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

  • Miss Bryan&#x27;s Class - Spring Grove Area School District

    Miss Bryan's Class - Spring Grove Area School District

    The homework planner can be found inside your child's school binder. If a student forgets their planner, homework assignments will also be posted on our classroom website everyday and periodically texted to parents through Remind 101. There are no excuses...
  • Concept Attainment - Kathy Marks Educational Consultant

    Concept Attainment - Kathy Marks Educational Consultant

    Concept Attainment. Advantages for students: Make connections between what they know and what they will be learning . Learn how to examine a concept from a number of perspectives . Learn how to sort out relevant information . Knowledge of...
  • The Skull and Temporomandibular joint II Prof. Abdulameer

    The Skull and Temporomandibular joint II Prof. Abdulameer

    The bones contribute to its concave wall are the temporal bone, sphenoid bone, parietal bone and the frontal bone . It is superior to the infratemporal fossa which lies beneath the zygomatic arch. The temporal fossa has the following borders:...
  • Presentation Template

    Presentation Template

    Counselling through IAPT services - We now meeting the overall access target. The service offers both face to face and digital IAPT counselling support. Mental Health Crisis Services- 4 hour response time target. Local clinicians working with local people for...
  • Digestion and Nutrition - PC&#92;|MAC

    Digestion and Nutrition - PC\|MAC

    The sublingual glands, inferior to the tongue, are the smallest of the major salivary glands and secrete a saliva that is thick and stringy. Diagram. ... The stomach is divided into cardiac, fundic, body, and pyloric regions and a pyloric...
  • Cause and effect essays - Jessamine County

    Cause and effect essays - Jessamine County

    The Crucible Cause and Effect Essay ... Arial Calibri ヒラギノ角ゴ Pro W3 Office Theme The Crucible Cause and Effect Essay A Little Review Real Life Examples Slide 4 Chain of events For cause and effect essays A Cause and Effect...
  • PowerPoint Sunusu

    PowerPoint Sunusu

    - 1. Masal - sesli Bir varmış, bir yokmuş; bir yaşlı ayakkabıcı ve sadece çocukların yaşadığı bir Düş Şehri varmış. Bu şehirde yaşamanın bir şartı varmış: Çocuklar birlikte oyun oynamaktan, birlikte düş kurmaktan vazgeçtikleri anda - ya da, kısaca büyüme...
  • Santa Clara University School of Law

    Santa Clara University School of Law

    How to Learn More LCS Library "The Official Guide to Legal Specialties" "Careers in Law" also see other practice-area specific books Talk to lawyers in different practice areas Talk to your professors about their experiences Book a counseling appointment with...