Cardiovascular Pathology Case 4

Links

Rad Web link: http://radweb.med.utah.edu/

Olympus link: https://nfusexp.med.utah.edu/citrix/nfuse17/login.asp

Library link: http://medlib.med.utah.edu/library/eresources/fulltext.html

Data for Case

Part 1

The patient is a 62 year old male with a history of asbestos exposure and interstitial lung disease diagnosed in 1995. He has been on steroids since then and is currently on home O2 at 12 L. He was recently treated for pneumonia and is on the lung transplant list. He presents today with severe shortness of breath and is admitted to the hospital to the pulmonary service for intubation and mechanical ventilation.

Review the Admission History and Physical from 12-18-02.

1. What are the cardiac causes of shortness of breath?

2. How does lung disease affect the heart?

3. Review the admission laboratory results how did these help rule out the possibility of a pulmonary embolus?

4. What do you see on his EKG?

5. What is your differential diagnosis?

Six months before this admission the patient underwent a work up for lung transplantation that included a heart perfusion study. This revealed no evidence of ischemia but did show right ventricular overload.

Additional workup at that time revealed marked pulmonary bullous disease on CT scan.

A Chest view composite from the CT scan also showed cardiac enlargement:

X-rays taken on this admission are shown here.

CXR of 12-20-02

CXR of 12-29-02

Compare the new films with ones from 6-11-02:

Part 2

The patient underwent broncho-alveolar lavage and pneumonia was ruled out. The patient was treated with oxygen and attempts were made to extubate the patient over the next several days. However with each attempt the patient could not maintain his O2 saturations.

Look at the patient’s O2 trends to get an idea of his lung function and how treatment with intubation helped.

Review the Cytology report for the BAL on 12-18-02.

Review the Microbiology reports to determine if there is infection.

1. How did intubation help this patient?

2. What effect does oxygenation have on the heart?

Part 3

On 12-29-02 the patient’s O2 saturations declined and the family decided not to re-intubate the patient per his wishes for non-invasive treatment only.

This is the last progress note.

Review the labs on the day of his death.

Review the Death Summary.

Part 4

The patient died on 12-30-02 and an Autopsy was requested. The Autopsy found that the patient had interstitial pneumonitis on top of his already severe interstitial lung disease; this was probably due to viral pneumonia. His heart was enlarged (590 gm) and the right atrium and ventricle were hypertrophied and dilated. There were hemosiderin laden macrophages in the lungs.

External view of the right ventricle showing enlargement:

Internal view of the right atrium and ventricle showing dilatation:

Picture of the Patent Foramen Ovale when the heart was fresh:

View of the Patent Foramen Ovale in the fixed heart:

Cut surface of the lung:

Close up of the end stage lung disease with interstitial fibrosis:

Microscopic of heart with hypertrophic fibers:

Sections of lung with end stage honey comb changes:

Sections of lung with interstitial inflammation, fibrosis and hemosiderin laden macrophages:

1. What is this type of heart disease called?

2. What is the cause of death?

3. What is the significance of the patent foramen ovale?

Part 5

Assignment for next week

Using all of the information you have gathered from the chart, prepare a presentation about this case as you would for attending rounds with a concise summary of the history, physical findings, labs and x-rays. Your presentation should be about 5 minutes long. A copy of your presentation needs to be handed in to your facilitator by the end of the lab on 12/11/03.

Incorporate the following into your report:

1. What are the effects of lung disease on the heart?

2. How is the diagnosis of Cor Pulmonale made?

3. How do you diagnosis and manage right heart failure?

4. What is a Patent Foramen Ovale, why does it occur in Cor Pulmonale and what risk does it impose on the patient?

TOP

DATA FOR CASE

Admission H&P 12-18-02

Laboratory Reports 12-18-02

PaO2 Trends

BAL Pathology Report

Microbiology Report

Radiology Reports

Laboratory Reports 12-29-02

Death Summary

Autopsy Report

Normal Values

Admission HP 12/18/2002

CC: worsening SOB, increased O2 requirements

HPI: Pt is a 62 yo male with pulmonary interstitial disease secondary to asbestosis, requiring baseline home O2 of 10L, who originally presented on 12/11/02 complaining of SOB, cough, rhinorrhea, without fever/chills/nausea/vomiting. He was admitted and treated for community acquired pneumonia with Azithromycin/cefotaxime/Bactrim SS. While at the hospital he had a negative cardiac workup (troponin I 0.04, CK 113, CK-MB 3.1). He reports a hospital course significant for one day in the ICU and two days in telemetry prior to being discharged on 12/14/01 on Azithromycin 250mg qd, Cefuroxime 500mg bid, Bactrim 800/160 3tabs qid. Following discharge, he continued to feel poorly. He returned to the ER earlier yesterday morning where he was noted to have hypoxia on ABG. They were able to stabilize his saturation level at 88% on 10-12L and so discharged him to home. At home he continued to have difficulty maintaining his saturation levels, and felt uncomfortable lying down in bed. He then decided to come to this hospital. In the ER he was found to be in respiratory distress with a LLL infiltrate on CXR and ABG of 7.44/29.1/52.7 with saturation of 83% on 15L.

ROS: chronic SOB, denies any acute changes in SOB but has recently noticed a change in his breathing pattern requiring "pursed lips" to breath over the past couple of days, denies nausea/vomiting/fever/chills, no worsening of his peripheral edema, no productive cough, denies pain or head-ache complains of constipation.

PMH:
1) interstitial lung disease: Currently on lung transplant list, with interstitial lung disease secondary to asbestos/plutonium/beryllium exposure in 1962 while in the Navy. His disease was diagnosed by open lung biopsy in 1995 with complications including pulmonary hypertension, cor pulmonale, and severe exercise intolerance. He has been steroid dependent since 1995 with typical dose of 20mg prednisone qd, and he has a baseline O2 requirement of 10-12 L to keep his saturation greater than 80%. Additionally he requires 4 pillows to sleep, and he suffers from lower extremity edema for the past year.
2) steroid induced diabetes mellitus
3) gout
4) htn

PSH:
1) Uvulopalatopharyngoplasty and septoplasty for OSA
2) severed tendon on right foot
3) hernia repair X 2 (age 18, 38)
4) bronchoscopy X 2 with lung biopsy

SH: denies history of tobacco use
occasional ETOH (one per week approx.)
denies illicit drug use

FH: daughter with asthma
no family history of interstitial lung disease
mother died of lymphoma
father died at 84 years old with CAD

ALLERGIES: NKDA

MEDS:
Furosemide 40mg po qd am
NPH 30U sc qd am
K 10mEq po qd am
Prednisone 20mg po bid
Testosterone 0.5mg po qd pm
Humalog SSI
Allopurinol 300mg po qd pm
Calcium Carbonate 1.25gm po qd pm
Lorazepam 1.0mg po qd
Prilosec 20mg po qd pm
Viagra 25mg po qd pm (for vasodilation and decrease cardiac work)
Vancenase Aq Ds 2 sprays qd
Coumadin varied dose (currently held for elevated INR)for decrease cardiac work
Colchicine 0.6mg po bid
Diltiazem 240mg po bid
Guaifed 600mg po bid
Azithromycin 250mg po qd pm
Cefuroxime 500mg po bid
Bactrim 800/160mg 3tabs po qid

VITALS: T 36.7, HR 92, R 24, BP 115/61, 72% on 15L

GEN: acute on chronically ill appearing male with cushingoid features, sitting on edge of bed in apparent respiratory distress
HEENT: conjunctivae injected with blepharitis. PERRL, EOMI, proptosis, OP clear without uvula, no oral lesions visible, JVP not appreciated secondary to thick neck, no thyromegaly, no carotid bruits
PULM: quick, shallow breaths without obvious accessory muscle use, has to speak in short sentences to catch breath, bilateral crackles approximately one-third of the way up bilaterally.
CV: Regular rate and rhythm without M/R/G
ABDOMEN: The abdomen is obese. Bowel sounds are normal without hepatosplenomegaly.   
EXTREMITIES: 2+ pitting edema in ankles to knees. Ecchymoses are present on the forearms bilaterally, with large hematoma on left.   
SKIN: multiple raised lesions on head and AK on arms/back

WBC 29.64, HCT 49.3, PLT 301, 86.6%POLY
Na 132, K 5.8, Cl 96, CO2 18, BUN 34, Cr 1.9, glu 99
INR 3.0
ABG 7.44/29.1/52.7/ 83% 15L

CXR LLL infiltration

A/P: 62 year old male with interstitial lung disease due to asbestosis/beryllium/plutonium, with steroid dependence and 12L home O2 requirements who was recently treated at the hospital for community acquired pneumonia, now presenting with continued SOB, hypoxemia, renal insufficiency. Differential includes PE but unlikely considering anticoagulation and INR of 3.0, cardiogenic but negative enzymes, likely cause of symptoms secondary to residual pneumonia in setting of severe interstitial lung disease.
--will do EKG to look for baseline and to r/o ischemic changes
--will hold Coumadin for elevated INR
--will change antibiotic coverage to Levaquin for broad coverage
--O2 non-rebreather for saturation > 90%
--will transfer to the ICU with consideration for intubation in light of respiratory distress
--rest of plan per ICU team

patient is FULL CODE

TOP

Clinical Laboratory Report

Collected Date  

Order Description  

12/18/02

URINALYSIS, COMPLETE

Name	Result/Unit		Ref Interval	Status
URINE COLLECTION	NOT SPEC
URINE COLOR	YELLOW
URINE APPEARANCE	CLOUDY	A
SPECIFIC GRAVITY, URINE	1.018		1.003-1.030
pH, URINE	5.0		5.0-7.5
URINE PROTEIN	NEG		NEG
URINE GLUCOSE	NEG		NEG
URINE KETONES	NEG		NEG
URINE BILIRUBIN	NEG		NEG
URINE BLOOD	SMALL	A	NEG
URINE NITRITE	NEG		NEG
URINE WBC SCREEN	NEG		NEG
URINE RBC/HPF	2-5 /HPF		0-5/HPF
URINE UROBILINOGEN	0.2 mg/dL		0.2-1.0
UR URIC ACID CRYSTALS	MANY	A

12/18/02

Blood Gas Analysis, Arterial, Right Radial

Name	Result/Unit		Ref Interval	Status
FiO2	15 L
pH	7.439		7.35-7.45
PaCO2	29.1 mmHg	L	35-39
PaO2	52.7 mmHg	L	61-82
COHb	0.7 %		0.1-2
MethHb	0.9 %		0.1-2
tHb	16.6 gm%		13-19
O2 Content	19.4 vol%		17-24
Pb	638 mmHg
HCO3	19.4 mEq/L		19-25
BE	-2.9 mEq/L	L	-2.5-2.5
O2Hb	83.4 %	L	92-99
Temp	37 C
Allen`s Test	+
Comment	ART PUNCTURE IN ER 3

12/18/02

PT/INTERNAT. NORMALIZED RATIO

Name	Result/Unit		Ref Interval	Status
PROTHROMBIN TIME	31.0 sec	H	12.0-15.5
INTERNATIONAL NORMALIZED RATIO	3.0 ratio
Comments: REFERENCE INTERVAL: International Normalized Ratio (INR) INR values should only be used when evaluating patients on oral anticoagulant therapy. INR 2.0 - 3.0 : Prophylaxis of venous thromboembolism,                 treatment of venous thrombosis (following                 heparin therapy), prevention of systemic                 embolism (atrial fibrillation, valvular heart                 disease, bioprosthetic heart valves, acute                 myocardial infarction). INR 2.5 - 3.5 : Mechanical prosthetic heart valves, recurrent                 systemic embolism.

12/18/02

BASIC METABOLIC PANEL

Name	Result/Unit		Ref Interval	Status
SODIUM	132 mmol/L	L	136-144
POTASSIUM	5.8 mmol/L	H	3.3-5.0
CHLORIDE	96 mmol/L	L	98-107
CARBON DIOXIDE	18 mmol/L	L	22-29
UREA NITROGEN	34 mg/dL	H	9-22
CREATININE, SERUM - mg/dL	1.9 mg/dL	H	0.8-1.5
GLUCOSE	99 mg/dL		64-128
ANION GAP	18 mmol/L	H	8-14
CALCIUM, SERUM OR PLASMA	8.8 mg/dL		8.4-10.2

12/18/02

CBC with PLT COUNT/AUTO DIFF

Name	Result/Unit		Ref Interval	Status
WHITE BLOOD CELL COUNT	29.64 K/uL	H	3.20-10.60
RED BLOOD CELL COUNT	5.39 M/uL		4.69-6.07
HEMOGLOBIN	16.8 g/dL		14.6-17.8
HEMATOCRIT	49.3 %		40.8-51.9
MEAN CORPUSCULAR VOLUME	91.5 fL		77.8-94.0
MEAN CORPUSCULAR HEMOGLOBIN	31.2 pg		26.5-32.6
MEAN CORPUSCULAR HGB CONC	34.1 g/dL		32.7-36.9
RED CELL DISTRIBUTION WIDTH	17.9 %	H	10.8-14.1
PLATELETS	301 K/uL		177-406
MEAN PLATELET VOLUME	8.9 fL		5.9-9.8
GRANULOCYTES %	86.6 %	H	44.0-76.0
MONOCYTE %	6.6 %		2.0-7.5
EOSINOPHIL %	0.3 %		0.0-6.0
AUTOMATED BASOPHIL %	1.2 %		0.0-1.7
GRANULOCYTE #	25.7 K/uL	H	1.3-7.0
MONOCYTE #	2.0 K/uL	H	.1-.5
AUTOMATED ABS EOSINOPHIL COUNT	0.1 K/uL		0.0-0.4
BASOPHILE #	0.3 K/uL	H	0.0-0.1
LYMPH #	1.6 K/uL		.8-3.1
LYMPHOCYTE %	5.3 %	L	14.7-42.6
SMEAR SCANNED	YES

TOP

PaO2 Trend
Date	Result/Unit	H/L	Ref Interval	Comments
12/29/02 08:25 PM	27.9 mmHg	LL	61-82
12/28/02 06:40 PM	46.4 mmHg	L	61-82
12/23/02 07:55 PM	108 mmHg	H	61-82
12/23/02 07:55 PM	108 mmHg	H	61-82
12/23/02 03:50 AM	81.3 mmHg		61-82
12/21/02 05:00 AM	163 mmHg	H	61-82
12/20/02 10:20 PM	69.8 mmHg		61-82
12/20/02 08:30 PM	67 mmHg		61-82
12/20/02 06:11 PM	77.6 mmHg		61-82
12/20/02 03:55 AM	63.2 mmHg		61-82
12/19/02 04:24 AM	74 mmHg		61-82
12/18/02 05:25 PM	112 mmHg	H	61-82
12/18/02 12:12 PM	118 mmHg	H	61-82
12/18/02 09:39 AM	78.7 mmHg		61-82
12/18/02 07:59 AM	71.1 mmHg		61-82
12/18/02 06:20 AM	53.3 mmHg	L	61-82
12/18/02 01:40 AM	52.7 mmHg	L	61-82

(63y M)

TOP

Anatomic Pathology Report

Collected Date  

12/18/02

NON-GYN SPECIMEN SOURCE

Lavage-Bronchoalveolar, (Lingula).

NON-GYN CLINICAL HISTORY

Asbestosis - immunosuppressed.

NON-GYN GROSS DESCRIPTION

15 mls of cloudy clear fluid.

NON-GYN ADEQUACY INTERP

Satisfactory for interpretation.

DIAGNOSIS / INTERPRETATION:

No malignant cells identified. No cellular evidence of Pneumocystis carinii.
No viral inclusions, fungal elements or bacteria identified. Gram, AFB and
GMS stains negative for organisms. Numerous hemosiderin laden macrophages.

TOP

Microbiology Report

Collected Date  

Order Description  

12/18/02

BLOOD CULTURE, BOTTLE SYSTEM, BLOOD, RIGHT TRIPLE LUMEN

Name	Result
FINAL REPORT	NO GROWTH

12/18/02

FUNGAL CULTURE, BRONCHIAL ALVEOLAR LAVAGE

Name	Result
FINAL REPORT	NO FUNGI ISOLATED

12/18/02

AFB CULTURE, BRONCHIAL ALVEOLAR LAVAGE

Name	Result
ACID FAST STAIN	NO ACID FAST BACTERIA SEEN
FINAL REPORT	NO ACID FAST BACILLI ISOLATED

12/18/02

RESPIRATORY VIRUSES DFA, BRONCHIAL ALVEOLAR LAVAGE, STERILE

Name	Result
FINAL REPORT	See Comments
Comments: NEGATIVE FOR INFLUENZA TYPES A AND B, PARAINFLUENZA TYPES 1,2,3, RSV AND ADENOVIRUS BY DIRECT FLUORESCENT~ANTIBODY. ------------------------ TEST INFORMATION: Respiratory Viruses DFA The sensitivity of the DFA tests for influenza, parainfluenza, and respiratory adenovirus is only 25-80%. Culture backup for negative results is strongly recommended. The sensitivity of the DFA for RSV is greater than 95% and does not require culture backup.

12/18/02

FUNGAL SMEAR-CALCOFLUOR WHITE, BRONCHIAL ALVEOLAR LAVAGE

Name	Result
CALCOFLUOR WHITE PREP	NO YEAST OR FUNGAL ELEMENTS SEEN

12/18/02

HSV CULTURE, BRONCHIAL ALVEOLAR LAVAGE, STERILE

Name	Result
FINAL REPORT	NO HERPES SIMPLEX VIRUS ISOLATED

12/18/02

RESPIRATORY CULTURE, BRONCHIAL ALVEOLAR LAVAGE

Name	Result
GRAM STAIN	NO ORGANISMS SEEN
GRAM STAIN	1+ PMNS
GRAM STAIN	1+ WBCS, NOT PMNS
FINAL REPORT	NO GROWTH

12/18/02

LEGIONELLA CULTURE, BRONCHIAL ALVEOLAR LAVAGE

Name	Result
FINAL REPORT	NO LEGIONELLA ISOLATED

12/18/02

VIRAL CULTURE with CMV CULTURE, BRONCHIAL ALVEOLAR LAVAGE, STERILE

Name	Result
FINAL REPORT	NEGATIVE FOR CMV BY EARLY ANTIGEN DETECTION
FINAL REPORT	NO OTHER VIRUSES ISOLATED

TOP

Radiology Report
Exam Date	Study Description
12/29/2002	CHEST XRAY 1V
CHEST, 12/29/02. HISTORY: Respiratory distress, look for infiltrates. FINDINGS: AP supine portable chest x-ray 12/29/01 compared with 12/28/01. There is no endotracheal tube or central venous lines apparent. There has been interval removal of a right IJ line. The cardiomediastinal contour is unchanged with cardiomegaly. Lungs show changes of pulmonary fibrosis. No evidence of pleural effusions. IMPRESSION: INTERVAL REMOVAL OF RIGHT IJ LINE WITHOUT APPARENT COMPLICATIONS. PULMONARY FIBROSIS WITHOUT EVIDENCE OF INCREASING PULMONARY EDEMA OR FOCAL CONSOLIDATION.
12/20/2002	CHEST XRAY 1V
SINGLE AP VIEW OF THE CHEST, 12/20/02 at 9:41 p.m. The comparison study is dated 12/20/02 at 8:49 p.m. FINDINGS: Endotracheal tube tip is approximately 3 cm above the carina. Feeding and NG tubes are noted to course through the stomach. Right internal jugular central venous catheter tip remains in the SVC. The cardiac silhouette is again noted to be prominent but stable in size when compared to the previous exam. There has been persistent hazy opacification of the left lung base, most consistent with a layering effusion and diffuse hazy interstitial opacification with an appearance most consistent with pulmonary edema. Left lower lobe remains opacified which may be secondary to underlying atelectasis versus pneumonia. IMPRESSION: TUBES AND LINES UNCHANGED IN POSITION AND STABLE. NO SIGNIFICANT CHANGE IN LAYERING LEFT PLEURAL EFFUSION WITH PROMINENCE OF CARDIAC SILHOUETTE AND PERIHILAR INTERSTITIAL OPACIFICATION CONSISTENT WITH PULMONARY EDEMA.
12/18/2002	CHEST XRAY 1V
CHEST, 12/18/02. HISTORY: Dyspnea, evaluate for pneumonia. FINDINGS: Single portable semiupright AP chest radiograph performed 12/18/01, comparison with 8/3/01. Lung volumes are diminished, particularly on the left. The left lung base demonstrates dense consolidative opacification obscuring the left costophrenic angle and hemidiaphragm. The cardiac silhouette is not well visualized. A moderate-sized left pleural effusion is present, adjacent parenchymal disease is suspected. PA and lateral radiographs are recommended to further evaluate. IMPRESSION: DIMINISHED LUNG VOLUMES, LEFT GREATER THAN RIGHT. MODERATE LEFT PLEURAL EFFUSION WITH SUSPECTED LEFT LOWER LOBE PARENCHYMAL DISEASE. RECOMMEND PA AND LATERAL RADIOGRAPH.
06/14/2002	MYOCARD PERF MO
HISTORY: Pulmonary arterial hypertension, pre-lung transplant evaluation. RADIOPHARMACEUTICALS: 3.02 mCi Thallium-201 24.0 mCi Tc-99m Cardiolite 51 mg Adenosine PROCEDURE, REST IMAGING: The patient was intravenously injected with Tl-201. SPECT images of the heart were obtained immediately. The patient returned later for stress imaging. STRESS IMAGING: During a 4 minute infusion of Adenosine, the patient was intravenously injected with Tc99m Cardiolite. SPECT images of the heart were obtained 30 minutes later. ECG and vital signs were monitored during stress. FINDINGS: There are no fixed or stress induced perfusion defects. Resting cine images demonstrates significant right ventricular activity. ECG gated images demonstrate no definite left ventricular wall motion abnormality. The right ventricle appears enlarged with decreased contraction. LVEF = 60% IMPRESSION: NO SCINTIGRAPHIC EVIDENCE OF ISCHEMIA OR INFARCTION. SCINTIGRAPHIC FINDINGS CONSISTENT WITH RIGHT VENTRICULAR OVERLOAD.
06/13/2002	THORAX CT WO
CT SCAN OF THE CHEST WITHOUT CONTRAST, 6/13/02. There are no comparison films. HISTORY: Pulmonary fibrosis. TECHNIQUE: 5 mm collimated scans were obtained from the lung apices to the domes of the diaphragm without IV contrast. This was followed by 1 mm collimated scans every 15 mm. FINDINGS: There are scattered small lymph nodes within the mediastinum, some of which are borderline pathologic in size, but this is often described with advanced pulmonary fibrosis and is not viewed with concerned. Limited evaluation of the upper abdomen is clear. The heart size is borderline enlarged, but there is no pericardial or pleural effusion present. No pleural thickening is seen. Mild to moderate coronary arterial calcification is present. Osseous structures demonstrate degenerative disc disease. Lungs demonstrate extensive pulmonary fibrosis with architectural distortion, inter and intralobular septal thickening and traction bronchiectasis. It is predominantly located within the lung bases and the periphery. There are extensive areas of ground glass opacity present bilaterally. However, in these areas of ground glass, there does appear to be evidence of mild to moderate traction bronchiolectasis and intralobular septal thickening. This finding is most characteristic for pulmonary fibrosis that is below the resolution of a collimation and is not felt to represent an active phase of alveolitis. A superimposed infection is also considered less likely. IMPRESSION: EXTENSIVE PULMONARY FIBROSIS BILATERALLY. THE EXTENSIVE GROUND GLASS OPACITY LIKELY REPRESENTS PULMONARY FIBROSIS BELOW THE RESOLUTION OF THE COLLIMATION. ACTIVE ALVEOLITIS IS CONSIDERED MUCH LESS LIKELY. NO SUSPICIOUS PULMONARY NODULES ARE PRESENT. CALCIFIED GRANULOMAS ARE PRESENT WITHIN THE RIGHT LOWER LOBE AND MIDDLE LOBE.

TOP

Clinical Laboratory Report

Collected Date  

Order Description  

12/29/02

ABG with Electrolytes, Lactate and Gluc, Arterial, Right Femoral

Name	Result/Unit		Ref Interval	Status
FiO2	100 %
pH	6.994	LL	7.35-7.45
PaCO2	55 mmHg	H	35-39
PaO2	27.9 mmHg	LL	61-82
COHb	0 %	L	0.1-2
MethHb	0.2 %		0.1-2
tHb	15.5 gm%		13-19
O2 Content	4.8 vol%	L	17-24
Pb	635 mmHg
A-aO2	505 mmHg
Na+	134 mmol/L	L	136-144
K+	6.8 mmol/L	HH	3.3-5
Ca++	4.52 mmol/L	HH	1.11-1.3
HCO3	12.7 mEq/L	L	19-25
BE	-20.1 mEq/L	L	-2.5-2.5
O2Hb	21.7 %	L	92-99
Hct	47.6 g/dL
Glucose	221 mg/dL	H	65-110
Lactate	16 mmol/L	H	0.7-2.1
Temp	37 C
Allen`s Test	N

12/29/02

CBC with PLATELET COUNT

Name	Result/Unit		Ref Interval	Status
WHITE BLOOD CELL COUNT	22.27 K/uL	H	3.20-10.60
RED BLOOD CELL COUNT	4.89 M/uL		4.69-6.07
HEMOGLOBIN	15.2 g/dL		14.6-17.8
HEMATOCRIT	44.5 %		40.8-51.9
MEAN CORPUSCULAR VOLUME	91.0 fL		77.8-94.0
MEAN CORPUSCULAR HEMOGLOBIN	31.2 pg		26.5-32.6
MEAN CORPUSCULAR HGB CONC	34.3 g/dL		32.7-36.9
RED CELL DISTRIBUTION WIDTH	16.8 %	H	10.8-14.1
PLATELETS	267 K/uL		177-406
MEAN PLATELET VOLUME	9.6 fL		5.9-9.8

12/29/02

PT/INTERNAT. NORMALIZED RATIO

Name	Result/Unit		Ref Interval	Status
PROTHROMBIN TIME	23.9 sec	H	12.0-15.5
INTERNATIONAL NORMALIZED RATIO	2.1 ratio

12/28/02

BASIC METABOLIC PANEL

Name	Result/Unit		Ref Interval	Status
SODIUM	137 mmol/L		136-144
POTASSIUM	3.7 mmol/L		3.3-5.0
CHLORIDE	94 mmol/L	L	98-107
CARBON DIOXIDE	36 mmol/L	H	22-29
UREA NITROGEN	35 mg/dL	H	9-22
CREATININE, SERUM - mg/dL	1.2 mg/dL		0.8-1.5
GLUCOSE	113 mg/dL		64-128
ANION GAP	7 mmol/L	L	8-14
CALCIUM, SERUM OR PLASMA	7.8 mg/dL	L	8.4-10.2

TOP

Death Summary : 12/30/2002

MICU DEATH NOTE

ID: Patient is a 62 year old male with pulmonary interstitial disease and h/o asbestosis diagnosed by open lung biopsy in 1994, requiring baseline home O2 of 12L, currently on lung transplant list, cor pulmonale, on chronic steroids since 1994, steroid induced diabetes mellitus, gout, OSA with symptoms, and htn who is admitted with worsening respiratory distress requiring intubation 12/18. Extubated 12/19/02.

Patient re-intubated 24 hr’s after first extubation. Then extubated again 12/22. Patient had been requiring high flow O2 per open face tent to keep saturations in 80's. Patient had been continuing to require high flow O2 and was noted to desaturate quickly off O2. Patient's o2 saturations remained in the 80's and patient had good mental status.

On 12/29/02 patient decreased o2 sats to mid to low 70's. Multiple attempts were made to improve oxygenation using non-invasive ventilation high flow O2 system and then BIPAP. O2 sats remained in mid 70's with both delivery devices. Patient's MS remained clear and patient hesitant to be re-intubated. However, patient did state that would agree to intubation as last resort. Family present in afternoon and aware of patient's decreased o2 sats. Patient's o2 sats then rapidly decreased to mid 60's, respiratory arrest and possible pulseless electrical activity cardiac arrest during intubation. Attending present during desaturation and code. CPR performed. Code called at 20:49.

TIME OF DEATH: 20:49
MECHANISM OF DEATH: Respiratory arrest

HOSP COURSE BY PROBLEM:

1) Pulm: Interstitial Pneumonitis due to asbestosis/beryllium/plutonium, with steroid dependence and 12L home O2 requirements who was recently treated for community acquired pneumonia, now admitted and intubated. Concern for atypical infection in immunosuppressed patient, but negative legionella, no evidence for infection on BAL. Unclear what insult caused patient to experience worsening respiratory distress. He was treated with 8 day course of Zosyn and Cipro empirically without any dramatic response and antibiotics were discontinued 12/24. Patient stable for several days following extubation but continued to require high flow 02 following extubation desaturated quickly off O2. Patient with worsening hypoxia and respiratory arrest leading to death as above.

2) Renal- Elevated creatinine on admit. Creatinine back to baseline UA and culture negative from 12/20.

3)CV- hemodynamically stable until 12/29 with decreased BP, likely secondary to aggressive diureses. Given fluid boluses with good response. Respiratory/cardiac arrest as above.

4)Heme- Patient on Coumadin as outpatient. There is no history of venous thromboembolism but patient anticoagulated due to risk of VTE in patients with pulmonary htn. Held Coumadin initially as patient with INR >3.0 on admit. Restarted Coumadin 12/24 and patient at therapeutic INR 12/29.

5)F/E/N: Patient OK’d to take PO's per swallow evaluation. On Neuro diet with pt sitting upright in chair and one-on-one supervision. Meds crushed and placed in applesauce.

6)ID: cont elevated WBC, but on steroids, afebrile, cultures (blood and BAL)negative to date.

7) Full CODE

TOP

Autopsy Pathology Report

Collected Date  

12/30/02

DATE OF AUTOPSY: 12/30/02

AUTOPSY CAUSE OF DEATH: Interstitial lung disease
OTHER CONDITIONS: Cor pulmonale
------------------------

AU CASE SUMMARY

CLINICAL HISTORY:
The decedent is a 62-year-old male with a known history of asbestosis/beryllium/plutonium exposure while in the military in the 1960's and a subsequent diagnosis of interstitial lung disease by open lung biopsy in 1995. Complications secondary to his lung disease included pulmonary hypertension, cor pulmonale, and severe exercise intolerance. He was steroid dependent and developed a steroid-induced diabetes mellitus. On 12/11/02 he was admitted to the hospital and was diagnosed and treated for community acquired pneumonia. At that time he had a negative cardiac work-up but was hypoxic and required 10-12 liters of oxygen to stabilize his oxygen saturation level at 88%. After a short stay at home he was readmitted to different hospital with respiratory distress, and a left lower lobe infiltrate on chest x-ray was found. The decedent required intubation. Extubation attempts and non-invasive ventilation delivery methods were unsuccessful, and he required reintubation. The decedent's oxygen saturations continued to decrease despite intubation, and he went into respiratory arrest. CPR was performed, but the decedent was unable to be revived and was pronounced dead at 20:40.

At autopsy the lungs have both gross and microscopic features of extensive diffuse interstitial fibrosis with honeycomb change. No pulmonary embolus was found nor was evidence found of a significant thromboembolic shower. The most significant finding that might explain the decedent's rather precipitous demise was that of a diffuse interstitial pneumonitis characterized by a chronic interstitial inflammatory infiltrate. This histologic finding most likely represents a viral pneumonia. The decedent's lung capacity was already severely decreased due to the underlying chronic interstitial lung disease, and the added insult of pneumonia was not well tolerated. Although the decedent had a known history of various environmental/occupational exposures, no definitive asbestos bodies were found in multiple examined sections of the lung tissue. The absence of these characteristic bodies does not definitively rule out the diagnosis of asbestosis but makes it much less likely. The exact etiology of the pulmonary fibrosis is not able to be determined by histologic examination.
------------------------

AU FINAL DIAGNOSIS

CLINICAL DIAGNOSES:
I. Interstitial lung disease
a. Remote asbestos/beryllium/plutonium exposure
b. Open lung biopsy in 1994 with reported diagnosis of interstitial lung
disease
c. Pulmonary hypertension and cor pulmonale
d. Clinically suspected right to left shunt
II. Hypertension
III. Steroid dependent diabetes mellitus

FINAL ANATOMIC DIAGNOSES:
I. Interstitial lung disease
A. Extensive interstitial pulmonary fibrosis with honeycomb change
1. Right lung, 1120 grams
2. Left lung, 940 grams
B. Pulmonary arteriopathy with moderate myointimal proliferation within
small arteries and arterioles
C. Pulmonary artery atherosclerosis, moderate
D. Cardiomegaly, Cor Pulmonale
1. Heart, 590 grams
2. Right atrial dilatation, severe
3. Right ventricular dilatation and hypertrophy
i. Endocardial fibrosis, mild
4. Patent foramen ovale
5. Left ventricular hypertrophy
E. History of asbestos, beryllium and plutonium exposure
II. Interstitial pneumonitis
III. Atherosclerosis
A. Coronary arteries, mild
B. Aorta, mild
------------------------

AU GROSS DESCRIPTION

EXTERNAL EXAMINATION: A duly executed permit for an autopsy restricted to the heart and lungs is received and the body is identified by a toe tag on the left great toe. The body length is 184 cm crown-to-heel and 87 cm crown-to-rump. The body is estimated to weigh 75 kg. The body is that of a normally developed Caucasian male who appears to be the stated age of 62 years. The body habitus is remarkable for central obesity. The head circumference is 57 cm and the head is normal in size and shape. Hair distribution is normal and the texture is coarse. Scalp hair is gray and up to 4.0 cm in length. Frontal balding is present. The face is not remarkable. The eyes are normal. The ears and nose are normal and the mouth is has good dentition. The skin is remarkable for early marbling and multiple ecchymoses with the following locations and dimension: Right upper chest, 9.5 x 9.5 cm; right and left forearms, multiple and up to 4.0 cm in greatest dimension. A small amount of skin slippage is also present on the anterior left forearm. An 8.0 cm irregular well-healed scar is present in the upper medial right forearm. An intravenous access line is located in the right wrist. The chest circumference is 103 cm and the chest is symmetric. The abdominal circumference is 107 cm and the abdomen is mildly distended. The back is normal. The external genitalia are normal for male sex. The extremities are remarkable for mild clubbing of the digits.

THORACIC CAVITY: A "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 pleural surfaces are smooth and glistening without plaques. The pleural cavities are without effusions. Prominent anthracotic lymphadenopathy is present within the mediastinum.
CARDIOVASCULAR SYSTEM: The heart weighs 590 grams (normal heart weight, 250-350 grams). The pericardial cavity contains 15 cc of serous fluid. The epicardium is smooth and glistening. There is severe dilatation of the right atrium and right ventricle. The right ventricle is also hypertrophied with a thickness of 0.8 cm and a length of 8.6 cm. The left ventricle is hypertrophied with a thickness of 1.8 cm. The left ventricular length is 10.0 cm. The atrial appendages are clear. The foramen ovale is fibrotic with semilunar patency. The myocardium is firm and brown with no fibrosis. The endocardium has mild fibrosis in the right ventricle. The trabeculae carneae and papillary muscles are hypertrophied in the right ventricle. The chordae tendineae are normal. The heart valves are thin and pliable. The heart valve ring circumferences are as follows: 13.0 cm tricuspid, 8.4 cm pulmonic, 12.0 cm mitral and 8.0 cm aortic. The heart valves have no vegetations. The coronary arteries have a right dominant pattern with mild atherosclerosis of all branches and minimal narrowing. Thromboses are not identified. The aortic arch is elastic and shows mild atherosclerosis consisting of lipid plaques. The pulmonary artery shows moderate atherosclerosis consisting of lipid plaques.
RESPIRATORY TRACT: The pharynx, larynx and proximal trachea are not examined. The mainstem bronchi are clear. The right lung weighs 1,120 grams and the left lung weighs 940 grams (normal lung weights, 300-400 grams each). The pleural surfaces are smooth and nodular with multiple bullae present in the right and left lower lobes. The pulmonary parenchyma shows posterior congestion and is partially aerated. Atelectasis is not present. On sectioning the parenchyma shows dense fibrosis with multiple small cysts (up to 0.5 cm in diameter) that are more prominent in the periphery and bases of the lung. Tumor masses and granulomas are not seen. The cut surfaces of the lung are red and they exude frothy yellow fluid. A small amount of mucus is present in the bronchioles and cystic spaces. No consolidations are seen. Anthracotic pigmentation is not marked. The pulmonary arteries do not have thromboemboli, but do have moderate atherosclerosis characterized by yellow lipid plaques. The pulmonary veins are clear.

CASSETTE SUMMARY:
A - Mediastinal hilar lymph nodes.
B - Lung, right lower lobe.
C - Lung, right middle lobe.
D - Lung, right upper lobe.
E - Lung, left lower lobe.
F - Lung, left upper lobe.
G - Heart, right and left ventricle.
H - Lung, right lower lobe, peripheral and central representative section.
I - Lung, right upper lobe, peripheral and central representative sections.
J - Lung, left lower lobe, peripheral and central representative sections.
K - Lung, left upper lobe, peripheral and central representative sections.
------------------------

AU MICROSCOPIC DESCRIPTION

Sections of the hilar lymph nodes show foci of sclerosis within which are minute fragments of polarizable material. Scattered anthracotic pigmentation is also present.
Sections of both the right and left lungs are similar and show extensive diffuse interstitial fibrosis and honeycomb change. The honeycomb change is more prominent in the peripheral segments of the lungs and is characterized by marked architectural distortion with multiple fibrocystic spaces lined by metaplastic bronchiolar columnar-type epithelium as well as focal squamous metaplasia. Prominent smooth muscle hyperplasia is also present. Occasional foci of metaplastic bone formation are seen. Foci of mucus plugging with associated acute inflammatory cells are noted. Scattered aggregates of hemosiderin-laden macrophages within both the alveolar spaces as well as the interstitium are evident. Multiple intraalveolar and interstitial multinucleated foreign body-type giant cell aggregates are present. No polarizable material is identified in association with these foreign body giant cell-type reactions, however. No asbestos bodies are identified in multiple sections.
The interstitium in areas of residual lung have evidence of a diffuse interstitial infiltrate comprised of chronic inflammatory cell infiltrates.
This infiltrate consists of both lymphocytes and macrophages. No viral cytopathic changes are identified. No evidence of an intraalveolar inflammatory infiltrate is identified.
The pulmonary arterial tree has moderate myointimal proliferation within small arteries and arterioles, and two small thrombi are identified which show evidence of early organization. The capillaries within the septa are notably tortuous.
Sections of the right and left ventricle each show features of myocyte hypertrophy; however, the hypertrophy is more pronounced within the right ventricular myocardium. No significant interstitial fibrosis, hemorrhage, or inflammatory cell infiltrates are identified.

SPECIAL STAINS: A trichrome special stain and an iron special stain are performed on block 1D, and controls stained appropriately. The trichrome stain confirms the extensive interstitial fibrosis within the lung in the areas of honeycomb change as well as interstitial fibrosis in the interalveolar septa in areas of residual lung tissue. This stain also highlights the narrowing of pulmonary arterioles by intimal hyperplasia. The iron stain confirms the presence of iron within foci of hemosiderin-laden macrophages in both the alveoli and interstitial spaces.

TOP

Laboratory Normal Values:

ACTH 9 - 52 pg/mL

Alpha-fetoprotein 0 - 15 ng/mL

Alanine aminotransferase (ALT) 6 - 50 U/L

Albumin 3.5 - 4.6 g/dL

Alkaline phosphatase 45 - 150 U/L

Ammonia 7 - 27 micromol/L

Amylase, serum (adult) 30 - 110 U/L

Aspartate aminotransferase (AST) 15 - 50 U/L

Bilirubin, total 0 - 1.5 mg/dL

Bilirubin, direct 0 - 0.3 mg/dL

Calcium 8.8 - 11.0 mg/dL

Carbon dioxide 20 - 29 mmol/L

Catecholamines, urine free

Epinephrine 0 - 25 microgm/day

Norepinephrine 0 - 100 microgm/day

Chloride 101 - 111 mmol/L

Cholesterol, total 100 - 200 mg/dL

Cholesterol, HDL 0 - 35 mg/dL

Cortisol (8 am) 6 - 23 microgm/dL

(8 pm) 0 - 9 microgm/dL

Creatine kinase 20 - 200 U/L

Creatinine 0.8 - 1.4 mg/dL

Erythrocyte sedimentation rate 0 - 20 mm/Hr

Estradiol, female <73 pg/mL (postmenopausal)

30 - 400 pg/mL (normal hormonal cycle)

Ferritin 7 - 340 ng/mL (male)

7 - 75 ng/mL (female)

Gastrin 0 - 100 pg/mL

Glucose 64 - 128 mg/dL

HCG, serum, quantitative

Male 0 - 5 IU/L

Female 2 - 8 IU/L

Homocysteine, plasma 4 - 12 micromol/L

Homovanillic acid (HVA), urine 0 - 15 mg/day

Iron, serum

Male 50 - 170 microgm/mL

Female 30 - 160 microgm/mL

LDH 105 - 230 U/L

Lipase, serum 16 - 63 U/L

Metanephrins, urine, adult

Metanephrine 0 - 300 microgm/gm of creatinine

Normetanephrine 0 - 400 microgm/gm of creatinine

Phosphorus 2.4 - 4.1 mg/dL

Plasma renin activity (upright) 0.5 - 3.3 ng/mL/hr

Potassium 3.7 - 5.2 mmol/L

Prostate specific antigen 0 - 4 ng/mL

Rheumatoid factor 0 - 20 IU/mL

Sodium 136 - 144 mmol/L

Thyroglobulin antibody 0 - 2 IU/mL

Thyroid peroxidase (TPO) antibody 0 - 2 IU/mL

(antimicrosomal antibody)

Thyroid stimulating hormone (TSH) 0.4 - 5 mU/L

Thyroxine 4.5 - 10.9 microgm/dL

T4, free 0.9 – 2.3 ng/dL

Total Protein, serum 6.3 - 8.2 g/dL

Total Protein, CSF 15 - 45 mg/dL

Troponin I <0.4 ng/mL; >2 ng/mL consistent with myocardial injury

Urea Nitrogen (BUN) 7 - 20 mg/dL

Uric Acid 2.7 - 6.6 mg/dL

Hgb 12 - 16 g/dL female

13 - 18 g/dL male

Hct 37 - 48 % female

42 - 52 % male

MCH 28 - 33 pg/cell

MCHC 32 - 36 g/dL

MCV 86 - 98 fL

RDW 11.5 - 14.5%

Platelets 150,000 - 300,000/microliter

WBC count 4300 - 10,800/microliter

PT 12.5 seconds

PTT 26.2 seconds

Fibrinogen 150 - 350 mg/dL

Lymphocyte subsets

CD4 cells (absolute) 440 - 1600/microliter

CD8 cells (absolute) 180 - 850/microliter

Quantitative Immunoglobulins

IgA 68 - 378 mg/dL

IgG 768 - 1632 mg/dL

IgM 60 - 263 mg/dL

TOP