepsis. She developed atrial fibrillation and rapid ventricular response and was eventually transferred to the medical intensive care unit on October 23. On October 30, the patient developed increased abdominal pain and a CT scan demonstrated free air beneath the diaphragm. The patient underwent a laparotomy which resulted in partial sigmoid resection and a loop ileostomy. On November 10, the patient again had increased abdominal pain and free air beneath the diaphragm was visible on radiographic studies. She again underwent laparotomy. Despite suspicion of a repeat perforated viscus, no definite source of perforation or infection could be identified. Despite aggressive medical therapy, the patient remained dependent on mechanical ventilation and total parenteral nutrition. After discussion of her situation and prognosis with family and physicians, the patient requested withdrawal of support. She expired on November 13, 2003.

 

Autopsy revealed a mildly obese Caucasian woman with cushingoid features. She appeared older than the stated age of 63. Plaques of purulent material were visible on the omental surface. No gross perforation of the bowel was identified. A large, bulky lymphoma (7 X 4 X 4 cm) was identified in the wall of the duodenum/jejunum. The spleen and liver both had a septic appearance microscopically. Nodular hyperplasia of the adrenals was present bilaterally. Sections through the native (left) lung showed cystic dilatation of airspaces, consistent with the patient's history of alpha-1 antitrypsin deficiency. Sections through the right lung revealed a lymphomatous tumor nodule (4 cm in diameter on gross inspection). The liver was congested and without cirrhosis. Periodic acid-Schiff-positive, diastase-resistant globules were visible in the liver microscopically; these are characteristic of alpha-1 antitrypsin deficiency. Additionally, there was moderate steatosis of the liver. The kidneys showed changes of chronic diabetic nephropathy. Additionally, focal areas demonstrated acute intersitial nephritis and acute tubular necrosis. A parathyroid adenoma was present, due to long-standing, chronic renal failure. There was a focus of follicular hyperplasia within the thyroid gland. Sections through the brain revealed a remote infarct of right caudate; the brain was otherwise normal for age. 

 

Alpha-1 antitrypsin (AAT) deficiency is a relatively common disorder, affecting an estimated one in 3000-5000 Caucasian persons. Alpha-1 antitrypsin is a 55 kD serum glycoprotein that is synthesized primarily in the liver and released into the blood, where it circulates unbound and diffuses into interstitial and alveolar fluids. The principle function of the molecule is to inhibit neutrophil-released proteases, including trypsin, elastase, cathepsin G, and proteinase 3. Normally, alpha-1 antitrypsin protects the alveoli from the destructive action of neutrophil proteases. The production of alpha-1 antitrypsin is controlled by a pair of genes at the Pi (protease inhibitor) locus. Although many different alleles have been identified, the most common is M. Individuals homozygous for M (PiMM) produce and release a normal amount of protein. Allele Z is associated with normal production of alpha-1 antitrypsin, but decreased secretion. In this mutation, there is a single amino acid substitution of lysine for glutamate 342. This results in impaired secretion of the molecule by the endoplasmic reticulum of the hepatocyte. If the protein is removed from the cell, it functions at 50-80% of the wild-type level.  PiMM individuals have serum levels of alpha-1 antitrypsin that are nearly 6 times greater than those who are homozygous for the Z allele (PiZZ).  Low alpha-1 antitrypsin levels may result in panlobular emphysema, often as early as the fourth or fifth decades. Cigarette smoking in susceptible individuals may hasten the onset of severe emphysema by as many as 10 years. Chronic liver disease may develop in some PiZZ individuals, although the mechanism is not completely understood. The most widely accepted theory suggests that accumulation of the abnormal protein in the hepatocytes leads to cell damage and death. However, only a portion of PiZZ individuals develop chronic liver disease. It is speculated that some individuals have an endoplasmic reticulum capable of processing the abnormal protein, thus assuring its degradation, and are therefore protected from its detrimental effects.

 REFERENCES:
1. Fairman, P "Alpha-1 antitrypsin deficiency",
www.emedicine.com/med/topic108.htm
2. Perlmutter, DH Clinics in Liver Disease. 2000; 4(2): 387-408.
------------------------

AU GROSS DESCRIPTION

EXTERNAL EXAMINATION: A duly executed permit for autopsy is received from (sister) and the body is identified by toe tag and wrist band. The body length is 165 cm crown to heel and 79 cm crown to rump. The body is estimated to weigh 75 kg. The body is that of a normally developed Caucasian female who appears to be older than the stated age of 63 years. The body habitus is obese. The head circumference is 53 cm, the head is normal in size and the shape is symmetric. Hair distribution is normal and the texture is normal. Scalp hair is gray and short in length. The face is moon shaped. The corneas of the eyes have been donated. The ears are normal. The nose is normal. The mouth is normal. The neck is normal. The skin shows a midline vertical abdominal incision (25.0 x 5.0 cm) with packing material and a drain in place. Two JP drains are found in the left lower quadrant. There is a colostomy bag in the right lower quadrant. There is an additional 11 cm scar extending from xiphoid to the top of the abdominal incision. There is a 20 cm horizontal scar extending from the right flank to the right midclavicular line, approximately 5 cm below the nipple. Additionally, there is a 24 cm horizontal scar extending from the right flank to the midclavicular line over the iliac crest. Purplish striae are visible on the flanks bilaterally. There is a 6.0 x 1.0 cm scar on the right neck. There is a 4.0 x 1.0 cm purplish discoloration on the right lower extremity with overlying vesicles (the largest measures 4.0 x 3.0 cm). There is 1+ dependent livor of the back. There is no rigor mortis. Intravenous access lines are found in the left chest and left femoral region. The chest circumference is 108 cm and the chest is symmetric. The breasts are normal on palpation. The abdominal circumference is 112 cm and the abdomen is obese.  The back is normal. The external genitalia are normal for female sex. The extremities are normal.

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 minimal atherosclerosis. The brain weighs 1,300 gm. The convolutions show normal gyri and sulci. The brain and spinal cord are saved for neuropathologic examination. After formalin fixation, the brain and spinal cord are examined at the Neuropathology Conference. External examination shows mild atherosclerosis of the circle of Willis. There are no lesions. Sagittal sections show a cystic lesion on the right head of the caudate measuring 1.2 x 0.3 x 0.3 cm. Remaining sections are normal brainstem. Cerebrum and spinal cord appear normal. 

THORACIC CAVITY: A modified "Y" incision is made. The subcutaneous fat measures 1.5 cm at the level of the nipples. Organ situs in the thorax is normal. The breasts are normal. The pleural surfaces are smooth and glistening. The left pleural cavity contains 1000 mL of serous fluid and the right pleural cavity contains 100 mL of serous fluid. The mediastinum is without lesions. The thymus is not identified. 

ABDOMINAL CAVITY: A midline incision is made. The subcutaneous fat measures 6.0 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 the sixth rib on the left. The liver is 12.0 cm below the right costal margin at the midclavicular line and the spleen is above the left costal margin at the midclavicular line. The peritoneal surfaces show fibrous adhesions and the peritoneal cavity contains 100 mL of serous fluid. The retroperitoneum is without lesions. 

CARDIOVASCULAR SYSTEM The heart weighs 354 grams. The pericardial cavity contains 5 mL 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 0.2 cm and the left ventricular thickness is 1.4 cm. The atrial appendages are free of thrombi. The foramen ovale is closed. The myocardium is soft and is red-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 11.1 cm tricuspid, 7.4 cm pulmonic, 8.8 cm mitral, and 7.2 cm aortic. The heart valves show no vegetations. The coronary arteries show a right dominant pattern with minimal atherosclerosis of all branches and minimal narrowing of all branches. Thrombosis of no vessels is found. The aorta is not elastic and shows moderate to severe calcific atherosclerosis. The major branches are all patent. The venae cavae are patent.

RESPIRATORY TRACT: The pharynx is without lesion. The larynx is without lesion. The trachea shows erythema. The mainstem bronchi show erythematous mucosa. The right lung weighs 1,030 gm and the left lung weighs 450 gm. The pleural surfaces are smooth and glistening. Emphysematous bullae are evident on the left lung in both lobes. The left and right lungs are inflated with formalin prior to sectioning. The pulmonary parenchyma is partially aerated. Atelectasis is not present. On sectioning, the parenchyma shows consolidation throughout the entire right lung and in the upper lobe of the left lung. Three tumor masses are identified in the right lower lobe; the largest measures 4.0 x 3.0 x 3.0 cm. Additionally
there is a focus of greenish discoloration (4 cm in diameter) in the right lower lobe base. Granulomas are not seen. The cut surfaces of the lungs vary from pink to red and they exude no fluid. Anthracotic pigmentation is not marked. The bronchi show erythematous mucosa. The pulmonary arteries do not have pre-mortem 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 100 mL of dark green-brown fluid. The gastric mucosa shows diffuse hemorrhage. The rugal pattern is normal. The pylorus is patent and the duodenum normal. There is a 7.0 x 4.0 x 4.0 cm firm, white, mural mass in the jejunum. Additionally, there are nodules in the mesenteric fat lining the entire small intestine. The mucosa of the small intestine appears normal. Peyer's patches in the terminal ileum are not prominent. The mucosa is velvety and the folds are normal. A segment of ileum has been diverted to create the colostomy. The appendix is normal. The large intestine shows occasional diverticula. The descending portion of the colon is surgically absent and the proximal rectum has been stapled shut. The mucosa is velvety and the haustral folds are normal. The bowel contents consist of a moderate amount of soft green stool. The mesenteric arteries and veins are normal. PANCREAS: The pancreas measures 19.0 x 2.5 x 1.0 cm and is the usual size, firm, and tan 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 1800 gm. The liver capsule shows adhesions to the overlying diaphragm. The liver edge is sharp. The hepatic parenchyma is soft and yellow-tan with a nutmeg pattern. Cirrhosis is not present and the lobular pattern is not visible. Tumor masses are not seen. The portal vein is not opened. The hepatic artery and veins are patent. The gallbladder is surgically absent. The ampulla of Vater is normal.

SPLEEN AND LYMPHATIC SYSTEM: The spleen weighs 182 gm. The splenic capsule is smooth and translucent with no lesions. The splenic parenchyma is dark red and liquified. The follicular and trabecular pattern is not visible. There are no accessory spleens found. The splenic artery is patent and the splenic
vein is patent. The hilar, cervical, and mediastinal lymph nodes are somewhat enlarged and vary from pink-tan to tan-white and moderately firm to hard. The largest identified node measures 3.0 cm in greatest dimension.
URINARY SYSTEM: The right kidney weighs 146 gm and the left kidney weighs 128 gm. The capsules strip with ease. The cortical surfaces of the kidneys are pale red and finely granular with several cysts visible from the surface. There are no scars. The cut surfaces show very pale red cortices measuring 0.4
cm in thickness. Corticomedullary demarcations are poor. The medullae are pale red. There are a few cysts present; the largest measures 3.5 x 2.5 x 2.0 cm. The pyramids are normal. The calyces and pelves are normal. The ureters 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 present. The bladder contains a small amount of yellow urine and no calculi. The urethra is patent. The renal arteries show minimal atherosclerosis. The renal veins are clear.
FEMALE GENITAL SYSTEM: The vagina is smooth. The cervix is nulliparous and its mucosa is smooth. The uterus is present and measures 5.0 x 1.5 x 8.0 cm, is normal in size and shape. There is a 1.5 x 1.5 x 1.0 cm subserosal fibroid and a 3.0 x 2.0 x 1.0 cm pedunculated submucosal fibroid. The endometrium is thin and tan. The myometrium is normal. The fallopian tubes are normal and the ovaries are normal and show the usual appearance on sectioning.
ENDOCRINE ORGANS: The pituitary is the usual size, shape, color, consistency, and rests in the sella turcica. The thyroid weighs 22 gm and is slightly enlarged. The thyroid has the usual shape, color, and consistency. On sectioning, the parenchyma is red-brown. There are two cystic nodules present in the left lobe of the thyroid, the largest measures 2.0 x 2.0 x 1.0 cm. The nodules are filled with yellow-green viscous fluid. One enlarged parathyroid gland (1 x 0.6 x 0.5 cm) is found. The right adrenal gland weighs 8.8 grams and the left adrenal gland weighs 8.3 gm. The adrenals are normal in size with the usual shape, color, and consistency. The cortex of the right adrenal demonstrates hemorrhage, while the left adrenal cortex is normal. Their medullae are normal.
MUSCULOSKELETAL SYSTEM: The body and extremities are symmetric with no
malformations. The skeletal muscles are red-brown and there is no evidence for muscle wasting. 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 CODE:
A - Bone marrow
B - Omentum with yellow-white plaque
C - Right and left adrenal
D - Parathyroid, pancreas
E - Spleen
F - Liver
G - Left kidney
H - Right kidney
I - Uterine fibroid
J - Thyroid
K - Mesenteric nodule
L - Left lower lobe
M - Left upper lobe
N - Right lower lobe, greenish discoloration
O - Right lower lobe, nodule
P - Bone
Q - Right middle lobe
R - Right upper lobe
S - Small bowel mass
T - Mesentery
NEUROPATHOLOGIC CASSETTE SUBMISSION:
BA: Choroid plexus.
BB: Left hippocampus.
BC: Left motor cortex.
BD: Right head of the caudate lesion.
BE: Midbrain.
BF: Pineal.
------------------------

AU MICROSCOPIC DESCRIPTION

 

BONE MARROW: Sections through the bone marrow (slide A) show multiple small fragments. The fragments appear mildly hypercellular (50-60%). There are adequate megakaryocytes. The M:E ratio is 2:1. There is normal maturation of the myeloid line.
ADRENALS: Sections through the adrenals (slide C) show a three-layered cortex. There is extensive vacuolization of some cells. There is a nodular appearance to both glands. One gland demonstrates hemorrhage diffusely. Both glands demonstrate variable degrees of autolysis.
SPLEEN: Sections through the spleen (slide E) show foci of extramedullary hematopoiesis. There are numerous neutrophils present within the sinusoids. Hemosiderin is present.
LIVER: Sections through the liver (slide F) show mild congestion. Neutrophils are present within the sinusoids. There is vacuolization of some hepatocytes. There are prominent intracytoplasmic eosinophilic globules within hepatocytes. The intracytoplasmic globules are periodic acid-Schiff positive, and diastase resistant. There is mild bile duct proliferation, fibrosis, and bile stasis. A trichrome stain shows mild fibrosis of the portal triads with no bridging fibrosis. An iron stain reveals iron within the Kupffer cells and lining the sinusoids, but not within the hepatocytes.
KIDNEYS: Sections through the kidneys (slides G and H) show occasional
glomeruli with slightly thickened mesangium. However, the majority of the glomeruli are globally sclerosed. There is hemosiderin deposition in the tubular epithelium and lumen. Vascular congestion is evident. Vacuolization of the proximal tubules is seen. The blood vessels demonstrate concentric medial thickening. There is hyalinization of the small arterioles. The majority of the tubules are autolyzed. However, in focal areas, viable tubules are visible. In these areas, a neutrophilic infiltrate is seen destroying the adjacent tubules. In occasional areas, neutrophils can be identified in the tubule lumen.
UTERUS: Sections through the uterine fibroid (slide I) show bundles of smooth muscle in varying orientation with regions of sclerosis. No necrosis is apparent.

THYROID: Sections (slide J) show skeletal muscle and adjacent thyroid follicles of varying size and shape. There is a single well encapsulated nodule with multiple, very small follicles.

LUNGS: Sections through the left lung (slide L-M) show cystically dilated air spaces with rare residual alveoli. The septae are focally fibrotic. Sections of the right lung (slides N-O, Q-R) show a nodule of cells with scant cytoplasm and large irregular nuclei. The cells are discohesive and form sheets. There are areas of necrosis within the nodule. The largest nodule on microscopic section (slide O) measures 0.9 cm. Severe vascular congestion is evident, particularly in the right lung. Gram and silver stains demonstrate no organisms. There is septal edema, a slight increase in inflammatory cells in the septae and alveoli, and leakage of fibrin in the alveolar spaces.
BOWEL MASS: Sections through the bowel mass (slide S) show a 2.1 x 1.7 cm nodule composed of small cells with scant cytoplasm and large, somewhat monotonous nuclei. There are areas of necrosis. No normal bowel is visible.
OMENTUM: Sections through the omentum (slides B, K and T) show adipose tissue with acute and chronic inflammation and focal fibrosis. A sheet of neutrophils and inflammatory debris is present on slide B in association with the omentum. Gram stain reveals gram-positive rods, gram-negative rods, and gram-positive diplococci.
PANCREAS: Sections through the pancreas (slide D) demonstrate mild autolysis.

BONE: Sections through the vertebral bone (slide P) demonstrate irregular, thickened trabeculae. In some areas, the lamellae are disrupted. There are prominent osteoclasts, and Howship's lacunae are evident.

PARATHYROID: Sections through the parathyroid gland (slide D) show plump, eosinophilic cells in large nodule compressing the adjacent normal parathyroid tissue.
BRAIN: Sections through the right caudate demonstrate cystic change and surrounding gliosis. Sections through the choroid plexus show mild edema.  Additional sections through the brain are normal for age.