Hallucinations and Incontinence
Initial Vitals
T 36.4 C HR 109 BP 89/53 RR 20 O2 sat 95% on 4LNC .
Presentation
A 61-year-old male with history of rectal and colon cancer, hypertension, CVA presents to the ED with altered mental status. His family reports that he has been progressively altered over the past week and started to get significantly worse yesterday. His wife at bedside states that patient also has been speaking less than usual and is reportedly having auditory and visual hallucinations. At baseline the patient is usually A&O x 3, is now A&O x 1. He also has been having increasing loss of control of bowel and bladder over the past month.
The patient is able minimal questions only; he states that he has no pain or shortness of breath. However, he is not on home O2 at baseline and arrives to the ED today on 4L LC. He is not ambulatory at home, is bed bound at baseline.
History limited secondary to patient condition.
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GENERAL: Awake. Answers minimal questions
HEAD: Head is normocephalic and atraumatic
EYES: EOMI. PERRLA. No scleral icterus. No conjunctival injection
ENT: Dry mucous membranes.
NECK: Supple. No masses. Full range of motion.
RESPIRATORY: No respiratory distress. coarse breath sounds in all lung fields.
CV: Regular rate and rhythm. Capillary refill less than 2 seconds.
ABDOMEN: Soft, non-distended, non-tender. No guarding. No rebound.
EXTREMITIES: Muscle wasting of bilateral lower extremities.
SKIN: Skin to the perineum and scrotum discolored/brown/black, with crepitus.
NEUROLOGIC: Alert and orientedx1. Face is symmetric.
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CBC: WBC 29, Hgb 15.4, Plt 75
CMP: Na 4.6, K 4.6, Cl 101, Co2 19, BUN 139, Cr 2.4, Ca 8.2, Alb 1.2, TP 6, T bili 2.4, Alb phos 150, AST 33, ALT 19
Mg 2.7, Phos 5.2
Lipase 25
Lactic Acid: 2.2
ProBNP: 2703
Troponin 13.4
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IMPRESSION:
Chronic intracranial changes, some soft tissue emphysema on the left side which may be related to venous contamination or injury from the neck or chest.
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IMPRESSION:
Presumed patchy regions of pneumonia within the left lower lobe with suspicion of a developing necrotic component
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Above Image
Scrotal infection with apparent gas-forming organism possible
Fournier's gangrene additional apparent abscess posterior to the urinary
bladder with apparent fistulous connection to the urinary bladder.
ED Course Outcome/Discussion
The above presentation is concerning for Fournier’s gangrene, a necrotizing infection of the perineum, scrotum, or genitourinary system.
After triage, sepsis protocol was initiated and the patient was started on a 30cc/kg bolus of NS and was given empiric vancomycin and zosyn. Upon reassessment after fluid bolus and antibiotics, the patient’s blood pressure significantly improved to 110 systolic.
General surgery and urology were consulted and evaluated the patient. After extensive discussion with the paitnet’s wife/POA, a decision was made to not proceed with surgical intervention given the patinet’s age and current cancer diagnosis.
The patient was admitted to the medicine service where further goals of care discussions were in conjunction with the palliative care service; the patinet’s family agreed that surgical intervention would not be in line with his wishes, and the patient was made comfort care measures only in the setting of his poor prognosis without surgical intervention. Unfortunately, the patient died five days after admission.
Takeaway Points
The definitive treatment of Fournier’s gangrene is surgical debridement, early surgical consultation is necessary in any case
Necrotizing infections are primarily a clinical diagnosis; have a high suspicion with pain out of proportion, hemodynamic instability, or crepitus/bullae on exam
Consider a patient’s goals of care early in diseases requiring invasive treatments or extended rehabilitation times. Consult palliative care team early in these cases.
Have a cool case that you would like to share? Please email thomas.rauser@uhsinc.com or scan the QR codes in the conference room or TVH ED. Special thanks to Dr. Dellvin Nguonly