Posted by HFHSM.D.-kb on March 11, 1998 at 13:05:02:

In Reply to: DIC, ARDS induced by hepatic failure? posted by Rajesh Gupta on February 21, 1998 at 18:11:34:

: Here is a case summary of someone who is very dear to me. I would appreciate
any opinions, pointers, help, etc.
Rajesh

CASE SUMMARY

This 36 year old male was absolutely alright till 19th Jan '98 when he got high
grade fever associated with chillls and rigour for which he was treated and anti
malarials and were given and he got better in 3 days. Patient again had fever
on 23rd Jan. THis time he was treated with antibiotics (Ciprofloxacin)
suspecting Enteric fever and patient got better. Patient again had fever on
30th Jan. He was admitted in Kailash Hospital, Noida on 5th Feb with breathing
difficulty. He was put on ventilator on 6th Feb, shifted to Apollo Hospital for
further management.

On Examination :
---------------

Patient was conscious, opening eyes, raising all four limbs. Icterus++,
Jaundice++, febrile, Cyanosis, scitis++, Pulse 134/m, BP 84/51 mm -- on
Dopamine 4ml/hr and Dobutamine 4ml/hr. On PCIRV with Inspiration (Pressure
control Ventilation).

PR - 25 cmH2O
TV - 0.50
Rate 18/m Flo2 - 100% Peep - 4
Maintaining good saturation - 97% on right lateral position.
Chest - B/L air entery +
occ. crepts +
CVS - S1, S2n
P/A - Spleenomigaty + ascitis +Hepatimegaly
CNS - no neck rigidity, pupils - B/L Perria, Plantan - down

All the investigations were done, showing renal failure and liver impairment
and high blood sugar. He was put on broad spectrum antibiotics : Insulin, IV
fluids, Ventilator and ionotropic support. Patient was continually running high
fever, so fill dose of Inj Faleigo and afriaxone and Tarund given, but patient
did not show any response. Patient got stress gastric ulcers so blood
transfusion was given off and on. Bone marrow aspiration for AFB and malaria
parasite was negative. Pertoneal and haemodialysis was doen several times for
renal failure. Broncoscopy was done bronchial tree appearence was suggestive of
fungal infections so antifungus was given. Culture report of bronchial lavage
showed Pseudnass infection so Primaxin was started. Patient had geratised tonic
clonic seizures lasting about 10 minutes subsided by Vaccuronium, so Primaxin
was stopped. At present patient condition was critical. Patient is unconscious,
not responding to deep painful stimulii. Maintaining blood pressure on
isotropic support on CMV mode of ventilator. Daily haemodialysis for renal
impairment. FFP for deranged blood parameters, plus other supportive treatment.
Patient is also having signs of DIC with generalised bleeding from the WT,
haematemesis, malina. Chest Xray picture is also suggestive of ARDS. At present
patient is in multiple organ failure due to septicaemia. Presently on
Aztirconam. ALl blood cultures negative. No M.P. seen. Total counts have
remained between 6000-7000 ***. He has severe DIC.

Hello,

A friend of ours, ShriKant Srivastava, is in critical condition at Apollo
Hospital, New Delhi, India. A case summary of his condition as given by the
hopspital is enclosed above. We want to get input from people/doctors/others
out there who have seen succesful treament for similar symptoms. If you have
come across patients who have been treated for similar symptoms and are in a
position to help by way of letting us know the line of treatment that was given
then please get in touch with us. The main contact people are,

Manu Lauria
email : manu@cadence.com
Address : Cadence Design Systems (I) Pvt Ltd,
SDF # B-8, NEPZ,
Noida, 210305.
India.
Phone : +91-11-91-562842 (Office)
+91-11-91-541804 (Residence)
Fax : +91-11-91-562231

Sandeep Pagey
email : pagey@cadence.com
Address : Cadence Design Systems (I) Pvt Ltd,
SDF # B-8, NEPZ,
Noida, 210305.
India.
Phone : +91-11-91-562842 (Office)
+91-11-91-555415 (Residence)
Fax : +91-11-91-562231

Captain Srinivas
email : srini@cadence.com
___

I appreciate the difficulties with your friend that you write about in your posting. Obviously, from the limited description of this very difficult situation. I can make no diagnosis. The presence of fever for several days prior to the development of multiorgan failure places sepsis high on the differential diagnosis. Many infections, particularly viral can involve the liver including CMV, EBV, Herpses simplex, Hepa**** A, B, and C and others. In addition, many of the medications he received in the febrile period and thereafter are potentially hepatotoxic.

Treating the underlying infection, whatever that may be, would be the first line of therapy while organ function was being supported. Liver transplanatation would be contraindicated in the setting of sepsis and would not appear to be appropriate from the description you have written.

The presence of splenomegaly and ascites does raise the additional possibility of preexisting liver damage which is now worse in the setting of infection.

I wish you and your friend the best in this difficult situation. If you have any further specific questions please let us know.

This material is being presented for informational purposes only and should not be considered a formal evaluation. If you have specific questions, you should contact your physician.
keywords: liver failure, DIC
HFHSM.D.-kb
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