89 year old female presents with altered mental status and abdominal pain.

The patient was brought to the Emergency Department by her family reporting 1-2 days of worsening disorientation, dysarthria, headache, and abdominal pain. The patient was unable to provide any history.

The patient's family reported that approximately 6 weeks prior to this admission she had been admitted to an outside hospital with possible pneumonia. She was treated with an unknown antibiotic and discharged home after 3 days to complete a 10 day course of antibiotics. Shortly after leaving the hospital she developed crampy abdominal pain, loose brown stools, nausea, and vomiting. There was no GI bleeding or purulent stools. She denied fevers or chills. These GI symptoms persisted after completing her course of antibiotics and she presented to Johns Hopkins Hospital approximately one week after completing the antibiotics. She reported no unusual ingestion of foods or recent travel. Her physical examination was notable for normal vital signs, a non-reducible ventral hernia, and otherwise normal abdominal examination. Labs were notable for a normal WBC, BUN= 68, creatinine= 1.3, normal UA, normal lipase and amylase. An abdominal CT was performed. Stool was positive for C. difficile antigen and toxin. She was discharged on po Flagyl to complete a 14 day course approximately 3 weeks prior to this admission.

Family reports that her GI symptoms improved after leaving JHH last time. She had been weak but improving until the two days prior to this admission. She'd had no fevers, chills, sweats, chest pain, cough, or dysuria. She had had a diminished appetite since the episode of colitis, but was taking some fluids and food. Two days prior to admission, she developed diffuse malaise and weakness. On the day of admission, she had worsening abdominal pain, dysarthria, and headache.

Other than described above, she'd been in good health and had not been hospitalized recently. The ventral hernia was longstanding and asymptomatic. She had been counseled about obesity.

Noncontributory.

She lives with her son in Baltimore, who is her caretaker. They have a pet cat and a healthy parrot. She does not smoke, drink, or use any illicit drugs. She was formerly employed at Bethlehem Steel as an administrator. She eats hamburger and eggs regularly. She does not drink unpasteurized milk and hates sushi, oysters, and all other forms of raw or undercooked food.

Calcium carbonate 500 mg po tid
Lasix 20 mg po prn edema
No herbals or alternative medications

No known drug allergies.

Her son reports that the patient has no history of heartburn, chronic abdominal pain, liver disease, constipation, or loose stools (other than this illness). She does not use antacids at home. Her routine health maintenance screening is up to date.

• T: 96 (oral) BP: 82/46 HR: 120 RR: 20.
• General: Obese woman with slurred speech
• HEENT: No facial droop.
• CV: Regular rate and rhythm, normal S1 and S2.
• Lungs: Coarse rales bilaterally.
• Abdomen: Diffusely tender without rebound, bowel sounds hypoactive, no masses. Ventral hernia.
• Rectal: Brown stool, heme-positive.
• Extremities: 3+ lower extremity edema bilaterally.
• Neurologic: Unable to follow commands, disoriented; dysarthric, no focal findings.

• Na 145; K 1.7; Cl 107; CO2 18; BUN 57; Cr 2.4; Glucose 7; Calcium 7.2; Total Protein 5.4; Albumin 1.8; TBili 0.8, ALT 29; AST 28; Alk Phos 77
• WBC 6600 (Bands 13%, Neutrophils 77%, Lymphocyte 4%); Hct 32.7; MCV 94.2; Platelet 122
• ABG pH= 7.21, PCO2= 47, PO2=101 on nasal canula 2 L/M
• Lactate 9.8; Serum myoglobin 1572.1

PA chest radiograph on admission: Normal left ventricle. Moderate obesity causing hypoinflation of lungs and moderate right hemidiaphragm elevation. Moderate arthritis shoulder joins with probable aseptic necrosis right humeral head.

Brain CT without contrast on admission: Minimal cerebral atrophy. No evidence of bleed, hematoma, midline shift, or sulcal effacement. Ventricles are normal in size. Normal gray-white differentiation. No acute abnormality.

Abdominal Imaging from Prior JHH Admission

• Image #1. Plain supine film of abdomen shows air in stomach and colon. No suggestion of bowel obstruction.
  
• Image #2. Four sequential images from CT exam. A. No free air. B. No bowel obstruction. C. Diffuse circumferential thickening of ascending colon, descending colon, and sigmoid colon. C. Ventral hernia containing loop of transverse colon. D. 3.3x 3.2 cm aneurysm abdominal aorta containing thrombus.
• Image #3. Closeup view of CT abdomen.

The patient was hypotensive upon arrival to the ED and was admitted to the MICU. She received fluid resuscitation, vasopressors, and empiric antibiotics. Abdominal radiograph showed no evidence of perforation. Within 6 hours of admission, blood cultures were growing gram positive cocci in chains that were subsequently identified as Group G Streptococcus. Despite aggressive therapy she developed worsening metabolic acidosis, acute renal failure, hypoglycemia, and inadequate tissue perfusion. Despite administration of sodium bicarbonate and glucose, her acidosis and hypoglycemia could not be corrected.

After discussing her worsening multiorgan failure with her family, she was not placed on mechanical ventilation. Approximately 24 hours after admission, she developed refractory hypotension, cardiac arrest, and expired.

What was the most likely cause of her neurologic symptoms?

What is the most likely etiology of her sepsis and multiorgan failure?