Unknown female, 70, Maryland
Johns Hopkins Death- Autopsy Report
Case No: 26.
Autopsy No.: #46758
Age (decades): 70
Sex: F
Decade of Autopsy: 1990
Key Number: 810547
appendectomy ;.
hysterectomy ;.
bladder repair ;.
osteoarthritis ;.
family history cerebrovascular accident cancer ;.
tick bite ;.
onset nausea ataxia right facial weakness ;.
admission local ;.
diagnosis LYME disease nervous system ;.
elevated serum cerebrospinal fluid igm igg titers borrelia burgdorferi ;.
intravenous ceftriaxone ;.
transfer progression cranial nerve deficits ;.
lyme disease ;.
secondary bell palsy cerebellar involvement ;.
right lid lag ;.
heberdeen nodules ;.
elevated serum cholesterol ;.
aspiration pneumonia ;.
pleocytosis ;.
mononuclear per lumbar puncture ;.
area increased signal ;.
weighting noted right cerebellar peduncle ;.
enhanced ;.
gadolinium ;.
white matter lesions corona radiata per magnetic resonance imaging ;.
multiple temperature spikes ;.
enterobacter species per sputum culture ;.
broad spectrum antibiotics ;.
right vocal cord paralysis per nasopharyngeal endoscopy ;.
acute respiratory arrest ;.
intubation ;.
extubation required one hour ;.
chest radiograph consistent ;.
new bilateral aspiration pneumonia ;.
admission stereotatic biopsy pontine lesion ;.
left gaze paresis anisocoria right cornea decreased sensation bell palsy uvula deviated right ataxia upper extremities ;.
consistent ;.
right pontine lesion ;.
blot negative lymph disease ;.
negative rheumatoid factor ;.
serum rapid plasma reagin positive ;.
broad spectrum antibiotics ;.
pulmonary infiltrates per chest radiograph ;.
anemia ;.
small left pleural effusion sonography ;.
atelectasis pleural effusion negative lymphadenopathy negative definite masses per computerized tomography ;.
extensive necrosis ;.
lymphocytes atypical poorly preserved suggestive negative diagnostic small cell malignant neoplasm per nervous system sterotactic needle aspiration ;.
necrotic tissue cannot determine specimen represents necrotic brain abscess tumor per pons needle biopsy ;.
steroid therapy ;.
tracheostomy ;.
mechanical ventilation ;.
hypotensive episode responsive fluid resuscitation ;. feeding tube ;.
heme positive loose stools ;.
conjunctivitis treated ;.
topical gentamicin ;.
right gaze palsy ;.
leukocytosis ;.
percutaneous endoscopic gastrostomy tube placement ;.
elevated cerebrospinal fluid glucose per lumbar puncture ;.
extremely atypical ;.
background mononuclear per cerebrospinal fluid analysis ;.
left subclavian venous line ;.
hypotensive episode responsive fluid resuscitation ;.
increasing bilateral atelectasis versus infiltrates per chest radiography ;.
antibiotic therapy ;.
enterobacter per sputum culture ;.
stable ring enhancing lesions posterior pons decreasing cortical edema exam less distortion fourth ventricle per magnetic resonance imaging study ;.
diarrhea ;.
positive assay clostridium difficile toxin ;.
weaning ventilator ;.
pulmonary toilet ;.
supraventricular tachycardia per electrocardiogram responsive verapamil ;.
recurrent atelectasis left lower lobe per chest radiograph ;.
continuous positive airway pressure maintain airway ;.
empiric flagyl ;.
right subclavian line ;.
maltophilia per sputum culture enterobacter ;.
enterococcus ;.
per urine culture ;.
cardiopulmonary arrest ;.
successful cardiopulmonary resuscitation ;.
coma score ;.
neurological exam consistent ;.
brain death ;.
heparin ;.
lidocaine pressor agents ;.
atrial tachycardia ;.
intermittent atrial flutter fibrillation per electrocardiogram ;.
increased arterial alveolar oxygen gradient ;.
burst suppression pattern consistent ;.
severe anoxic brain injury per electroencephalogram ;.
negative resuscitate status ;.
death ;.
well differentiated primary cns lymphoma ;.
associated hemorrhage necrosis right inferior cerebellar peduncle brain ;.
severe ischemic ;.
anoxic ;.
encephalopathy cerebral cortex cerebellum brain ;.
lacunar infarcts midbrain putamen brain ;.
adenoma right kidney ;.
acute chronic pancreatitis pancreas ;.
chronic passive congestion intrahepatic cholestasis steatosis liver ;.
organizing pneumonia right left lower lobes lung ;.
focal active pneumonitis lungs ;.
scattered cytomegalovirus intranuclear inclusions ;.
organized thromboemboli lung ;.
leiomyomas stomach esophagus ;.
congestion edema lungs ;.
weight gms ;.
calcified granulomas ;.
greatest diameter ;.
lower lobe left lung ;.
mild atherosclerosis left anterior descending right coronary arteries heart ;.
cardiomegaly ;.
left ventricular hypertrophy heart ;.
fatty infiltration right ventricle heart ;.
atherosclerotic plaque ;.
stenosis superior mesenteric artery ;.
moderate complicated atherosclerosis aorta ;.
mild atherosclerosis pulmonary artery ;.
degenerative joint disease vertebra ;.
hemorrhagic urethritis cystitis urinary bladder ;.
hematomas rib fractures anterior chest wall thorax ;.
cardiopulmonary resuscitation ;.
ulcer gastroesophageal junction ;.
cytomegalovirus inclusions underlying endothelium ;.
diverticulosis colon ;.
tracheostomy tube trachea ;.
heberdeen nodes nodes radial deviation distal
interphalangeal phalanges hands ;.
mild pedal edema ;.
surgical absence uterus ovaries ;.
hysterectomy ;.
Maryland- Unknown male, 30
Johns Hopkins Death- Autopsy Report
Case No: 2.
Autopsy No.: #22718
Age (decades): 30
Sex: M
Decade of Autopsy: 1990
Key Number: 698753
spinal disc surgery years ago ;.
isoniazid treatment positive purified protein
derivative ;.
erythematous rash right eyelid ;.
swelling tenderness left wrist ;.
erythematous papules bilaterally ;.
bilateral shoulder myalgia ;.
prednisone treatment ;.
improvement musculoskeletal complaints rash ;.
progressive dyspnea ;.
outpatient chest computerized axial tomography
revealing bilateral interstitial lung infiltrates ;.
scaly red rash extensor surfaces elbows knees ;.
painful oral ;.
fifteen pound weight loss ;.
presentation emergency room progressive dyspnea ;.
pulmonary function tests revealing mixed obstructive restrictive lung disease ;.
normocytic anemia ;.
elevated liver function tests ;.
electromyography nerve conduction studies revealing myopathy ;.
irritative consistent ;.
dermatomyositis ;.
muscle biopsy ;.
revealing negative specific pathologic changes ;.
fatty liver per computerized axial tomography ;.
positive immunosorbent assay LYME disease ;.
negative rheumatologic workup ;.
ana rheumatoid factor ;.
spiral computerized axial tomography chest revealing mass right lower lobe ;.
vocal cord leukoplakia ;.
skin biopsy ;.
direct immunofluorescence showing granular igm igg along basement membrane consistent ;.
dermatomyositis ;.
temperature elevation ;.
bronchoscopy ;.
lavage positive pneumocystis carinii cytology ;.
revealing pulmonary macrophages lymphocytes occasional histiocytic aggregates suggestive granulomatous inflammation ;.
respiratory decompensation followed respiratory distress hypoxemia ;.
transfer medical intensive care unit ;.
progressive insufficiency ;.
intubation ;.
adult respiratory distress syndrome ;.
hypoxemia requiring ;.
treatment ;.
broad spectrum antibiotics including bactrim
pneumocystis ;.
thrombocytopenia hemolysis ;.
pneumomediastinum pneumopericardium subcutaneous emphysema ;.
oxide trial ;.
right upper quadrant ultrasound progressive insufficiency revealing fatty liver distended gallbladder ;.
treatment ;.
intravenous immunoglobulin ;.
hypotension ;.
leukopenia ;.
bone marrow biopsy ;.
showing hypocellular marrow ;.
virtual absence granulocytes dyserythropoiesis hemophagocytosis ;.
withdrawal supportive measures ;.
death ;.
extensive infarction necrosis hyaline membrane disease ;.
occasional atypical pneumocytes lungs ;.
organizing thrombi vascular changes ;.
proliferation lungs ;.
moderate interstitial fibrosis lungs ;.
contraction band necrosis ;.
nuclear degeneration heart ;.
hypocellular bone marrow ;.
depletion granulocytes megakaryocytes dyserythropoiesis hemophagocytosis ;.
congestion white pulp depletion hemophagocytosis spleen ;.
hemorrhagic microinfarct cerebellum brain ;.
multiple microinfarcts medulla frontal cortex occipital cortex brain ;.
moderate myopathic changes skeletal muscle ;.
distension ;.
biliary sludge gallbladder ;.
steatosis cholestasis liver ;.
superficial erosions ;.
stomach ;.
focal fat necrosis pancreas ;.
spermatogenic arrest ;.
submucosal hemorrhage anterior tongue ;.
focal atherosclerotic stenosis left anterior descending artery heart ;.
serosanguineous effusions right ;.
left ;.
pleural cavities ;.
serosanguineous effusion ;.
pericardium ;.
numerous crusting skin erosions ;.
measuring ;.
corpus ;.
cause death ;.
part ;.
pulmonary infarction necrosis ;.
dermatomyositis
Maryland- Unknown female, 40
Johns Hopkins Death Autopsy Report
40 year old woman misdiagnosed with MS. Had positive Lyme serology, symptoms; medications were stopped, she died.
Case No: 7.
Autopsy No.: #26488
Age (decades): 40
Sex: F
Decade of Autopsy: 1990
Key Number: 26972
diagnosis multiple sclerosis age ;.
progressive deterioration neurologic status requiring total care admission ;.
intravenous adrenocorticotropic hormone ;.
adjustment medications ;.
phenobarbital ;.
positive LYME serology ;.
admission meridian nursing center hills ;.
paraplegia ;.
postural tremor ;.
recurrent ;.
coli urinary tract infection ;.
aspiration thin liquids ;.
increased difficulty swallowing ;.
decreased oral motor control ;.
five pound weight loss past six months ;.
declining mental status ;.
patient family decision gastrostomy tube placement secondary patient wishes
against artificial life support ;.
initiation comfort care only orders ;.
discontinuation food fluids ;.
elevated temperatures degrees ;.
shallow respirations ;.
apneic spells ;.
decreased responsiveness ;.
death hours ;.
extensive multiple periventricular demyelinated plaques bilateral cerebral
hemispheres cerebellum basal ganglia brainstem high levels cord ;.
brain weight ;.
moderate hydrocephalus vacuo ;.
purulent material ;.
bacterial overgrowth bronchi bilateral lungs consistent ;.
aspiration ;.
focal hemorrhage small foci acute bronchopneumonia apical posterior basilar
bilateral lungs ;.
combined weight ;.
squamous metaplasia urinary bladder ;.
cause death part ;.
multiple sclerosis ;.
Maryland- Unknown male child, 11
Johns Hopkins Death- Case Report
Case Report: The patient is an eleven-year-old African American male who was in his previous state of good health until approximately one-month before presentation when he developed a swelling in his left groin that was progressively increasing in size. He was seen approximately three weeks later by his primary physician who diagnosed inguinal lymphadenitis and treated with Keflex. He was also immunized with the varicella vaccine. A PPD was placed which was negative.
One day before presentation, he developed a headache, sore throat, and aching back and legs while at school. He was treated symptomatically at the school clinic and his headache resolved. The following day, he was noted to have a mild tremor in both hands and some dragging of his left foot. That evening he developed a generalized tonic-clonic seizure and was promptly brought to the ER.
In the ER, he was actively seizing and apneic. He was intubated and loaded with phosphenytoin. He received a dose of ceftriaxone and a non-contrast head CT was normal. He was transferred to the PICU. Other than a mild leukocytosis, his initial labs were unremarkable and included a negative toxicology screen. His seizures remained difficult to control requiring multiple anti-seizure agents including propofol drip. He had intermittent fevers and was treated with acyclovir and cefepine beginning on the second hospital day. Bacterial and viral cultures from the blood and CSF were negative. Serology for HIV and EBV was negative and PCR testing for HSV was also negative.
The patient never regained consciousness and he continued to decline with lactic acidosis and cardiac failure. He died on the fifth hospital day. Further history revealed that the patient had been exposed to a new kitten approximately 1.5 months before presentation. Serologic testing of his serum for Bartonella henselae and quintana (performed at the CDC) are shown in Table 1. Serologic tests and PCR tests of the CSF for Bartonella henselaewere negative.
Table 1.
Serologic testing for Bartonella henselae and B. quintana using IFA
B. henselae B. quintana
IgG (H&L) 512 2048
IgG (gamma) 128 512
IgM 128 128
Bartonella henselae/Cat-scratch disease encephalopathy
Organism: The causative organism of cat-scratch disease encephalopathy isBartonella henselae, a small, gram-negative and extremely fastidious rod.Bartonella species are oxidase negative and aerobic. Recovery of Bartonellaspp. has been accomplished using chocolate agar or other media without antimicrobials incubated for at least 21 days in 5% CO2 at 35 to 37°C. B. bacilliformis, geographically confined to the South American Andes, is an erythrocyte-invasive bacterium associated with severe febrile illness and profound anemia.
Its vector is the sand fly Lutzomyia verrucarum. B. quintana was first recognized as the cause of "trench fever" seen in battlefield troops of World War I and is transmitted by the body louse. Transmission of B. henselae has been firmly linked with felines and evidence suggests that the cat flea is a potential vector among animals. The incidence of Bartonella infections in immunocompromised patients is not known. In immunocompetent patients, approximately 10 instances of cat scratch disease (CSD) per 100,000 persons occur annually in the United States with approximately 60% of cases occurring in persons under 20 years of age.2
Clinical Manifestations: Symptoms associated with bacteremia in B. henselaein immunocompromised patients are characterized by insidious development of fatigue, malaise, body aches, weight loss, progressively worsening fevers and headache. Both B. henselae and B. quintana are associated with bacillary angiomatosis, vascular proliferative lesions seen almost exclusively in immunocompromised patients. Bartonella infection in immunocompromised patients can also cause bacillary peliosis hepatitis (formation of venous lakes in the liver), endocarditis, and bacteremia.
Instances of Bartonella bacteremia and endocarditis have been reported in immunocompetent patients but the incidence is thought to be very low. More commonly, CSD is seen in immunocompetent patients infected by B. henselae. The primary cutaneous lesion of CSD occurs 3 to 10 days after a cat scratch or bite. This wound gradually resolves. Regional adenopathy, the hallmark finding in CSD, occurs approximately 10 days after the injury. One third of patients will also present with fever lasting 1 to 2 weeks. Approximately 2% to 3% of patients will develop Parinaud’s oculoglandular syndrome characterized by regional lymphadenitis and unilateral conjunctivitis. Neurologic involvement is seen in approximately 2% of cases.3 CSD encephalopathy has recently been reported as a cause of status epilepticus in children.
Diagnosis: As described above, diagnosis of Bartonella spp. by culture is slow and difficult. Antibodies to B. henselae have been demonstrated in between 88% and 95% of patients with CSD using both an indirect immunofluorescence assay and enzyme immunoassay. Using IFA, higher relative titers of B. quintana are frequently seen in CSD cases but are thought to represent cross-reactivity. PCR assays using 16S rDNA primers specific to Bartonella spp. have also been successful in diagnosis.3
Treatment:
Immunocompromised patients: Erythromycin 500mg q6h or Doxycycline 100mg q12h for 12 weeks. Immunocompetent patients: No specific antimicrobial therapy recommended.