Case 156 -- Progressive Mental Status Change

Contributed by Jiangzhou Wang, MD, PhD, Larry Nichols, MD and A. Julio Martinez, MD
Published on line in August 1998


This 36-year-old white male had end-stage renal disease due to sclerosing glomerulonephritis. He underwent cadaveric kidney transplantation and was treated with immunosuppressive therapy. On the 20th postoperative day, he had Legionella pneumonia and on the 44th day he had cytomegalovirus pneumonia. Over the ensuing 27 months following transplantation, he had episodes of transplant rejection, a diarrheal illness, a urinary tract infection, neutropenia, pruritis, myalgias, arthralgias, chills, frontal headaches, sinusitis and a facial abscess.

The patient was hospitalized with jaundice and change of mental status. He was afebrile, but his blood pressure was 140/100 mmHg. He had an acneform skin rash on his chest and back, and a grade I/VI systolic ejection murmur. Laboratory testing showed: bilirubin 11.3 mg/dL (direct 7.0 mg/dL), alkaline phosphatase 240 IU/L, aspartate aminotransferase 110 IU/L, creatinine 2 mg/dL and white blood cell count 3,300/uL (44% neutrophils, 23% bands, 20% lymphocytes, 10% monocytes, 1% eosinophils). Liver biopsy showed cholestasis, hepatocellular injury and acute portal and periportal inflammation. The etiology of the patient's liver disease was not obvious.

On hospital day 25, the patient developed fever (38oC), chills and a cough. He had pulmonary rales over the left lower lobe. Chest radiograph revealed one small, nodular lesion in the left lower lobe and another in the right upper lobe. Tracheal aspirate culture yielded heavy Streptococcus pneumoniae and sputum culture yielded heavy Candida albicans. He was treated with penicillin. He developed high spiking fevers, myalgias and arthralgias. His mental status deteriorated until he became unresponsive to verbal commands on hospital day 29. His eyes intermittently deviated to the right. The corneal reflexes were absent. The optic discs were flat. All extremities moved, but muscle tone was decreased on the left side. Neuroradiological studies were performed (see below). He developed hard erythematous skin nodules, 2 cm in diameter; skin biopsy showed subcutaneous fat necrosis, acute inflammation and fibrin thrombi in small blood vessels. Left temporal lobe brain biopsy showed multiple thrombi and recent infarction. The patient was treated with oxacillin and gentamicin for possible embolic endocarditis, but his condition progressively worsened until he died on hospital day 43.


Computerized tomography scan of the head showed multiple areas of increased density in the cerebral cortex consistent with multiple infarcts or septic emboli (Image 01).




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