Mindnumbing I

There is a case at Stanford which has been haunting me for the last week. (Note: details have been changed). We were told about a ridiculously sick transfer from an outside hospital. A young woman with a history of lymphoma, immunosuppressed with chemotherapy presents to an outside hospital several months ago. There she is diagnosed with MRSA endocarditis, possibly from IVDU, with septic emboli to the lungs. She is put on vancomycin for 6 weeks via PICC line. She goes home, then returns to the hospital about a week later with epistaxis (nose bleed). In the emergency department, they pack the nose with gauze to stop the bleed, and because she is slightly thrombocytopenic (presumably from chemotherapy), she was admitted to the hospital. A CT scan (unclear why this was obtained) showed cavitary nodules which were worrisome and a sputum culture grew out Aspergillus. The CT also caught part of the liver and showed a mass which was biopsy-proven hepatocellular carcinoma. Separately, the patient started having altered mental status and becoming more somnolent. A lumbar puncture was not consistent with meningitis. An MRI of the brain showed ill-defined lesions of unclear etiology. There was also concern for endocarditis, but transthoracic echocardiograms were negative (it is not clear why a transesophageal echocardiogram was not pursued). Meanwhile, the epistaxis started draining purulent material and a CT scan of the sinuses showed maxillary and ethmoid sinusitis. She also had facial swelling on the same side, and an ophthalmology consult diagnosed periorbital cellulitis. As the patient became more and more complicated, she accumulated antibiotics and more tests until finally the outside hospital transferred her to us. Although ostensibly, the transfer was for diagnosis of the brain masses, this is what the patient looked like when she reached us.

Image is in the public domain, from the CDC.