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Subject: Clinicopathologic Conference Date: July 23, 2008

Lecturer: Ronaldo Abueg, M.D Transcriber:   Sally


Guest Consultat: Dr. Tangsumting-Abu Editor: Mario
Topic: 2nd CPC Pages: 4

2nd Clinicopathologic Conference

General Data:
R.A., 31 y/o male, married balikbayan, native of Isabela was admitted on Dec. 22, 1995.

Chief Complaint: Diarrhea

HPI:
While in the USA working as a clerk at Mt. Sinai Hospital in Chicago, the patient was diagnosed to
have cysticercosis in October 1995 in the USA and was now treated with tapering doses of Dexamethasone.
He developed diarrhea on Nov. 26, 1995, while still in the US, which persisted until he arrived in the
Philippines on Nov. 29, 1995. He first stayed in Navotas, and then proceeded to Isabela, where he was
confined at a hospital for persistence of diarrhea, despite taking antidiarrheals. Another consult for
persistence of diarrhea was made. The management consisted of IV fluid rehydration. The diarrhea ceased
temporarily, but was replaced by nausea, vomiting, abdominal distention and fever, prompting transfer to our
institution.

PMH:
Labile hypertension and elevated BUN – 1 year PTA, for which he was taking Atenolol and
Allopurinol.

PE:
BP= 90/60, HR= 104 bpm, RR = 21 cpm, T = 37.3°C

General Survey:
Weak looking, fairly nourished, well-developed male, conscious, coherent, oriented to time, place
and person. He appears his chronologic age of 31 years.
Skin: No abnormalities noted.
Head: Moon Facies noted
Eyes: Right and Left: pupils 2-3 mm equally reactive to light, EOMs intact, (+)
ROR, (-) for hemorrhage, exudates
Ears: Right and left: Rinne AC>BC, Weber midline
Nose: no gross deformity
Throat Tonsils not enlarged, (-) exudates
Chest and Lungs: symmetrical chest expansion, no retractions, bronchovesicular breath sounds
CVS: adynamic precordium, normal rate, regular rhythm, no murmurs
Abdomen: distended, hypoactive bowel sounds, tympanitic and tenderness all over
Extremities: with muscle wasting and grade II bipedal edema
Neurologic Exam: no abnormalities noted

Course in the wards:


An impression of Cushing’s syndrome, mixed amebic and bacillary dysentery and malnutrition was
given. Metronidazole, Ampicillin and total parenteral nutrition were given and steroids were resumed. The
diarrhea abated, but the abdominal pain remained, along with anorexia and vomiting.
Esophagogastroduodenoscopy was done, revealing multiple gastric acid and duodenal ulcers. Cimetidine,
sucralfate and Mylanta were started. Steroid was deferred temporarily, later resumed on alternate day
dosage, when the patient showed improvement. On the 13th hospital day, coffee-ground material was noted
per NGT; stools became black. Frank bleeding set in to the point of hypotension. Ranitidine was given in
lieu of Cimetidine and iced lavage was instituted. A repeat gastroscopy revealed 30% healing of the gastric
ulcers with brisk oozing. The duodenal lesions were covered with blood. Relatives refused the proposed
surgical intervention.
Infectious disease consult was made because of the remittent fever. Sepsis was entertained,
although repeated blood cultures were negative; antibiotic coverage was appropriately instituted. Endocrine
consult gave the impression of hypoadrenalism and resumption of low dose steroid was advised. Insulin was
given for hyperglycemia. Neurologic consult concurred with the other consults.
Twenty-six units of blood were transfused. Acute renal failure set in; respiratory failure developed,
for which he was intubated and attached to a respirator. The patient died on Jan. 23, 1996, on the 31 st
hospital day, 17 days after coffee ground material was noted per NGT.

2nd CPC 1
Lab Work ups:

Complete Blood Count


Patient’s Result
Hemoglobin 134
Hematocrit 0.41
White Blood Count 17x109/L
Differential Count
Segmenters 0.68
Lymphocytes 0.15
Stab Cells 0.05
Eosinophils 0.01
Monocyte 0.01
Platelet 350,000

Urinalysis
Color Yellow
pH 6.0
Specific gravity 1.010
Sugar Negative
Albumin Negative
RBC 0-1/HPF
WBC 0-1/HPF
Epithelial Cells Rare
Casts negative

Fecalysis
Color Dark brown
Consistency Formed
RBC Negative
WBC Negative
Mucus Negative
Ova and Parasites Negative

Clinical Chemistry
Patient’s Result
Na 134 mmol/L
K 3.8 mmol/L
Cl 90 mmol/L
LDH 184 U/L
AST 29 U/L
ALT 6 U/L
Ca 1.8 mmol/L
Total Bilirubin 11.9 umol/L
Total Protein 32 g/L
Albumin 14 g/L
Globulin 18 g/L
Cholesterol 1.6 mmol/L
RBS 7.2 mmol/L
CK 55 U/L
Phosphorus 0.9 mmol/L
Alkaline Phosphatase 15 U/L
Uric Acid 0.27 mmol/L
BUN 1.6 mmol/L
Creatinine 44 umol/L

EEG: Normal
Proctosigmoidoscopy
Anus: external hemorrhoids
Rectum: no mass
Procto: scope inserted up to 25cm. The mucosa is rough, bumpy, with patches of chronic and acute
inflammatory changes. Exudates noted.
Impression: Colitis r/o dysentery

Rectal Swab C/S: Normal flora


Gastroscopy: Multiple small gastric and duodenal ulcers all over pylorus. Narrowed duodenum up to the
mid part.

2nd CPC 2
Impression: Multiple duodenal and gastric ulcers with gastritis and duodenitis.

Free T3 RIA = 0.8 pmol/L (N=4.2-12)


Free T4 RIA = 11.9 pmol/L (N=8.8-33)
Impression: Serum free T3 is in the hypothyroid level while serum free T4 level is within the euthyroid state.

X-rays:
Chest: haziness, left base, with blunting of costophrenic angle. Impression: Pneumonia, left base.
Follow-up Chest X-ray: right parahilar densities increasing in size, probably secondary to pneumonia.
Abdomen (supine and upright): slight dilatation of small and large bowels. Impression: Paralytic ileus.
KUB: no localizing signs

Autopsy Findings External Examination


- Adult male
- Extremities: pale with rigor mortis changes
- Lungs: External surface covered with thin fibrinopurulent material with focal areas of thickening with
appears fibrous when cut

Autopsy Findings Microscopic Description

Lungs
- Focal areas of necrosis and hemorrhages
- Polymorphonuclear infiltrates
o Interstitial pneumonia with severe superimposed bronchopneumonia
- Septated hyphae with mycelia
o Hemorrhagic infarcts Hyphae within the blood vessels
o Recent organizing thrombi
- Acute Respiratory Distress Syndrome

Esophagus
- Focal areas of erosions mostly on distal third

Stomach
- Blood all over mucosal surface with focal areas of erosions, antrum severely eroded

Small Intestines
- Worms in duodenum
o Severe infestations of adult worms measuring 2.0 to 4.0 mm.
o Foreign Body giant cells around infested crypts
- Worms in the jejunum

Large Intestines
- Severe congestion with occasional ulcers and infiltrated mainly by mononuclear cells. Lymph
vessels dilated causing lymphangiectasias

Spleen
- Normal

Liver
- Moderate fatty changes

Heart
- Occasional hypertrophy of muscles fibers with focal interstitial fibrosis

Kidneys
- Except for congestion, microscopic sections were normal

Adrenals
- Unremarkable

Brain
- areas of necrosis with histiocytic infiltrates at the region of pontine, nuclei and longitudinal fibers of
the cortico-spinal and cortico-bulbar tract with small recent hemorrhages of the pons

FINAL ANATOMIC DIAGNOSIS (Read up on EACH of the Disease)

1. Massive gastrointestinal hemorrhage (2 liters) secondary to chronic ulcerations, distal third of


esophagus, stomach, small and large intestines
2. Massive Roundworm infestation, duodenum and jejunum (Capillariasis)
3. Acute Respiratory Distress Syndrome Secondary to Severe Bronchopneumonia with
Pulmonary mycotic (Mucormycosis) infection and hemorrhagic infarcts

2nd CPC 3
4. Recent small hemorrhages, Pons with areas of recent necrosis and histiocytic infiltrates at
the region of pontine nuclei and longitudinal fibers of the cortico-spinal and cortico-bulbar
tract

Pathophysiology of Capillariasis infection


- caused by the nematode Capillariasis philippinensis
- transmitted via ingestion of bird-eating fresh or brackish water fish
- Infection has an insidious onset with nonspecific abdominal pain and diarrhea
- Invasive larvae cause intestinal inflammation and villus loss
- Subsequent autoinfection can lead to a severe wasting syndrome – hypoproteinemia,
hypoalbuminemia, hypocholesterolemia, hence the name Wasting disease.
- If left untreated, progressive autoinfection can lead to protein-losing enteropathy, severe
malabsorption and ultimately to death from cachexia, heart failure or superinfection.
- Burs in the jejunum

Pathophysiology

Ingestion of fish with Capillaria Chronic Steroid use

Diarrhea, GIT infestation and wasting disease Massive GI Bleeding

Superinfection and immunosuppression

Fungal pneumonia, ARDS

Multiple Organ Failure (secondary to hypoperfusion)

Demise of the Patient

Just some additional notes taken during the “super fast” lecture.
- CBC: Eosinophilia is not elevated in Capillariasis
- Distal 3rd of the jejunum was affected
- The patient had Diffused Epithelial Damage
- Cause of Death: Hypovolemic Shock
- Drug of Choice for Capillariasis: Mebendazole and Albendazole
- The patient had a Class II hemorrhage

Capillariasis (from Harrison’s because I can’t find anything in Robbins, I’m so sorry.)
- Caused by ingestion of raw fish infected with Capillaria philippinensis
- Autoinfection can lead to severe wasting syndrome
- Occurs in the Philippines, Thailand and elsewhere in Asia
- Involves fish from fresh and brackish water.
- When humans eat infected raw fish, the larvae matures in the intestines into adult worms, which
produce invasive larvae that cause intestinal inflammation and villous loss.
- It has an insidious onset with nonspecific abdominal pain and watery diarrhea
- If untreated, progressive autoinfection can lead to protein-losing enteropathy and severe
malabsorption and ultimately to death from cachexia, cardiac failure, or superinfection.
- The diagnosis is established by identification of the characteristic peanut-shaped (20 by 40 um) eggs
on stool examination. Severely ill patients require hospitalization and supportive therapy in addition
to prolonged anthelmintic treatment with mebendazole or albendazole.

***GOD BLESS on our evals!!!

Guys, please read your robbins on each disease the patient had, as well as the cause of
death… thanks

2nd CPC 4