D.H.Clinical Pathology Conference

August 24, 2015

Stella Lai MDRonald Hamilton MD

HPI

29 yo M w/ h/o ulcerative colitis, basal cell carcinoma and metastatic melanoma who presented to ED for diffuse HA, nausea, transient visual disturbance (flashing lights in L upper visual field), transient L hand numbness + tingling, speech difficulty and acute onset confusion.

Other History

PMHx/PSHxHTNNephrolithiasisUlcerative ColitisBasal Cell Carcinoma s/p resectionMetastatic Melanoma w/ known brain, lung, chest wall, lymph node, thigh and gluteus involvement s/p numerous biopsies + resections and treatment w/ IL2, aflibercept, dendritic cell vaccine +/- interferon booster and pembrolizumab

AllergiesAtivan (parodoxical agitation)

MedsVitamin B6, Vitamin B12, Vitamin D, Vitamin E, MV, Dexamethasone Taper, Keppra 1000mg BID, Mesalamine 4800mg QHS, Zofran PRN, oxycodone PRN

Social HxLives w/ wife. No smoking, alcohol or illicits.

Family HxMother: Prothrombin Gene Variant w/ h/o DVT/PEMaternal GM: Breast Cancer @ 55

ExamVS: 37.2, BP 143/90, HR 98, RR 17, O2 Sat 97% RAMS: Alert and oriented x 3, Agitated, Repetitive/slow/

labored speech, Follows simple commandsCN: VFs intact, PERRL, EOMI, No facial asymmetryMOTOR: 5/5 strength throughoutSENSORY: Intact to light touch throughoutREFLEXES: 2+ biceps/triceps/patella/achilles, No ankle

clonus, No HoffmansCOORDINATION: ?GAIT: ?

Clinical Localization….of confusion, diffuse headache, nausea, speech

difficulty (sounded like it was mostly expressive), L hand numbness/tingling and L upper VF flashing lights.

Hospital CourseReceived 10mg IV Decadron and 25g IV mannitol in ED, and was admitted for further management. He was continued on Decadron 4mg IV 6 hours and returned back to baseline 24 hours after admission. He was d/ced on dexamethasone slow taper w/ instructions for repeat brain MRI in 1 month.

Hospital Course2 months later, he presents w/ acute abdominal pain. It was initially tolerable but progressed to stabbing, 10/10 pain that was not responsive to oxycodone. CT abdomen revealed L renal vein thrombosis and diffuse metastatic disease. He was initially placed on heparin gtt which was stopped b/c of his known hemorrhagic metastatic brain lesions. He underwent repeat neuroimaging.

• MRI ETC:

Hospital Course

3 days after admission, abdominal pain acutely worsened. CT abdomen revealed free air and small bowl perforation. Not a surgical candidate b/c of hemodynamic status. The next day, he arrested (?2/2 PE) requiring 30 minutes of CPR for ROSC. He was intubated and maxed out on 3 pressors. Given poor prognosis, he was made CMO and expired.

Pathology

Gross PathologyWell-demarcated lesionsVariable amount of pigmentationCould be hemorrhagic and necrotic

Micro PathologyPleomorphic MelanocytesMitosisNecrosisStaining + for S-100, HMB-45, Melan-A