Radiology Case Presentation Sami Natour, MS4 UVA School

Radiology Case Presentation Sami Natour, MS4 UVA School

Radiology Case Presentation Sami Natour, MS4 UVA School of Medicine Clinical History

E.L. is a 58 year old male with a past medical history of PVD, aortic stenosis, HTN, HLD, who was transferred from an OSH for management of MSSA bacteremia complicated by endocarditis and presumed septic emboli to the brain Presented to OSH with confusion and headache and found to have MSSA bacteremia of unknown source. He began treatment with nafcillin prior to transfer TEE demonstrated severe AR and multiple aortic valve vegetations MRI Brain demonstrated findings suspicious for septic emboli Notable Physical Exam Findings, Labs Afebrile, Vitals were within normal limits on presentation to UVA Gen: Oriented to person, place, and time.

Neck: Normal ROM, supple CV: Holosystolic and early diastolic murmurs loudest at the right 2 nd intercostal space, radiating to the carotids. RRR. Pulm: Crackles heard at bilateral bases Abd: Soft, no tenderness Skin: No Janeway lesions or Osler nodes appreciated Notable Labs WBC: 28.87 BUN/Cr: 27/1.4 Hgb: 8.3 AST/ALT: 38/<6 PLT: 219 - 7/29, 7/30, 8/8 Blood cultures positive for MSSA

Imaging (performed at OSH) TEE (AV vegetations, severe AR) MRI C-Spine, CT Abd/Pelvis, CXR all unremarkable MRI Brain demonstrated (as follows) T2/FLAIR

DWI T2/FLAIR Hospital Course Patient was admitted to the ACS service and a multidisciplinary team was consulted for management. A source could not be identified and he continued to spike fevers. The decision was made to schedule him for AV repair. Prior to his surgery, he developed

chest pain with dyspnea and ST depressions in V1-V4 concerning for posterior MI. Anticoagulation was withheld due to risk of hemorrhagic conversion of brain lesions. Patient was transferred to the CCU for hemodynamic optimization. Nitroglycerin drip was started with resolution of chest pain. On the night of transfer, his respiratory status worsened requiring intubation and troponins trended upward. He was taken for cardiac catheterization with revascularization of obtuse marginal artery but incomplete aspiration from left circumflex. After this procedure he became progressively hypotensive requiring vasopressors and ultimately went into PEA arrest. The patients cause of death was presumed to be cardiogenic shock due to acute MI from septic emboli into coronary circulation.

Radiographic features Diffuse cerebral (cortical, subcortical, and deep white matter) and single right cerebellar foci of increased T2/FLAIR signal and restricted diffusion corresponding to PCA and MCA territories T2/FLAIR hyperintensity differential: - CNS tumors (primary and metastatic disease) - Vasculitis (e.g. Behcets disease)

- Infectious (e.g. abcess or embolic disease) - Demyelinating diseases - Ischemic pathology - Traumatic injury Use history and clinical findings to guide this broad differential References 1. Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med. 2013 Apr 11;368(15):1425-33. doi: 10.1056/NEJMcp1206782. Review. Erratum in: N Engl J Med. 2013 Jun 27;368(26):2536. PubMed

PMID: 23574121. 2. Guzmn-De-Villoria JA, Ferreiro-Argelles C, Fernndez-Garca P. Differential diagnosis of T2 hyperintense brainstem lesions: Part 2. Diffuse lesions. Semin Ultrasound CT MR. 2010 Jun;31(3):260-74. doi: 10.1053/j.sult.2010.03.002. Review. PubMed PMID: 20483393.

Recently Viewed Presentations

  • The Enlightenment and the Great Awakening: A Comparison

    The Enlightenment and the Great Awakening: A Comparison

    Paul Revere: A Boston silversmith and messenger who spread the news the British were coming. 6. Lexington & Concord: Sites in Massachusetts of the first battles of the American Revolution. ... Parliament passed the Townshend Acts in 1767, leading to...
  • EXTRA DIMENSION - Yonsei University

    EXTRA DIMENSION - Yonsei University

    Large Extra Dimension. First of all, it . can be detected . by experiment or measurement maybe soon if it exists. ... M5 is the reduced 5D Planck mass. A(y) is given by solving above action. Which means form of...
  • Immigration Resolutions: Resolutions by Name Resolution by Aim

    Immigration Resolutions: Resolutions by Name Resolution by Aim

    Sometimes the resolution is favourable to the client and may support INZ's aim of bringing the best people to New Zealand and/or meeting its obligations as a good global citizen. Sometimes the resolution contributes more to protecting the integrity of...
  • Texas Public School Finance Overview

    Texas Public School Finance Overview

    Estimate Data Report (Late submissions not accepted) Estimate Data Report opens July 1st with firm deadline of August 1st. 2018-2019 Estimate Data Report. This report is used by TEA to determine state-aid for the charter school until Six-week District Summary...
  • Delivering a PowerPoint Presentation MOAC Lesson 11 Slide

    Delivering a PowerPoint Presentation MOAC Lesson 11 Slide

    Delivering a PowerPoint Presentation. MOAC Lesson 11 (John Wiley & Sons, Inc., 2012) Slide Orientation. The direction that material appears on a page when printed (John Wiley & Sons, Inc., 2012) ... Setting up a Slide Show.
  • Judy Blume - Appalachian State University

    Judy Blume - Appalachian State University

    Judy Blume Judy's Personal Life Born in 1938 in New Jersey 2 Children-- Daughter Randy and son Larry 1 Grandson- Elliott Married George Cooper in 1987 Resides in different islands along the East Coast Judy's Picture Books The One in...
  • Higher Geography Lithosphere Core

    Higher Geography Lithosphere Core

    Take a copy of this map and stick it into your jotter. Colour the three rock types differently. SEE NEXT SLIDE LITHOSPHERE CORE INTRODUCTION Compare your map to a relief map in the Atlas. Discuss your findings in class and...
  • Heating the Earth -

    Heating the Earth -

    Heating the Earth Energy From the Sun Where We Get Our Energy The Sun is a major source of energy for Earth. Forms of Energy Different forms of energy include heat, light, electrical, mechanical, sound, nuclear, and chemical.