Patient Case Study By: Paul, Jen, Chris, & Ben Chris, Jen, Paul, By: a second hospital for a possible liver transplantation. transplantation. liver a possible for hospital a second to transferred was autoimmune presumed with old woman year 65 A ● ● ● ● ● ● ● Family history states no liver problems no liver states history Family field in healthcare Worked travel recent No animals no other cat, Indoor alone Lived of smoking history Minor week per spirits of distilled half gallons 3-5 drinker: Heavy Case & Social History consumption: presume Doctors test liver-function abnormal receives Patient - - Massachusetts General Hospital Patient is prescribed is prescribed Patient reveals: testing Additional - - 6 years Negative for viral hepatitis hepatitis viral for Negative titer antibody antinuclear Elevated autoimmune hepatitis autoimmune glucocorticoids glucocorticoids before and and stops drinking heavily drinking and stops admission to cirrhosis from her heavy alcohol alcohol heavy her from hospital. Various tests were performed, checking for... checking performed, were tests Various hospital. experiences Patient 7 weeks before admission , jaundice , fatigue fatigue and seeks treatment at another another at treatment and seeks Antinuclear Antibody Titer ● ● ● ● Therefore, elevated levels of antinuclear antibody titer reveals a potential autoimmune disease disease autoimmune a potential reveals titer antibody of antinuclear levels elevated Therefore, cell. (host) the of, nucleus and the in, proteins attacks which of autoantibody is a subtype antibody antinuclear The called are These self. or host, the from are antigens the case, in this that except pathogens), by those (like antigens by Autoimmune ○ ○ This would explain the presumptive autoimmune label for her autoimmune hepatitis autoimmune her for label autoimmune presumptive the explain This would and antibodies cells effector autoreactive to rise Give ■ responses resemble normal immune responses because they are specifically activated activated specifically are they because responses immune normal resemble responses Termed: Termed: self-antigens autoantibodies , or or , autoantigens . ultrasound on an density increased by distinguished nodes form to accumulate which liver in the collections fibrous yields cirrhosis) (from damage liver Liver: Nodular with treated was patient the response, In a revealed ultrasound An ● Used to treat her autoimmune hepatitis autoimmune her treat to Used ○ Therapy lasted 4 weeks, patient was prescribed prescribed was patient weeks, 4 lasted Therapy ■ Different corticosteroid corticosteroid Different nodular liver nodular Prednisone Prednisone (immunosuppressive): (immunosuppressive): Azathioprine livers? causes the phenotype seen in nodular Question: What process most directly D) A) B) C) E) Autoimmune response response Autoimmune accumulation Fatty Necrosis Fibrosis Inflammation livers? causes the phenotype seen in nodular Question: What process most directly D) A) B) C) E) Autoimmune response response Autoimmune accumulation Fatty Necrosis Fibrosis Inflammation

supplements on her own discretion discretion own on her supplements herbal take to opted patient the azathioprine, to of transitioning Instead ● ● Buckthorn may also alleviate symptoms of cirrhosis symptoms also alleviate may Buckthorn diseases liver treat to is believed thistle Milk ○ Contains silymarin Contains 3 weeks prior to admission ● Patient’s daughter noted mother had jaundice mother noted daughter Patient’s 1 week before admission of this patient’s jaundice? Question: What is most likely the cause D. A. B. C. E. None of the above of the None GI into drain to of bile Failure of hemosiderin Accumulation bilirubin of unconjugated Accumulation leukocytosis Excessive D. A. B. C. E. cause of this patient’s jaundice? Question: What is most likely the None of the above of the None GI into drain to bile of Failure of hemosiderin Accumulation bilirubin of unconjugated Accumulation leukocytosis Excessive ● ● absent Hydronephrosis performed: were tests More home. of her floor shock delirious found Patient on the on the and in 4 days prior to admission

levels lactate elevated in Implications Anaplerotic Metabolism does that carry? increase, what implication for metabolism Question: When Ala- and Asp-AT levels D) A) B) C) E) Decreased oxygen need oxygen Decreased activity Cycle Krebs Increased normal pH than Lower production in ammonium Decrease metabolism in protein Decrease D) does that carry? increase, what implication for metabolism Question: When Ala- and Asp-AT levels A) B) C) E) Decreased oxygen need oxygen Decreased activity Cycle Krebs Increased normal pH than Lower production in ammonium Decrease metabolism in protein Decrease ● ● ● lactulose lactulose intravenous oral methylprednisone methylprednisone and Administered Medications vitamin K vitamin rifaximin rifaximin to reduce INR reduce to to reduce her hepatic encephalopathy hepatic her reduce to (given prior to intravenous infusions) intravenous to prior (given

administration: K vitamin after normalize did not INR Coagulopathy ● ● occurs in the liver cells) liver in the occurs of prothrombin synthesis because failure liver acute with consistent (a condition dysfunction synthetic of hepatic presence the Confirms time prothrombin standardize to made INR fibrogen production, this could mean... Question: if a patient has problem with D) A) B) C) E) None of the above of the None above of the All slowly very occurs or occur, not does formation Clot states inflammation prolonged to lead This could is poor utilization K Vitamin D) fibrogen production, this could mean... Question: if a patient has problem with A) B) C) E) None of the above of the None above the of All slowly very occurs or occur, not does formation Clot states inflammation prolonged to lead This could is poor utilization K Vitamin Her level: Her Creatinine Level Urinanalysis: - - kidney injury kidney of acute hallmark Clinical output urine little very mg/dL, 3.6 - Stage 3 Stage from in the body? Question: where does creatinine originate D) A) B) C) E) Mainly circulates in blood as creatinine circulates Mainly as creatinine Liver phosphate as creatine Liver as creatinine Muscles phosphate as creatine Muscles A) from in the body? Question: where does creatinine originate D) B) C) E) Mainly circulates in blood as creatinine circulates Mainly as creatinine Liver phosphate as creatine Liver as creatinine Muscles phosphate creatine as Muscles ● creatinine level creatinine Soon after, oliguric acute kidney acute oliguric because of because hepatorenal syndrome hepatorenal

injury injury developed with her her with developed (HRS).

high

● ● midodrine midodrine infusion albumin ○ ○ shunting and improve renal perfusion renal and improve shunting reduce drugs these resistance, vascular systemic increasing by HRS in vasodilation peripheral reverse mainly and midodrine Octreotide had patient ■ prolonging survival until liver transplant liver until survival prolonging and octreotide octreotide no improvement no was administered was were given in combination to treat HRS treat to in combination given were in creatinine level or urine output urine or level in creatinine

Gram’s stain: Gram’s a blood culture: prompted which leukocytosis, and developed patient prescribed, were and octreotide midodrine After - - Corkscrew-shaped, gram-negative rod bacterial cells bacterial rod gram-negative Corkscrew-shaped, blood culture aerobic in an growth microbial detectable yielded period incubation hour 56 Fever and Leukocytosis

piperacillin–tazobactam and dose, one after discontinued was therapy ceftriaxone Empirical Prescribed Medication and Leave vancomycin vancomycin Patient is transferred... Patient and therapy was initiated was therapy ceftriaxone ceftriaxone were administered; administered; were ● ● for her age group, and her oxygen saturation was below normal range of her age group age of her range normal below was saturation oxygen and her group, age her for elevated slightly was temperature her however range; a normal within mostly were vitals Her backwards. week of the days the recite still could she Additionally, and time. place, person, to oriented was but fatigued, appeared patient The ○ ○ ○ ○ ○ Massachusetts General Hospital Oxygen Saturation: Oxygen old: years >65 at rate Breathing Pressure: Blood Rate: Heart Temperature: 65 beats per minute per beats 65 37.1 to <37°C to 37.1 126/60 to <120/<80 mmHg <120/<80 to 126/60 ON ADMISSION 94% to 96%-98% to 94% 18 to 12-28 breaths per minute per breaths 12-28 to 18

and C Checked for viral origins of Hepatitis A, B ● ● Furtherly consistent with autoimmune hepatitis hepatitis autoimmune with consistent Furtherly negative back came tests All Admission Lab Results TML/CINJ049.html# https://library.med.utah.edu/WebPath/CINJH Photo: Reference Physical Examination Findings ● ● bilirubin levels in the blood. blood. the in levels bilirubin by caused eyes) (and/or skin Jaundice having skin her patient’s The = The appearance of yellowish of yellowish appearance = The sclerae sclerae jaundice. were icteric high high with with ● ● Physical Examination Findings Cont. to subcutaneous bleeding. subcutaneous to due skin the under of bruising appearance the of signs also showed She of blood vessels dilation by caused vessels blood of swollen appearance the angiomata, spider also had scattered skin patient’s The ○ ○ Can be linked to her her to linked Can be by Caused increased estrogen levels estrogen increased ecchymosis, ecchymosis, high INR high which is which https://medicalbite.com/spider-angioma.html Photo: your knowledge of coagulation) knowledge your NOT could choice Which a standard. it and compares clot, blood to your for takes it time the time, prothrombin your uses INR the short, In Ratio). Normalised (International INR high her to linked be said to was bleeding subcutaneous by caused of skin discoloration this of ecchymosis, signs shows patient Our D. A. B. C. E. be a reason a patient presents a high INR (longer clot times)? (Hint: Use Use (Hint: times)? clot (longer INR a high presents a patient a reason be None of the above of the None Hemophilia disorder bleed the Having (Warfarin) medication of blood-thinning Use failure liver of acute Occurrence K in vitamin deficiency severe A Physical Examination Findings Cont. ● ● ● sacrum. significant Clinically wave. fluid possible with and distended nontender, soft, found to was abdomen Her crackles bibasilar Upon ○ Due to abdomen conditions, liver and spleen were not palpable not were and spleen liver conditions, abdomen to Due auscultation , which suggests fluid in her air spaces. air fluid in her suggests which , of the patient’s lungs, she was revealed to have have to revealed was she lungs, patient’s of the edema edema was seen in the patient’s lower legs to the the to legs lower patient’s in the seen was ● ● ● Frontal View Chest Radiograph consistent with pulmonary edema pulmonary with consistent lung right the of fissure minor the along Fluid cavity chest and lungs the between tissue the is which space pleural of fluid in the Effusions Pleural Bilateral opacities air-space patchy Multifocal ○ bibasilar crackles bibasilar the with consistent Radiograph

which is a finding is a finding which =

build up sized/1-100/69-78-500-500-100.jpg Photo:http://www.chestx-ray.com/images/igallery/re Reference Healthy Lung Healthy Radiograph vs vs Radiograph Patient Lung Patient CT Image of Chest ● ● thickening septal interlobular mild as as well lung patient’s of the lobes upper in the predominant opacities ground-glass of the presence the Confirms material of contrast administration any without Performed ● ● Axial CT Image of the Abdomen physical examination. physical the during observations confirms volume small have to also is seen patient The disease or damage of liver is a sign contour hepatic a shows image this material, contrast any Without

ascites of the liver which which liver of the nodular nodular

which which What could NOT be a possible cause of this? shown by both the CT and her distended abdomen. cavity. Our patient appears to be experiencing ascites Ascites is the accumulation of fluid in peritoneal D. A. B. C. E. An increase in capillary permeability in capillary increase An pressure osmotic in blood colloid increase An system renin-angiotensin of the Activation liver a cirrhotic to due resistance in vascular increase An liver a cirrhotic to due of albumin reduction A must be strongly considered. strongly be must infection and shock, of fever presence the In therapy. immunosuppressive received recently who cirrhosis with in a patient deterioration of sudden causes possible many are There health. deteriorating rapidly her for trigger the identifying urgently on focus to is imperative it diagnosis, this revisiting than rather presumptive, be may hepatitis of autoimmune diagnosis previous patient’s the While

shock and acute liver failure failure liver acute and shock

due to her to due

determine whether these symptoms were caused by bacteremia. by caused were symptoms these whether determine to used was culturing Blood and shock. of fever signs displayed Patient Blood Culturing for promoting infection of the patient? diagnosis. Which drug was most likely responsible drugs were administered to the patient prior this patient was suffering from bacteremia. The following The results of the blood culture established that D. A. B. C. E. None of the above of the None Vancomycin Rifaximin Lactulose Prednisone diagnostic test should be used? bacteremia. Given this limited timeframe, what narrow down the bacterial species responsible for physicians require diagnostic tests that can quickly The patient's condition is rapidly deteriorating, so the D. A. B. C. E. None of the above above of the None testing Toxicology tests susceptibility Antimicrobial staining Gram's conditions and environmental media different using blood culturing Additional against pathogen. against treatments targeted aid in designing Results extended spirals. extended the shows arrow bottom the while rods, curved the indicates arrow left The hospital. other the at performed stain Gram of the Photo 1: Figure Gram’s Staining shared these traits. these shared species bacterial many not characteristics; specific Very yielded: results stains; Gram’s of set own their conducted they therefore results, culture blood the reconfirm to wanted General Massachusetts ● ● Appearance Gram-negative ○ ○ ○ “Gull-wing” arrangement “Gull-wing” spirals Extended rods Curved Gram’s Staining Results performed at Massachusetts General. Massachusetts at performed Stain Gram of the Photo 3: Figure phenotypic analysis of potentially bacteria pathogenic of potentially analysis phenotypic and administration antibiotic of broad on a combination relied case this on physicians tests, blood culture do non-standard to time takes it Because Plan of Action 3. 2. 1. presenting with cirrhosis cirrhosis with presenting in patients decompensation rapid cause to able be must pathogen The blood culture in a standard grow to able be must pathogen The form a spiral adopt to able be must pathogen The Requirements of Pathogen pallidum Treponema of pathogens: a couple by caused been have could bacteremia patient’s the results, on these Based ● ● ● Treponema Causes bacteria Spiral-shaped ○ ○ Acute decompensation of cirrhosis is not characteristic of syphilis characteristic is not of cirrhosis decompensation Acute symptoms syphilis stage secondary to similar symptoms Patient’s ■ Identification of the Bacteria too thin to be visualized using Gram staining Gram using visualized be to thin too throat and sore loss, hair , fatigue, aches, muscle glands, lymph swollen Fever, ● ● ● ● Requires specialized media and environmental conditions when cultured from blood from cultured when conditions and environmental media specialized Requires disease and Lyme recurring Cause bacteria Gram-negative of most uncharacteristic content wall cell but as Gram-negative, Stain bacteria Spiral-shaped ○ rashes (the characteristic “bulls-eye” rash), swollen lymph nodes lymph swollen rash), “bulls-eye” characteristic (the rashes migrans Erythema aches, muscle/joint fatigue, , chills, fever, include month) (<1 symptoms Early Streptobacillus moniliformis minus Spirillum ● ● ● ● ● ● ● ● ● ● Able to grow within the standard blood culture media blood culture standard the within grow to Able States United northeastern the Found within fever rat-bite bacillary Causes bacteria Gram-negative Rod-shaped conditions blood culturing specialized Requires of Asia found outside is rarely S. minus fever of rat-bite a variant Sodoku, for Responsible bacteria Gram-negative Spiral-shaped ○ ○ Symptoms include fever, vomiting, headache, muscle pain, joint pain, rash pain, joint pain, muscle headache, vomiting, fever, include Symptoms rash nodes, lymph swollen wound, bite the at ulcer/swelling fever, include Symptoms ● ● ● ● ● Found within temperate/tropical climates temperate/tropical Found within blood culture in standard grow not will conditions, blood culturing specialized Requires Leptospira hemorrhaging pulmonary with along failure, and kidney liver with associated Infection bacteria Spiral too thin to be visualized using Gram staining Gram using visualized be to thin too Vibrio vulnificus Vibrio ● ● ● ● ● Can be transmitted through raw seafood raw through transmitted Can be as spiral-shaped rarely rods, as curved appears Often disease liver with afflicted already hosts Targets Symptoms: Gram-negative ○ ○ Liver disease often associated with iron overload iron with associated often disease Liver death and sometimes lesion, skin blistering pressure, blood low dangerously chills, fever, infection, bloodstream infection, skin fever, vomiting, nausea, cramping, stomach with diarrhea watery in health, decline Rapid ■ V. vulnificus utilizes iron, aids their growth aids their iron, utilizes Anaerobiospirillum succiniciproducens Anaerobiospirillum ● ● ● ● ● Normally grows under anaerobic conditions anaerobic under grows Normally of alcohol consumption or diabetes, disease, of liver a history with patients Targets distress and gastrointestinal leukocytosis, fever, with associated Infection bacteria Spiral Gram-negative Campylobacter Campylobacter ● ● ● ● ● ● Campylobacter jejuni Campylobacter medium blood culture in standard Grows Found worldwide gastroenteritis self-limiting Causes spirals and extended rods curved as both Appear bacteria Gram-negative ○ ○ ○ however is less commonly seen. commonly is less however C. fetus feces by contaminated poultry raw within Often individuals in immunocompromised bacteremia into develop Can further may also be responsible, responsible, also be may is the most common most is the Helicobacter ● ● ● ● ● Campylobacter Helicobacter gastroenteritis Cause conditions blood culturing in standard Can grow bacteria shaped and spiral rod Curved Gram-negative ○ immune systems. systems. immune compromised with individuals in bacteremia Can cause is not as prevalent as as prevalent is not ● performed. They performed two tests: Catalase Test & Oxidase Test & Oxidase Test Catalase tests: two performed They performed. the identify further to order In ○ ○ oxidized and colorless when reduced. when and colorless oxidized when blue dark turns Reagent chain. transport electron bacterial of the an enzyme oxidase, oxidase Test:The Oxidase slide. on a microscope peroxide of hydrogen a drop placing by is done test catalase The observed. are of oxygen bubbles peroxide, hydrogen to is added isolate bacterial of amount a small when (catalase-positive), catalase possess bacteria the If Test: Catalase Phenotypic Tests gull-wing–shaped gram-negative rods gram-negative gull-wing–shaped

test is used to identify bacteria that produce cytochrome c cytochrome produce that bacteria identify to is used test phenotypic testing was testing phenotypic

● phenotypes are not specific to them. to specific not are phenotypes these note to important is it but species campylobacter a be could bacteria of this identity the suggested This activity. oxidase and production for catalase positive both were tests The Results of Phenotypic Tests

● supported by the results of standard biochemical assays biochemical of standard results the by supported and spectrometry mass ionization–time-of-flight) desorption laser (matrix-assisted of MALDI-TOF results the by confirmed was diagnosis microbiologic ultimate The Mass Spectrometry

final diagnosis? the bacteria responsible for patient’s Based on the given information, what is D. A. B. C. E. Helicobacter Helicobacter Campylobacter succiniciproducens Anaerobiospirillum vulnificus Vibrio moniliformis Streptobacillus Campylobacter Campylobacter bacteremia in a patient with presumed presumed with in a patient bacteremia autoimmune hepatitis. autoimmune Final Diagnosis D. A. B. C. E. What are possible ways All of the above of the All bacteria carrying insect or animal with Contact feces Infected people infected with Contact poultry Raw could be acquired? Campylobacter

● ● ● ● as a result, she was reintubated. She was not able to recover, and she died one day later. day one died and she recover, to able not was She reintubated. was she as a result, hypoxemia; of progressive had symptoms She later. days 2 worsened condition her However, extubated. was so she improvement, some showed health her Afterward, days. 9 for ventilator on the kept was She survive. to ventilator a mechanical required she point, this At failure. respiratory developed She deteriorate. to continued she but vasopressors, administer to continued hospital The symptoms. with her treated by caused had bacteremia patient the that discovered was it After azithromycin and Follow-up meropenem . However, these drugs did not alleviate her her alleviate did not drugs these . However, Campylobacter , physicians physicians , be pathogenic? What part of Campylobacter causes it to - damage and the arrest of cell cycle division cycle of cell arrest and the damage DNA causes which CDT, toxin, distending cytolethal called toxin Releases - Triggers apoptosis in affected cell in affected apoptosis Triggers

Prior Years 6 Summary hepatitis w/autoimmune diagnosed Patient Time Relative to Admission to Mass. Gen. Mass. to Admission to Relative Time treatment. prednisone a begins She jaundice. fatigue, malaise, develops Patient Prior Weeks 7 supplements. herbal to prednisone from switches Patient Prior Weeks 3 Prior Week 1 returns Jaundice Time Relative to Admission to Mass. Gen. Mass. to Admission to Relative Time Prior Days 4 to other hospital. other to wrong goes Everything : Admitted Admitted : Admitted General Hospital General Massachusetts to hospital unknown from Transferred After Days 12 dies she deteriorates, condition Patient