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A5305 - An Unusual Case Rejection
Author Block: R. Akkari1, E. Kyereme-Tuah2; 1Internal Medicine, University of Maryland Capital Regional health at prince georges hospital, Cheverly, MD, United States, 2Critical care Medicine, University OF Maryland Shock Trauma, Baltimore, MD, United States.
60-year-old male with a past medical history of hypertension and schizophrenia presented to the emergency department via ambulance, unresponsive with Glasgow Coma Scale score of 3. Patient was found to have nonresponsive pupils and a weak gag/cough reflex. CT Brain without contrast was unremarkable for any acute findings while CTA of the brain was significant for basilar artery occlusion. The patient was last seen well more than 12 hours prior to presentation, thus precluding thrombolysis. Urine toxicology screen was normal and laboratory tests essentially within normal parameters. Admitted to ICU, eventually became febrile to 104F. Had increasing dilute urine and increasing serum sodium up to 150 mEq/L, consistent with central diabetes insipidus and suspected cerebral edema. Emergent CT brain revealed impending uncal and transtentorial herniation with edema. Patient was eventually pronounced brain dead and as per local policy, organ donor services were contacted. Patient was rejected after initial acceptance due to an abnormal Hemagen Chagas test. Chagas disease, (American trypanosomiasis) is an anthropozoonosis caused by obligate intracellular flagellate protozoon Trypanosoma cruzi, which infects humans and other mammals [1] [2]. It is estimated that more than 300,000 persons with T. cruzi infection live in the US [3]. Clinically, the disease presents itself with an acute phase which generally manifests with mild or nonspecific febrile syndrome lasting between 3 to 8 weeks [4]; and a chronic phase which presents itself in various forms most commonly as cardiac, gastrointestinal and neurological [4] [2]. If the acute phase remains untreated T. cruzi infection is lifelong and thus chronic able to manifest after some decades of progression (about 10-30 years after the acute phase) [4]. The cardiac form which affects about 10 to 25% of patients [4] is the most common manifestation of the disease, which causes a manifestation of myocardial dysfunction including failure, mural thrombus, ventricular aneurysm and cardiac arrhythmias [5]. Neurological involvement leading to ischemic strokes has been implicated as a cause of death in Chagas disease patients [5] [6], The most frequent stroke syndrome seen in patients with Chagas involves anterior circulation [8], although posterior circulation thrombi ( basilar Artery strokes) does occur. Basilar artery strokes carry a poor prognosis and in some series had up to 85% mortality. The patient had been in the armed services stationed out of the country, though the family thought he had been in central and southern America.