Friday, June 24, 2011

An Unfortunate Consequence


I was working in the hepatitis clinic, in a public hospital one morning when I was called by my supervising physician who asked me to go to the in-patient unit and see a 25 year old male patient.  My attending had been called by the rheumatology attending who informed him of this particular patient.   I asked a few questions and then hung up.  I finished seeing my out-patients in the clinic and then paged the rheumatology attending. 
“Dr. Andrews, this is Sharon.  Tom (my attending) has told me about this patient you want us to see.  What’s going on with him?”
“Sharon, he’s got chronic hepatitis C, his antibody test came back positive in this morning’s labs.  He was admitted to the hospital last night, due to his having 102 fevers, bacteremia and necrotic lesions on the back of both of his lower legs.  He’s on our service due to the fact that he has medium vessel vasculitis due from the hepatitis C virus.  The back of both of his lower legs are necrotic and basically gone.  He’s going to need surgical grafting, that is, if he is a candidate.  Surgery may not want to do anything else besides their initial debridement done last night, because they will see him as a poor candidate, he smokes 3 packs a day, hasn’t quit using intravenous street drugs and probably weighs about 100 pounds, if that.  He’s also a dumpster diver, he’s lucky if he gets anything nutritious on a daily basis.  Anyway, I’m getting ready to start in-patient rounds with the rheumatology fellow, we’ll be seeing him shortly, do you want to join us?”
“Sure, where are you going to start?”
“We’ll be up on the 9th floor medicine side.  This patient is on 8 medicine.”
“Okay, well seeing that this patient is on 8, why don’t I go up and review his chart, get started on the GI-Hepatology consult for you, and then when you finish with your patients on 9, I assume you’ll be coming by 8 to see him?”
“That would be the plan.”
“Okay, well then I’ll meet up with you on 8, until then I’ll get started on the consult.”
“Great.”

This patient ended up having two of the various extra hepatic (meaning outside of the liver) manifestations of his viral hepatitis.  (see below) Not only did he have bacteria in his blood stream which was due from his having two large and open wounds on his lower legs but he also had deposited immune complexes into his blood vessels in his legs which over time had cut off his circulation.  This had lead to his having necrosis of his lower posterior legs and losing not only the skin but the underlying muscle. 

Chronic hepatitis C can cause numerous extra hepatic manifestations.  These manifestations are due to the virus causing the immune system to become unregulated and it begins to attack the patient’s systems.  These manifestations can include:
Cryoglobulinemia (immune complexes being formed and deposited in various organs/systems, blood vessels)
Lymphoma (a cancer of the lymph glands)
Idiopathic thrombocytopenia (a low platelet count, platelets are used to clot off a bleeding episode)
Auto immune hepatitis (the patient’s immune system begins to attack the patient’s own liver)
Leucocytoplastic vasculitis (small vessel disease, an inflammatory disease of the small vessels where immune complexes are deposited)
Porphyria cutanea tarda (a condition where the patient deposits porphyria in their skin cells)
Lichen planus (a type of skin rash)
Diabetes mellitus (the patient becomes unable to regulate their own blood sugar levels and has to take oral medications and/or insulin to keep the blood sugar under control)
Membranous proliferative glomerulonephritis (a condition where the patient deposits immune complexes in the kidney and over time the patient loses kidney function)
Cardiomyopathy (an enlarged heart or a heart that no longer pumps correctly)
Myocarditis (an inflammation of the heart muscle)
Mononeuritis multiplex (various nerves are involved which have lost the necessary blood flow to survive, usually due from immune complexes being deposited in blood vessels which then are no longer able to give oxygen and other nutrients to the involved nerves)

About 45 minutes later, as I was focused on finishing writing up the consult note, Dr. Andrews taped me on the shoulder.  
“Are you ready?”
“Sure am.  Let me just sign these orders and then give them to the ward clerk to order for our patient in the am.”
After handing off the patient’s chart to the ward clerk, I followed Dr. Andrews down to the patient’s room. 
“Hi, Brian, you remember me from when you were admitted to the hospital through the emergency room last night, correct?” asked Dr. Andrews.
“Yep, I do.”
“You just meet Sharon a little while ago, she works for the GI-hepatology service.  She’ll be the one who will see you in the hepatitis clinic, once you’re discharged.   And on my right, is Dr. Miller, he is the rheumatology fellow this month and will be following you along with the surgical service.”
“Okay.”
“Sharon, I assume you got a good look at the back of Brian’s lower legs?  You saw what surgery is going to have to try to repair?”
“Yes, I did.”
“Well, once he clears out the bacteremia that’s in his blood stream with the IV antibiotics he’s on, surgery will hopefully be taking him to the operating room to debride his lower legs some more, and then put a mesh dressing over them.   Then he’ll have to finish up the two weeks of IV antibiotics before surgery even wants to go and try any sort of muscle graft.”
“Okay, well then I’ve got all of his blood work for his hepatitis C ordered for in the am.  That will give us all of the preliminary information I’ll need.  I can go ahead and also order an ultrasound of his liver.  Then when he is ready to begin his treatment program, which I assume won’t be for quite some time, seeing he’s got quite a bit of surgery ahead of him, as well as drug rehab, then I can order his liver biopsy.”

There are various pieces of clinical information that we need to be able to treat patients with chronic hepatitis C.  A partial list includes: patient’s genotype (there are 11 different ones in the world, within the U.S. we typically only come across 3 of them, genotype 1 (hard to treat), genotype 2 and 3 (easier to treat), viral load (we use 600,000 as our cutoff, anything below this is a good sign that the patient will respond to treatment, above this is a sign to us that they may not respond and clear the virus). 
With the ultrasound of the liver we can acquire the following information: how large or small is the liver, if it’s small then it is probably cirrhotic (end stage), whether the liver has fat in it (which is due to the virus depositing it there), and whether there are any suspicious lesions which could lead us to believe they may have liver cancer (caused by the virus).
A liver biopsy acquires a very minute piece of liver and from this the pathologist can tell us what stage of disease the patient is in.  In other words how much damage has occurred to the liver from the virus.    

“Sounds good to me.  He’s going to be in-house for several weeks, so why don’t you just check in on him every so often and I’ll make sure that you’re informed when we get ready to discharge him so that he can see you on the out-patient side.”
“Sounds like a plan to me.”
“Has surgery been by to see you today, Brian?” asked Dr. Andrews.
“Yeah, they came by this morning.  They told me that if I come back with negative blood cultures by Friday then they will schedule me for the an additional debridement on Saturday morning. “
“Alright, well then I’ll see you tomorrow on rounds.”
With that the three of us left Brian’s room and went back to the nurse’s station.  I excused myself from Dr. Andrew and his fellow and returned to the GI lab to inform my supervising physician of the plan on Brian.
Every so often over the next 6 weeks I went up to the medicine floor and checked in on Brian and read the most recent chart notes on him.  Brian had been to the operating room twice for surgical debridement and they had finally been successful in doing bilateral muscle grafts to the back of both of his lower legs.  He had good circulation and physical therapy was working with him on his ambulation skills. 
Discharge planning had come up with a plan to send Brian to a drug rehab unit where he could work on his addiction to street drugs.  He would be there for at least 6 weeks.  Surgery would be following him in clinic.  So with that in mind I went in and advised Brian that I would see him in 8 weeks in my clinic.  Dr. Andrews had informed me that he didn’t want Brian to have to wait the whole year off of intravenous street drugs before I started treating him for his chronic hepatitis C.  He informed me that Brian’s vasculitis was still active despite immunosuppressive drugs and would remain so because surgery didn’t want them understandably to use prednisone on him, seeing that would affect his healing process.  So the only thing that was going to put a halt to the vasculitis was to treat and get rid of the hepatitis virus.

Brian had a lot of emotional/mental issues that he had to work through.  Not only did he have to address his reasons for using street drugs, but he also had to address his having acquired a chronic viral disease from his illicit drug use.  He had very little, if any, support from friends and family members to help him or encourage him to acquire healthier eating patterns, quite his drug use and stop his smoking.  The brick wall in front of him was immense and would take him quite a while to be successful at overcoming everything in his path towards being healthy once more. 
 
Eight weeks went by and I was surprised when I walked into a clinic exam room to find Brian there.  He was rather talkative and nervous, hobbling around on his crutches.   
“Hey, Brian, how are you?”
Somewhat in a rapid fire speech pattern, Brian said, “Slowly getting better.  I just had my check-up with surgery last week and they cleared me from needing to see them again.  They told me that my muscle grafts are as healed as they are going to get.  I’m still using my crutches to help me ambulate, because I don’t have a lot of strength yet in my legs.  I’m now doing out-patient drug rehab, I finished the in-patient program.  I’ve been drug free now for 3 months.  But I’m still having to deal with my cravings.”
“Well it sounds as though you are on your way to improving your health.  I’m glad to hear it.  You’re scheduled to see rheumatology this afternoon in clinic I see on your patient schedule.  I know that they are going to want you to get started on your hepatitis treatment program sooner rather than later, how do you feel about that?”
“I’m not sure I can handle those weekly injections at all.  It’s probably going to give me flashbacks to my using street drugs.  I’d rather put off my treatment for a couple of months until I’m further into my drug rehab.”
“Okay, that sounds reasonable.  Why don’t we go ahead and schedule your liver biopsy for in 2 months? Then I can see you back in 3 months, and tell you the results of it.  And if at that time you feel you can handle the weekly injections then we can start.  Does that sound reasonable to you?”
“Yeah, I can handle that.”
I went ahead and advised him what to expect with the liver biopsy and then went to go schedule it.  I came back into the exam room to find Brian nervously rocking back and forth on his crutches.
“Are you okay, Brian?”
“Yeah, I think so.  It just makes me nervous to think about doing those weekly needle injections for my hepatitis C, that’s all.  I’ll just have to work through it.”
“Well if you don’t want to do it, that’s okay.  Or if you think it’s too soon, let me know.  Here’s the information on your liver biopsy date and where to go.  So I’ll see you a couple of weeks after the biopsy and we’ll talk about your treatment again then, okay?”
“Yeah, okay.”
With that I said good-bye to Brian and he went to the lab to get his blood work drawn for his rheumatology appointment. 
Three months later Brian was on my clinic schedule but he didn’t show.  I wasn’t surprised.  Dr. Andrews had told me that he hadn’t shown for his last rheumatology appointment either which was six weeks prior.  I went into the computer to check to see whether he had acquired his liver biopsy and he hadn’t shown up. 
Two weeks later I received a page from psychiatry asking me to come up and see a patient on the in-patient unit.  It was Brian.  He was severely depressed, and had attempted suicide.  They told me that Brian had verbalized he was afraid of doing the treatment and was having numerous flashbacks to when he used street drugs.  They wanted me to come to the in-patient side and just explain and teach Brian what to expect.  They were putting him on anti-depressants.  So I went over that afternoon and sat with Brian for a while as we went over again what to expect and that he had the power to decide when he was ready, I was not going to push him into it. 
I saw the attending psychiatrist several weeks later and he informed me that Brian had been discharged, was being treated as an out-patient when he came into the emergency room last week in full code.  He had injected enough heroin into himself to end his life.  

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