April 2024 Critical Care Case of the Month: A 53-year-old Man Presenting with Fatal Acute Intracranial Hemorrhage and Cryptogenic Disseminated Intravascular Coagulopathy

Robert A. Raschke MD MS ^1,2

Kim Josen MD²

Ethan Weisman BS³

¹Department of  Medicine and Biomedical Informatics, University of Arizona College of Medicine-Phoenix, Phoenix AZ USA

²Pulmonary and Critical Care Medicine, HonorHealth Osborne, Scottsdale, AZ USA

³ The Honors College, Arizona State University, Tempe, Arizona, USA

History of Present Illness: A 53-year-old man was admitted for acute onset of left hemiparesis, left facial droop and dysarthria witnessed by his wife (a nurse) while they were watching TV that evening. She reported the patient had no previous history of coronary artery disease or cerebral vascular disease, prior to an admission occurring three weeks earlier. The patient presented at that time with acute, severe left-sided chest pain that began while he was doing some heavy yardwork. While being evaluated in the emergency department (ED), he developed left-sided facial numbness, hemiparesis and dysarthria. A CT scan of the brain was normal. Neurological symptoms resolved before lytic therapy could be administered. Troponins and EKG were normal. A D-dimer was >20 mg/L, but a CTA of the chest showed no pulmonary embolism and was otherwise unrevealing. The chest pain resolved without specific therapy. Subsequent CTA of the head and neck and a brain MRI were both normal. Other labs drawn during that two-day hospitalization, including a CBC, complete metabolic profile, INR and aPTT, were all essentially normal. The patient was diagnosed with transient ischemic attack, atypical chest pain and new onset hypertension, and discharged on 81 mg aspirin and 2.5 mg amlodipine daily.

The patient did well over the intervening three weeks except for poor control of his hypertension, with blood pressures measured at home as high as 178/105. On the morning before his current presentation, the patient coughed up blood. The patient’s wife examined his mouth and noted several “blood blisters” of his buccal mucosa which she attributed to his poorly fitting dentures. The patient was otherwise well until the onset of stroke symptoms at 2200, after which he  complained of diffuse headache. 

Past Medical History: The patient had no known allergies. He had a history of emphysema, GERD and hypercholesterolemia and was taking rosuvastatin, esomeprazole and inhaled fluticasone/umeclidinium/vilanterol in addition to amlodipine and aspirin. He had a remote history of major trauma resulting in asplenia. He didn’t smoke, vape, drink alcohol excessively or use drugs. He worked as a truck driver.

Physical Examination: Initial physical examination was significant for HR 117 bpm, RR 18 bpm, temp. 36.5°C, BP 169/99 mmHg. His Glascow Coma Scale (GCS) was 14 and he was dysarthric, with a rightward gaze preference and a dense L hemiplegia. Ecchymoses of his left knee and right shoulder were noted. A stat CT brain showed a 6x4x4cm intraparenchymal hematoma centered on the right basal ganglia, effacing the right lateral ventricle and causing 6mm of midline shift. It was confirmed that the patient had not taken any antithrombotic medications or clopidogrel. Admission labs demonstrated a WBCC 22.8 x10³/uL, Hb 12.8 g/dL and platelet count of 64 x10³/uL. An automated five-part differential (neutrophils, lymphocytes, monocytes, basophils, and eosinophils) was normal. The INR was 2.2 and aPTT 38 secs. Fibrinogen was 62 mg/dL and a D-dimer >20 ml/L. A complete metabolic profile was unremarkable.

Routine management of acute hemorrhagic stroke includes which of the following except? (Click on the correct answer to be directed to the )

1. Rapid control of systolic blood pressure to levels <140mmHg using intravenous antihypertensives if necessary.
2. Rapid reversal of antithrombotic effects of medications such as warfarin with four-factor prothrombin complex concentrate (4F PCC), and Xa inhibitors with andexanet alpha or 4FPCC.
3. Platelet transfusion to maintain platelet count >100 x10³/uL in patients with thrombocytopenia.
4. Platelet transfusion to restore platelet function in patients with normal platelet counts, but platelet dysfunction due to aspirin or other antiplatelet drugs.
5. Neurosurgical consultation.

Cite as: Raschke RA, Josen KM, Weisman E. A 53-year-old Man Presenting with Fatal Acute Intracranial Hemorrhage and Cryptogenic Disseminated Intravascular Coagulopathy. Southwest J Pulm Crit Care Sleep. 2024;28(4):49-55. doi: https://doi.org/10.13175/swjpccs016-24 PDF 

April 2022 Critical Care Case of the Month: Bullous Skin Lesions in the ICU

Margaret Wat MD PhD, Jawad Bilal MD, Martin Chacon MD, Stephen Klotz MD, and Janet Campion MD

University of Arizona College of Medicine-Tucson

Tucson, AZ USA

History of Present Illness: A 29-year-old woman with past medical history of mixed connective tissue disease [lupus predominant], prior pulmonary embolism complained of a 2-week history of nonproductive cough. The cough began after her son was diagnosed with respiratory syncytial virus (RSV). Symptoms progressively worsened and now she is admitted from the  emergency department (ED) with generalized weakness and progressive shortness of breath. Earlier in the day at an outside hospital, she tested positive for RSV, negative for COVID-19 and had normal O2 saturations and was discharged home. She has not received COVID-19 vaccine. Symptoms progressed, 911 called and in the ED, she was found to have temperature = 104°F, SpO2 = 64% on room air, and fasting blood sugar in the 40s. She was lethargic with visible respiratory distress and unable to answer questions.

Past Medical History:

• Mixed connective tissue disease [features of systemic lupus erythematosus, rheumatoid arthritis, polymyositis, scleroderma]
• Membranous lupus nephritis [class V]
• History of pulmonary embolus
• Posterior intracranial artery infarct with venous sinus thrombosis in February 2020
• Hypertension
• Recent septic shock due to pneumococcal bacteremia 2 months prior to admission
• Post-op C section

Medications:

• Atovaquone 750 mg BID
• Eliquis 5 mg BID
• Fluconazole 150 mg Q 72h
• Hydroxychloroquine 200 mg daily
• Nifedipine 30 mg daily
• Pantoprazole 40 mg BID
• Prednisone 5 mg daily
• Vitamin D3 2000 IU daily
• Albuterol PRN SOB
• Ferrous sulfate 325 mg daily
• Losartan 25 mg daily

Social History and Family History

• Married, nonsmoker, rare social ethanol use, no recreational drug use
• Father with hypertension, mother with autoimmune disease

Physical Examination

• T = 40°C, heart rate = 130 beats/min, respiratory rate = 28 breaths/min, BP = 100/61 mm Hg, SpO2 = 95% on 100% nonrebreathing mask, BMI = 24
• General: Lethargic well-nourished young woman unable to answer questions, accessory respiratory muscle use
• HEENT: Dry mucosa, no scleral icterus, injected conjunctiva
• Pulmonary: No audible wheeze, crackles, rhonchi
• CV: Tachycardic, regular, no murmur
• Abd: Tender bilateral upper quadrants, nondistended, no HSM
• Neurological: Moving extremities but unable to follow commands, CN grossly intact
• Psychiatric: Unable to assess, mentation/mood normal earlier in day per her husband
• Extremities: Warm with mottled UE and LE digits, scattered areas of purpura (Figure 1)

Figure 1. Photographs of extremities taken during day 1 and 2 in the ICU.

With this patient's presentation, what is the most likely cause of the purpura? (Click on the correct answer to be directed to the second of six pages)

1. Angioinvasive fungal infection
2. Thrombotic related to cryoglobulinemia
3. Septic emboli
4. Thrombosis from disseminated intravascular coagulation (purpura fulminans)
5. Depositional vessel disease from calciphylaxis

Cite as: Wat M, Bilal J, Chacon M, Klotz S, Campion J. April 2022 Critical Care Case of the Month: Bullous Skin Lesions in the ICU. Southwest J Pulm Crit Care Sleep. 2022;24(4):57-61. doi: https://doi.org/10.13175/swjpccs014-22 PDF

February 2017 Critical Care Case of the Month

Morgan Wong, DO

Nicholas Villalobos, MD

Department of Internal Medicine

University of New Mexico

Albuquerque, NM USA

History of Present Illness

A 68-year-old man presented to the emergency department with a one-day history of lower back pain, arthralgias, and malaise. The patient had a previous splenectomy and was concerned about influenza.

Past Medical History, Social History, and Family History

He has a history of osteoarthritis, seasonal allergies, and splenectomy. He is a nonsmoker. Family history is noncontributory.

Physical Examination

Upon admission, the patient’s vital signs were notable for a temperature of 35.3 degrees Celsius, blood pressure of 74/44 mmHg, oxygen saturation of 85% on room air with a respiratory rate of 24 breaths per minute. Physical exam was prominent for non-pitting edema of the distal upper and lower extremities, as well as diffuse macular rash of the palms and soles.

Laboratory

CBC

• White blood cell count of 6.77 X10³ cells/uL
• Hemoglobin of 13.8 gm/dL
• Hematocrit of 43.7%
• Platelet count of 19 x 10³ /uL

Chemistry

• Creatinine of 3.0 mg/dL
• CO2 < 10 mmol/L
• Anion gap >18 mmol/L
• Liver function tests
• Alanine aminotransferase (ALT) of 511 U/L
• Aspartate aminotransferase (AST) of 529 U/L
• Total bilirubin of 1.0 mg/dL

Coagulation

• INR of 2.07
• Prothromin time of 22.5 seconds
• Partial thromoboplastin time of 82.3 seconds
• Fibrinogen level was 71 mg/dL

Arterial blood gases

• pH of 6.91
• pCO2 54 mmHg
• pO2 263
• HCO3 of 7.7 mmol/L

Procalcitonin >200 ng/ml.

His blood peripheral smear was examined.

Figure 1: Peripheral blood smear on admission. 

Given the results of the preliminary laboratory results and peripheral smear what hematologic abnormality are you most concerned with at this time? (Click on the correct answer to proceed to the second of five pages)

1. Autoimmune hemolytic anemia (AIHA)
2. Disseminated intravascular coagulopathy (DIC)
3. Microangiopathic hemolytic anemia (MAHA)
4. Thrombotic thrombocytopenic purpura (TTP)

Cite as: Wong M, Villalobos N. February 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;14(2):54-9. doi: https://doi.org/10.13175/swjpcc144-16 PDF