the arlene berry story

8/15/2019 The Arlene Berry Story

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edress Information & Analysis

An Enigmatic Experience Project 2000-2015

Te Arlene !erry "tory # $pdate 2015

A "oc%ing Portrait of ntario's (ealt )are "ystem

I*T +$)TI*

Arlene !erry died s,ddenly and ,nexpectedly at te early age of 1. less

tan 2 o,rs after /eing admitted to te ir%land and +istrict (ospital on

ay 2rd of 20003 Tere is a p,/lic interest in %no4ing o4 Arlene !erry

came to er deat and o4 er ealt care proiders are implicated3

er te past 15 years I ae spent to,sands of man o,rs researcing

tis ,nnecessary deat3 Alto,g tis as /een an enigmatic experience for me.

I am een more coninced no4 tan eer tat Arlene !erry's deat is clearly te res,lt

of gross medical negligence and in acting 4it 4anton and rec%less disregard for ,man

life. /eing te allmar% of criminal negligence ca,sing deat3 +etermine te facts3

)irc,mstance and spec,lation cannot tr,mp fact3 Te record spea%s for itself and is

igly s,ggestie3

A !rief (istory

Arlene !erry 4as a ro/,st yo,ng lady of only 1 years of age 6 4ereer

se 4ent se 4as li%e a /reat of fres air to all 4o %ne4 er3 "e /elieed

tat fising 4as a peacef,l means of tac%ling life's stresses. 4ile enjoying

7,ality o,tdoor time 4it friends and loed ones and especially er cildren3

"e 4as an aid fiser-girl. i%er. camper. and moter of t4o 8a /oy and a

girl93 "e ad a eart of gold. al4ays placing te needs of er cildren/efore er o4n3 !ot cildren 4ere only in teir early teens at te time of

teir moter's deat3 Alto,g er da,gter ad come of age and 4as /y

ten liing on er o4n. Arlene !erry still cared for er son. te yo,ngest of

te t4o. ,ntil er deat on ay 2t of 20003

It is interesting to note tat Arlene !erry ad a istory of 4or%ing in and


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aro,nd logging camps in norteastern ntario. primarily in seasonal

reforestation or silic,lt,re actiities as directed. s,c as :tree planting: jo/s

/et4een atace4an. and ir%land ;a%e. ntario3 Te odd jo/ consisted of

clean,p 4or%. s,c as slasing. gatering. piling and /,rning dead

/r,s4ood3 Alto,g se smo%ed. se 4as neer a eay smo%er3 "e 4as

an aid angler and se loed fising. ,nting. camping. i%ing and coo%ing

o,tdoors oer a campfire3 A ne4ly fo,nd o//y ad incl,ded gatering

drift4ood. pine cones. licen. and spagn,m mosses. as 4ell as ario,s

gro,nd pines. collected ,s,ally in mid fall of te year 4en ig ,midity

and cool temperat,res preailed. and ,sed for creating crafts and c,rios of

all %inds to elp ma%e ends meet3 "e een did a little roc%o,nding.

4ereer tere 4ere interesting roc%s and minerals to /e collected3 "e

loed te great o,tdoors3

Te


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Atelectasis is defined as diminised ol,me affecting all or part of a l,ng3

"ince /ot conditions inole a collapsed l,ng. symptoms are similar and

can range from mild and /arely noticea/le to seere or cronic3 Ben a

small portion of te l,ng 4ea%ens. it collapses3 If tis area is small. it does

not al4ays affect te f,nctioning of l,ngs3

In tis instance. te inj,ry seemingly resoled j,st as 7,ic%ly as it appeared

4it noting more tan a good nigt's rest and a daily regimen of I/,profen.

a non-prescription *"AI+ 8non-steroidal anti-inflammatory dr,g9 tat is

commonly ,sed for s%eletal pain and inflammation3 *ota/ly. a small

pne,motorax may resole on its o4n and re7,ire no specific treatment

/eyond rest3 At any rate. Arlene did not perceie er inj,ry serio,s eno,g

to 4arrant medical attention at tat time3

i/ inj,ries incl,de /r,ises. torn cartilage and /one fract,res3


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a/sorption to ealty tiss,es3 Te most common mecanism is d,e to

sarp /ony points arising from a ri/ fract,re penetrating ple,ra and

damaging l,ng tiss,e3 "eeral types of atelectasis existG eac as a

caracteristic radiograpic pattern and etiology3

Atelectasis is diided pysiologically into o/str,ctie and nono/str,ctie ca,ses3 *ota/ly. in tis case. te radiologist reported tat tere 4as Han

area of consolidation noted in te left l,ng /ase posteriorly 4it /l,nting of

te left costoprenic s,lc,s. s,ggestie of a /roncial o/str,cting lesionC3

)a,ses of o/str,ctie atelectasis incl,de foreign /ody. t,mor. and m,co,s

pl,gging3 !lood clots or scar tiss,e may also o/str,ct or /loc% te

/roncial air4ays3 A fall. an accident or a seere inj,ry can constrict and

compress te l,ngs3 A/normal ealing response d,e to inj,ry of te l,ngmay res,lt in te prod,ction of excess scar tiss,es tat interferes 4it l,ng

f,nction3 ;,ng scarring can also res,lt from a ariety of infections3

;,ng inj,ries leading to scar tiss,e deelopment can incl,de long-term

expos,re to toxins. /acterial or f,ngal gro4t. as 4ell as iral and parasitic

infection3 ;,ng spots are more common tan most people tin% and many

are prod,ced /y armless scarring in te l,ngs ca,sed /y respiratory

infections in te l,ngs3

P,lmonary atelectasis is one of te most commonly enco,ntered

a/normalities in cest radiograps3 RecogniFing an a/normality d,e to

atelectasis on cest radiograps can /e cr,cial to ,nderstanding te

,nderlying patology3

;,ng scarring occ,rs d,e to patological deposition of fi/ro,s tiss,e3

Tis is a progressie disease ,s,ally and ence needs fre7,ent periodic

monitoring3 Te most common associated infections are cronic l,nginfections3 any l,ng infections can sim,late cancer. and teir

differentiation. /ased on imaging findings. can sometimes lead to a

pres,mptie malignant process3 Te infections may /e f,ngal.

myco/acterial. parasitic or. rarely iral3 ost. if not all of tese infections

can mas7,erade as a primary or metastatic l,ng carcinoma3


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"ome conditions do not attac% te l,ngs directly. /,t neerteless d,e to

teir effects on tiss,es tro,go,t te /ody. lead to scar formation3 Tese

incl,de l,p,s. scleroderma. re,matoid artritis. dermatomyositis.

polymyositis. "jogren's syndrome. and sarcoidosis3 "ymptoms of l,ng

scarring are similar and incl,de a feeling of /reatlessness. especially

d,ring or after pysical actiity. a dry co,g. feer. cills. 4eeFing. cest

pain. nigt s4eats. 4eigt loss. decreased energy leel. and finger tips tat

/ecome enlarged and ro,nded3 er time. tese symptoms /ecome

progressiely 4orse3

)ronic Atelectasis occ,rs 4en te patient as /een s,ffering from a

collapsed l,ng and is also dealing 4it oter complications tat incl,de

diffic,lty /reating. infection. and scarring of tiss,e or fi/rosis3 ;,ng

atelectasis and localiFed ac,te l,ng inj,ry are factors li%ely responsi/le fortis ,n,s,al istology and along 4it te clinical istory are important in

recogniFing te /enign nat,re of tis type of lesion. reportedly :mista%en

for adenocarcinoma:. te most common type of l,ng cancer. 4ic ,s,ally

/egins in te m,co,s-prod,cing cells of te l,ng3 It's also te most

common type of l,ng cancer in 4omen and in Hpeople 4o ae neer

smo%edC3


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"arcoidosis as signs may Hmimic adenocarcinomaC3

Eery year people are diagnosed and treated incorrectly /y

teir tr,sted pysicians3

P,lmonary fi/rosis occ,rs 4en te l,ng tiss,e is damaged3


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tat donJt 7,ite fit3 In partic,lar. /iases against patients tat are or ae

/een long term smo%ers are common and ae /een so4n to affect a

pysicianJs j,dgment. practice style and leel of care3 In tis instance yo,Jre

li%ely to get a diagnosis of l,ng cancer een if yo, donJt ae it3

People 4it p,lmonary sarcoidosis typically deelop sortness of /reat ora dry co,g as inflammation c,ts do4n on teir l,ng capacity3 Extreme

exa,stion is one of te more common symptoms3


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occ,r in te l,ng in a ariety of infectio,s and noninfectio,s diseases3

ran,lomato,s processes s,c as T!. f,ngal infections. and sarcoidosis

can all resem/le *ont,/erc,lo,s myco/acterial gran,loma 8*T9 infections3

*ont,/erc,lo,s myco/acterial gran,loma can enlarge 4ito,t clinical

manifestations or any satellite lesions and caitations. leading to amisdiagnosis of l,ng cancer3 *ont,/erc,lo,s myco/acteria 8*T9 are

enironmental organisms tat are normally fo,nd in soil and 4ater3 "eeral

patients ae ,ndergone pne,monectomy. ,s,ally partial. for pres,mptie

l,ng cancer tat t,rned o,t to /e an infection3

Intracranial gran,lomato,s masses presenting as space occ,pying lesions.

alto,g rare. ae also /een descri/ed in te literat,re3 Intracranial

gran,lomas presenting as space occ,pying lesions can ca,se focalne,rology and imaging 4ic may mimic tat of t,mor3 )a,ses incl,de

infections. systemic gran,lomato,s disorders. and iatrogenic from preio,s

s,rgery. as in tis case3 Intracranial space occ,pying lesions are t,mors or

a/scesses present 4itin te crani,m or s%,ll3 Tey are one of te tree

types of lesions tat can occ,rG te oter t4o are asc,lar 8trom/osis.

em/oli etc9 and lesions d,e to tra,ma3

nce parasites start an infection. tey can effectiely resist te letaleffects of macropages and prod,ce cronic infection tat can lead to

inflammation3 Parasites can ind,ce gran,lomato,s inflammation tat seres

to ins,late te patogens tat resist destr,ction3 Tese gran,lomas are

reg,lated /y T cells tat recogniFe parasite-released antigens3 In te tiss,es

macropages acc,m,late and secrete cemicals tat ind,ce fi/rosis and

stim,late te formation of gran,lomato,s tiss,e and proo%e fi/rosis3

As gran,lomas gro4. tey can compromise te ealt of an organ. incl,ding

te l,ngs3 Alto,g non-necrotiFing gran,lomas are te ,s,al finding in

sarcoidosis. necrosis can also occ,r. and is referred to as necrotiFing

sarcoid gran,lomatosis3 Te difference /et4een gran,lomas and oter types

of inflammation is tat gran,lomas form in response to antigens tat are

resistant to te first line of defense in te /ody3 Tis consists of

inflammatory cells s,c as ne,tropils and eosinopils3 Te antigen ca,sing


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te formation of a gran,loma is most often an infectio,s patogen or a

s,/stance foreign to te /ody. /,t often te offending antigen is ,n%no4n

8as in sarcoidosis93

Essentially. a gran,loma is j,st s4ollen tiss,e3 It is a mass of inflamed

gran,lation tiss,e from inj,ry or infection. ,s,ally associated 4it ,lceratedinfections. or inasion /y a foreign /ody3 ran,lomas form 4en te

imm,ne system attempts to 4all off s,/stances tat it perceies as foreign

/,t is ,na/le to eliminate3

A Hgran,lomaC is a /all of imm,ne cells associated 4it ario,s disease

states incl,ding sarcoidosis. )ron's. and t,/erc,losis. ence te term

:gran,lomato,s diseases:3 ran,lomas are also te patologic allmar% of

sarcoidosis. 4it te disease sometimes mas%ed /y oter conditions ordisease processes3


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/eca,se gran,lomas 4it necrosis ,s,ally ae infectio,s ca,ses 3

Te )T caracteristics of necrotiFing gran,loma are indisting,isa/le from

tose of malignant t,mors3 Alto,g most cases of sarcoidosis eiter

regress or remain sta/le. 10-15D progress to p,lmonary fi/rosis3 enerally.

p,lmonary f,nction 4orsens 4it an increasing stage of disease. /,tradiologic staging does not correlate 4ell 4it te seerity of p,lmonary

f,nction a/normalities3 ften. te radiograpic a/normalities appear 4orse

tan te degree of f,nctional impairment act,ally present 3

ran,lomas are seen in a 4ide ariety of diseases3 Infections tat are

caracteriFed /y gran,lomas incl,de t,/erc,losis. leprosy. istoplasmosis.

cryptococcosis. coccidioidomycosis. /lastomycosis and cat scratc disease3

"ome more common non-infectio,s gran,lomato,s diseases inc,ldesarcoidosis. )ron's disease. . Begener's gran,lomatosis. ),rg-"tra,ss

syndrome. p,lmonary re,matoid nod,les. /erylliosis. and aspiration

pne,monia3

Te diseases associated 4it gran,lomas eac ae a different preferred

metod of treatment. and /eca,se gran,lomas are so 4ide-spread te

possi/ilities for treatment are almost limitless3 Ac,te infections so,ld /e

treated aggressiely 4it anti/iotics. and tese can also /e prescri/edpropylactically to preent infection3 If an a/scess forms in association 4it

te gran,loma it can /e treated and drained /y a s,rgeon3

Bitin 2 to 5 years. a/o,t 25D of tose 4it "arcoidosis 4ill deelop

resid,al fi/rosis in te l,ngs or else4ere. giing rise to :resid,al disease:3

No, can also get resid,al scarring associated 4it fi/rosis after a l,ng

infection3 esid,al fi/rosis is scar tiss,e tat is left /eind after an infection.

or s,rgery3 Resid,al anyting is a leftoer3 In tis case. resid,al means te

fi/rosis 4as left /eind as permanent scarring of te l,ngs. /efore and after

te l,ng resection3

Past researc s,ggests tat sensitiity to enironmental factors may /e

associated 4it sarcoidosis ris%3 It is 4idely /elieed tat sarcoidosis may

/e ca,sed /y a fa,lty imm,ne response to an inaled s,/stance. s,c as


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4ood smo%e. etc3 Tis teory is s,pported /y eidence demonstrating tat

people 4o 4or% and lie in certain places appear to ae an increased

cance of deeloping sarcoidosis. s,c as people 4o spend a lot of time

aro,nd d,st. cemicals. forest prod,cts and /,ilding materials 8tro,g

teir antigenic or adj,ant properties9 are all at a sligtly increased ris% of

contracting sarcoidosis3

"ymptoms associated 4it sarcoidosis can appear s,ddenly and ten j,st

as 7,ic%ly resole spontaneo,sly3 "ometimes. o4eer tey can contin,e

oer a lifetime3 "ymptoms can /e related to te specific organ affected. or

tey can /e non-specific general symptoms. incl,dingM

• 4eigt loss

• loss of apatite

• fatig,e

• feer

• cills and nigt s4eats3

"arcoidosis may inole one organ system or seeral3 It ,s,ally starts in te

l,ngs or lymp nodes in te cest3 It is to,gt tat inflammation of te

aleoli 8tiny sac li%e air spaces in l,ngs 4ere car/on dioxide and oxygen

are excanged9 is te start of te disease process in te l,ngs3 Tis may

eiter clear ,p on its o4n or lead to gran,loma formation and fi/rosis 8scarring93 er ?0D of patients ae some type of l,ng pro/lem3 nce

considered a rare disease. sarcoidosis is no4 te most common of te

fi/rotic l,ng disorders3

)entral *ero,s "ystem 8)*"9 inolement /y sarcoidosis 8also termed

ne,rosarcoidosis9 is relatiely common among patients 4it systemic

sarcoidosis and as a /e4ildering ariety of manifestations3 P,pillary

a/normalities. incl,ding internal optalmoplegia ae also /een descri/ed

in sarcoidosis3 "arcoidosis can also ca,se a type of meningitis3 )asescomplicated /y fatal meningo-encepalitis ae also /een reported3 An

association /et4een ne,rosarcoidosis and ,illain-!arrO polyne,ropaty is

also reported in te literat,re3

+iseases of te )*" and P*" are ca,sed /y many different types of

patogens. some of 4ic are represented /y /acteria. ir,ses. f,ngi.


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parasites. and toxins3 +iseases of te nero,s system incl,de meningitis or

encepalitis3 *e,rologic symptoms of )*" infections incl,de eadace.

encepalopaty. diff,se 4ea%ness. incl,ding ac,te flaccid paralysis3

*,mero,s st,dies ae o/sered a predilection for sarcoidosis to /ecomeclinically apparent in 4inter and early spring. Hpea%ing in spring montsC.

and ariations so4 iger pea%s in 4inter 3 If it is ass,med tat te latency

/et4een expos,re to te ca,satie agent and deelopment of sarcoidosis

related symptoms is in te order of a fe4 4ee%s to a fe4 monts. it seems

li%ely tat expos,re may first occ,r in many cases in te Hlate fall to early

springC3

Bood smo%e. s,c as ,sing 4ood stoes or fireplaces for ome eating

may /e a ris% factor for "arcoidosis3 Te incidence increases in 4inter

tro,g early spring3 ore tan one million )anadian families eat teir

omes at least partly 4it 4ood3 ;ate fall to early spring is te pea% time

for 4ood /,rning. 4en ome eating /ecomes a factor3 "ignificant air

7,ality pro/lems occ,r in 4inter monts d,e to near/y residential 4ood

/,rning3 Be smell te smo%e in o,r o,ses and it irritates te eyes and

troat to go o,tside3 Tis is typical of ed ;a%e as 4ell as m,c of nortern

ntario from east to 4est d,ring te late fall and 4inter monts3

Past st,dies ae also noted a cl,stering in parts of te co,ntry 4ere tere

is more logging. l,m/ering and sa4mill actiity3 In partic,lar. st,dies s,ggest

tat sarcoidosis cases occ,r t4ice as often 4ere l,m/ering and 4ood

milling is a principal or secondary ind,stry3 Te past sarcoidosis literat,re

so,ld /e considered caref,lly for te possi/ility tat te associations 4it

l,m/ering. 4ood milling and 4ood /,rning are s,rrogates for te sensitising

antigens tey ar/o,r3

Arlene !erry arried /ac% in ed ;a%e d,ring te early fall of 1??@. 4ere

se ad /een liing and 4or%ing as a o,se%eeper at te Red +og Inn te

preio,s 4inter3 Te accomodations 4ere proided /,t te 4ages 4ere lo43

At some point se claimed to ae p,lled a m,scle in er /ac% flipping a


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mattress at 4or%3 "e often complained of acing discomfort in er lo4er

/ac%3 (er /ac% pain 4o,ld come and go as it did. and ad /een confined

primarily to te tail/one area3

Bile liing in Red ;a%e. Arlene !erry ad /een seeing a +r3 inot of te

ed ;a%e edical Associates for a ariety of ailments /elieed to ae /een4or% related. /,t o/io,sly not considered /y er doctor to /e ,rgent

eno,g to 4arrant serio,s medical attention3 At some point se 4as forced

to 7,it er jo/ and loo% for less demanding 4or% d,e to lo4er /ac% pain

incl,ding sortness of /reat and soon fo,nd employment as a scool-

crossing g,ard3 "e moed o,t of te motel and into an old mid siFed

4ood eated mo/ile ome tat ad /elonged to some friends3 "e ad

also enrolled in a )P co,rse offered locally a/o,t te same time3 As I

recall. it 4as /et4een te late fall of 1??@ and early 4inter. at te t,rn of 1???3

!y mid to late 3 (er preio,s family +. +r3 Ed4ard ordan /egan treating er

ass,mptiely for 4at e termed to /e a :s,spected /roncitis:. in spite of

enlargement of te distal segments of te fingers. 4at is %no4n as Hdigitalcl,//ingC3


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!lac%listing is m,ltiple proiders denying care to a certain patient or p,tting

a patient in arms 4ay 4it a connotation of 4illf,l /lindness. or iatrogenic

neglect3 In norteastern ntario /ac% in 2000 tis 4as readily accomplised

tro,g * T( *et4or%. te so called tele-ealt proiders 4o sare

information a/o,t diffic,lt. or diffic,lt to diagnose or diffic,lt to treat

patients. 4it noting more tan a pone call or a n,ance in a referral.

negatiely /randing te patient3

A repeat cest film 4as finally o/tained sortly after te time +r3 ordan

claims e ad seen te patient in *oem/er 1???. o4eer it too% anoter

doctor to read er x-ray cart. and to order more appropriate testing /efore

anyting 4as done3 According to a comm,nication receied /y te )P" in

correspondence receied from +r3 ordan ''te radiologist reported tat

tere 4as an area of consolidation noted in te left l,ng /ase posteriorly 4it /l,nting of left costoprenic s,lc,s. s,ggestie of a /roncial

o/str,cting lesion. s,c as a carcinoma left main stem /ronc,s:3


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a/normal tiss,e fo,nd on or in a personJs l,ng3 It can /e te res,lt of an

infection or illness. 4ic may clear ,p 4ito,t ca,sing te patient long-term

pro/lems3


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of inflammation or infection3 Peraps te 4orst part of tis iss,e is tat false

positie diagnoses are *T altogeter ,ncommon3 In fact. it is estimated

tat as many as forty percent of all initial tests for cancer co,ld /e done in

error3


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lo49 for te remainder of er days3

According to te ,tpatient record at P-5. te patientJs recent ead )T

scan so4ed :* ETA"TA"I":. and er mediastinoscopy 8te proced,re to

examine te mediastin,m inside of te ,pper cest /et4een and in front of

te l,ngs9 4as fo,nd to /e :*EATI=E:3


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infectio,s form fo,nd in asymptomatic carriers3 )ysts of tis type can /e

spread directly from person to person or indirectly tro,g food or 4ater3

Te asymptomatic carrier and patient 4it mild cronic ame/iasis can

deelop ac,te symptoms at any time. especially if /ody resistance /ecomes

lo4ered /y anoter illness3 Te symptoms of ame/ic dysentery ,s,allydeelop 2 to 4ee%s follo4ing expos,re to te parasite 8April 1Q. 200093

++ ay 2. 200093 Te more important symptoms of ame/ic dysentery

incl,de malaise. generaliFed 4ea%ness. a/dominal pain or cramping.

diarrea. fatig,e. feer 8lo4-grade9 omiting. /loody stool. and ,nintentional

4eigt loss3

An asymptomatic carrier is one 4o ar/ors disease organisms in teir

/ody 4ito,t manifest symptoms. ence :a person co,ld /e a carrier andnot een %no4 it:3 +etected arc 1Qt of 2000. 4it an approximate time-

line /et4een arc 1Qt 6 to onset of fl,-li%e symptoms /eginning on or

a/o,t ay 10t of 2000 s,ggests an iatrogenic etiology3 Te term iatrogenic

means Hdoctor ca,sedC3 )areless patient management and poor treatment

lead to iatrogenic complications3

Iatrogenic infection is infl,enced /y factors li%e Hpoor sanitation and

ygieneC. e3g3. external inoc,lation 4it Hcontaminated ands. s,rgicalgloes. instr,mentsC. s,c as insertion of a Hcontaminated /roncoscope

into te l,ng tro,g te mo,tC. etc3. res,lting from medical treatment or

proced,res. and /eca,se * record of it is created in te first place. te

,nscr,p,lo,s pysician passes te /,c% togeter 4it all te possi/le /lame

for 4ateer appens. and te patient doesnJt get diagnosed or treated in a

timely manner. or at all3 Tis 4o,ld not /e ,n,s,al for a doctor 4it a

istory of Hmedical omicideC. as in tis case3

In April 1??. de la oca 4as carged 4it Hsecond degree m,rderC. e

receied a s,spended sentence. tree years pro/ation and a six mont

s,spension of is medical licence for is role in te cto/er 1??1 deat of a

Q@-year-old l,ng cancer patient3 (e admitted Hdosing er 4it a noxio,s

s,/stanceC 6 potassi,m cloride 6 as 4ell as morpine3 illing te patient


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is easier tan proiding good ospital careS

+r3 de la Roca ad a propensity for selectie treatment 84as %no4n to

discriminate against smo%ers9. incl,ding a criminal past istory of

e,tanasia3 Ironically. de la oca as since moed from Timmins to

ar%am. ntario 4ere e is no4 practicing HcolonoscopyC3

Amoe/iasis is te second leading ca,se of deat from parasitic disease

4orld4ide3 In *ort America. amoe/iasis is most often fo,nd in immigrants

and in people 4o ae traeled to or 4o ae come into contact 4it

people from deeloping co,ntries. or 4o lie or 4or% in instit,tions or

ospitals tat ae poor sanitary conditions3 *ota/ly. a ig incidence of

amoe/ic cyst-passers among food andlers in ospitals is also reported in

te medical literat,re3

In )anada. amoe/ic infection is mostly enco,ntered in small patces of

pop,lation tat ae migrated from endemic areas3 Ironically. amoe/iasis

4as remoed from national s,reillance as of an,ary 2000. a/o,t te same

time Arlene !erry ad er left l,ng remoed3 *ota/ly. in ntario. tere ae

/een /et4een 2 and 11 cases of Hame/iasisC in "imcoe ,s%o%a area alone

eery year since 20003

Entamoe/a istolytica is te patogen 8protoFoan parasite9 responsi/le for

'amoe/iasis'3 E3 istolytica can also /e present on te ands of an infected

person3 Amoe/ae spread /y forming infectie cysts3 Entamoe/a istolytica

often /,rro4s deep into te 4alls of te intestines. ca,sing infections and

a/scesses3


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and gl,cos,ria 8te excretion of gl,cose into te ,rine. most commonly d,e

to ,ntreated dia/etes mellit,s393

l,cos,ria leads to excessie 4ater loss into te ,rine 4it res,ltant

deydration. a process called osmotic di,resis3 !lood c,lt,res and

periperal /lood ram stains 4ill /e negatie for /acteria and otermicroorganisms3

*onspecific la/oratory findings in periperal /lood may incl,de te follo4ing M

o B!) co,nt is eleated 4it a ne,tropilic predominance3

o )omplete meta/olic panel 8)P9 may so4 a/normalities. incl,ding yponatremia

associated 4it ac7,ired dia/etes insipid,s. and yperglycemia3

!rain a/scess is fre7,ently a complication of meningitis3 Infection of te

central nero,s system is to,gt to /e ematogeno,s. from sites of

primary infection in te l,ngs or te s%in3 Te infection may mimic space-

occ,pying lesions in )*". and te infected patient may present 4it

emiparesis. apasia or seiF,res3 apid deterioration occ,rs soon after

onset3

Presenting symptoms of AE are nonspecific and can last for monts /efore/ecoming clinically significant3 nce te infection inoles te )*" 8central

nero,s system9. deat often res,lts 4itin days to 4ee%s3 Te co,rse of

te disease is insidio,s and fatal in most cases. mainly d,e to delayed

diagnosis. AE is an 'opport,nistic' infection. ,s,ally seen in de/ilitated.

malno,rised indiid,als3

Te term Hgran,lomato,sC indicates emorragic necrotiFing lesions or

/rain a/scess 8detected /y ne,roimaging scans9 4it seere meningeal

irritation3 Tese amoe/as ca,se a s,/ac,te or cronic gran,lomato,s

encepalitis3 !rain a/scesses expand oer time. placing te s,rro,nding

/rain at ris%3 If left ,ntreated. te increasing siFe of te a/scess8s9 4ill

ca,se deat3 ,pt,re of an amoe/ic /rain a/scess can lead to soc% and

deat3

Acantamoe/a and !alam,tia ae t4o stages. cysts and tropoFoites.


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in teir life cycle3 *o flagellated stage exists as part of te life cycle3 Te

tropoFoites replicate /y mitosis 8n,clear mem/rane does not remain intact9

Te tropoFoites are te infectie forms and are /elieed to gain entry into

te /ody tro,g te lo4er respiratory tract. ,lcerated or /ro%en s%in and

inade te )*" 8central nero,s system9 /y ematogeno,s dissemination 3

Acantamoe/a spp3 and !alam,tia mandrillaris cysts and tropoFoites are

fo,nd in tiss,e3

Acantamoe/a sets in 4it insidio,s. focal ne,rologic canges tat

mimic te clinical pict,re of single or m,ltiple space-occ,pying /rain

lesions3


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As mentioned. expos,re occ,rs tro,g te respiratory tract or s%in lesion

4it ematogeno,s spread tro,g te central nero,s system 8)*"93


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inflammatory process medically %no4n as ame/oma3 Tis inflammatory

formation also %no4n as an ame/ic gran,loma ca,ses large local lesion of

te colon and may easily trigger /o4el o/str,ction3 Ame/omas or ame/ic

gran,lomas are an ,n,s,al se7,elae of ac,te ame/iasis3

Ame/ic gran,loma 8ame/oma9. commonly mista%en for cancer. can /e acomplication of te cronic infection 8UQ 4ee%s93 P,lmonary amoe/iasis

4ito,t lier inolement occ,rs sporadically as a res,lt of aematogeno,s

spread from a primary site. te colon3 )ysts can /e seen as single or

m,ltiple 4ell-defined omogeno,s lesions s,rro,nded /y oter4ise normal

l,ng parencyma on a plain cest x-ray3

ran,lomas are t,mo,r-li%e masses tat encase destroyed large or parasitic

eggs3 Tey deelop most often in te colon or rectal 4alls /,t can also /efo,nd in te l,ngs. lier. peritone,m. and ,ter,s3

Te symptoms of amoe/iasis are similar to /acterial dysentery as 4ell as

ario,s forms of food poisoning. alto,g tis illness is not ca,sed /y a

/acteria /,t rater a parasite3 Te parasite is also a ca,se of /loody

diarrea3 Additional symptoms and signs of ame/ic dysentery incl,de

a/dominal pain. 4eigt loss. fatig,e. and deydration 84ic can /e

partic,larly armf,l93 Parasitic infections may also manifest as systemic disease3 Te clinical spectr,m of amoe/iasis is /road ranging from

asymptomatic passage of cysts tro,g f,lminant colitis to localiFed

a/scesses of te lier. l,ng. /rain. and oter tiss,es. 4ere tey form

poc%ets of infection 8a/scesses93

)omplications

)omplications ,s,ally deelop after te tropoFoites enter te /lood stream to infect

oter organs3

13 Ame/oma gro4t into intestinal l,men

1. Ris% of !o4el /str,ction

2. Ris% of Int,ss,sception

2. Toxic egacolon

3 Pne,matosis coli

3 A/scess formation

http://www.fpnotebook.com/Surgery/GI/IntstnlObstrctn.htmhttp://www.fpnotebook.com/Surgery/Peds/Intsscptn.htmhttp://www.fpnotebook.com/GI/Bowel/Mgcln.htmhttp://www.fpnotebook.com/Surgery/Peds/Intsscptn.htmhttp://www.fpnotebook.com/GI/Bowel/Mgcln.htmhttp://www.fpnotebook.com/Surgery/GI/IntstnlObstrctn.htm


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1. ;,ng A/scess

23 !rain a/scess

3. ;ier A/scess

13 "ee signs a/oe

23 Ris% of r,pt,re

3 Ris% factors for complication13 ,ltiple cysts or cysts U10 cm in siFe

23 ",perior rigt lier lo/e inolement

3 ;eft lier lo/e inolement

3 )o,rse

13 "pontaneo,s resol,tion /y Q monts in QQD

23 Persist U1 year in 10D

Amoe/ic inolement of /rain is a rare complication of amoe/iasis3 It is life

treatening /,t 4it te adent of ne4er anti/iotics it can /e treated or managed /y s,rgical decompression and amoe/icidal dr,gs if diagnosed

early3 Te symptoms of amoe/ic /rain a/scess resem/le tose of /rain

t,mo,r3 Amoe/ic cere/ral a/scesses may /e m,ltiple. and aried in siFe3

)linical symptoms of cere/ral amoe/iasis are ,s,ally preceded /y

gastrointestinal or epatic or respiratory symptoms3 *ota/ly. m,ltiple /rain

a/scesses may not ca,se focal deficit to s,ggest teir presence3

*ota/ly. +r3 )la,dio +e ;a oca immigrated to )anada from exico. 4eree grad,ated from te *ational A,tonomo,s $niersity of exico3 *ota/ly.

exico is a ot/ed for amoe/iasis and is a so,rce of infectio,s cysts3 Te

term amoe/iasis 84en ,n7,alified9 generally refers to E3 istolytica

infection. 4ic is common in exico3 In exico a/o,t 50D of te

pop,lation is considered to ae ar/ored te disease at one time or oter3

,ltiple a/scesses are fre7,ent in exico 4ere parasitic intestinal

infections are m,ltiple infections tat constit,te approximately 0D of

analyFed indiid,als in 4ic it is possi/le to detect more tan one

patogen togeter 4it commensal parasites tat are an indicator of

fecalism3


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,s,ally generally 4ell 4it mild or moderate a/dominal pain3 "ymptoms

often fl,ct,ate oer 4ee%s or een monts 4it te patient /ecoming

de/ilitated3


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te cyst /ecomes infected. it co,ld lead to a/scess3 Tis 4as *T cancer

and +r3 +e ;a oca not only identified finding a :cyst: 4it 4ic e

imself 4as familiar. transmitted to tis patient /y imself 8directly or

indirectly9 e %no4ingly so,gt to pass it off to is patient as terminal

cancer 4en it 4as *T. %no4ing tat te cyst. once ,nleased. 4as going

to /e te deat of er and so staged er as HT *I 4it resid,al disease on

te aortaC3


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d,e to na,sea3 "e lost er appetite and deeloped a serio,s aersion to

food3 Ten /egan te a/dominal pain 8,pper and lo4er9 alternating 4it

/o,ts of diarrea and constipation progressing to /loody stools. incl,ding at

least one a/normally large ard painf,l /o4el moement tat 4as

accompanied /y eadace. omiting. nigt s4eats. and general feelings of

malaise3

er te last 4ee% of er life. Arlene !erry noticed increasing 4ea%ness of

er legs3 "e tended to /ecome easily irritated and some4at conf,sed3

"e deeloped m,scle 4ea%ness. diffic,lty in 4al%ing. facial 4ea%ness

mar%ed /y a croo%ed smile. sl,rred speec. and dro4siness progressing to

extreme fatig,e3 (er eadaces /ecame more fre7,ent and more seere3


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4ic prod,ces lier a/scesses. and occasionally a/scesses of te l,ng and

/rain3 P,s from an ame/ic a/scess /asically is classically tic% and

cocolate-/ro4n or redis-/ro4n in color 4ic apparently res,lts from

/lood. 4ic is more li%ely to enter te a/scess caity after te initial

aspiration3 Te p,s ,s,ally is tic% and gl,tino,s. /,t it can /e tin3 Te

feat,res most s,ggestie of an ame/ic a/scess are /acteriologically sterile.

tic%. relatiely odorless p,s regardless of its color3

An amoe/ic a/scess of te lier 4ill contain necrotic lier tiss,e at its centre3

$pon aspiration tis often as a dar% /ro4nis red colo,r called :ancoy:

or :cocolate: p,s . /,t te p,s may also /e yello4. grey or greenis3 Te

p,s as no offensie odo,r. ,nli%e most /acterial 8anaero/ic9 a/scesses.

4ic is an important difference3 Te 4all of te a/scess contains

tropoFoites. /,t te necrotic lier tiss,e itself does not3

A /ro4n mil%sa%e-li%e 8or ancoy paste-li%e9 material is often aspirated

from lier a/scesses3 Te appearance of a p,r,lent fl,id of a cocolate-li%e

appearance follo4ing te p,nct,re of an a/scess. discarge. or tro,g

omiting. are igly s,ggestie signs3 Te diagnosis of a epatic a/scess

may /e s,spected from clinical findings3 ;e,%ocytosis 4ill /e ig3 Tose

4it intestinal amoe/iasis may li%ely deelop a condition %no4n as inasie

amoe/iasis3 It can deelop d,ring te ac,te attac% or 1 monts later.4ic in tis case 4o,ld coincide 4it te left l,ng pne,monectomy3


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"epsis is an illness in 4ic te /ody as a seere response to infection3

Tis response may /e called systemic inflammatory response3 )ere/ral

iscemia is a reality in sepsis3

Amoe/iasis is /ot infectio,s and transmissi/le /y direct or indirect contact

and sooner or later follo4s te progress of a potentially letal opport,nisticinfection re7,iring emergent management tat. ,nless diagnosed and

treated in a timely manner. can rapidly H%ill 4itin o,rs or daysC once

symptoms appear3

*ota/ly. all of te signs and symptoms contained erein

are common findings in amoe/ic infection and eac and

eery one of tem are present 6 scattered a/o,t on te

face of tis patient's medical record3

Te o,tpatient record seen at P-5 doc,ments a day istory of /loody

/o4el moements 8/loody stool9 4en oiding. eidenced /y :/loody !Js x

days:. can s,ggest a parasitic etiology3 Te same record doc,ments tat

se 4as :pale-loo%ing and letargic:3 I /leeding is te most serio,s so,rce

of /loody stools3 Tere is noting on record to s,ggest tat a stool c,lt,re

test 4as eer done3

Te record at P-5 dated ay 22nd of 2000 doc,ments a recent istory of

,rinary-tract infection. eidenced /y :(ere 1 4ee% ago for $TI3 ;ast period

on Qt of ay:. follo4ed /y a recent istory of :emat,ria: 8/lood in ,rine9

for :tree days:. seen at P-53 Te ealtcare proider 4o sa4 er made

te diagnosis of $TI3 Te same record doc,ments a prescription for )ipro.

for treatment of ,rinary-tract infection3 A /elated test res,lt eidenced at

P-55 later ret,rned a finding of :* ro4t:G te same record doc,ments

:"EPT A +" I=E* !E


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,rinary tract infection 8$TI93 =ir,ses. f,ngi. and parasites can all ca,se $TIs3

$TIs occ,rs 4en /acteria or oter infectio,s organisms inade any part of

te ,rinary tract3 Infections of te lo4er tract are of te ,retra 8,retritis9 or

te /ladder 8cystitis93 Infections of te ,pper tract are of te %idney

8pyelonepritis9 or te ,reters 8,reteritis93


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4omen and te conditions can ary from cystitis 8an inflammation of te

,rinary /ladder9 to seere infections of te %idneys or /ladder3 Tere can /e

many complications of ,rinary tract infections. incl,ding deydration. sepsis.

%idney fail,re. and deat3 *ota/ly. te onset of menstr,al period eidenced

at P-5 is also 4itin te same time frame of illness3 $rinary tract

infections d,e to "tapylococc,s a,re,s typically occ,r secondary to

/lood-/orne infections3

Te record at P-5 doc,ments :


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sedatie dr,g3 "edation can ca,se /ot ypertension and ypotension3 05

o,rs on ay 2rd and is eidenced at A-1 and A-5 of te record3


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a 4ea%ness of ol,ntary moement. or partial loss of ol,ntary moement

or /y impaired moement3

Ben ,sed 4ito,t 7,alifiers. paresis ,s,ally refers to te lim/s. /,t it can

also /e ,sed to descri/e te m,scles of te eyes 8optalmoparesis9. te

stomac 8gastroparesis9. and also te ocal cords 8=ocal cord paresis93Ac7,ired diff,se paresis in an intensie care ,nit 8I)$9 can res,lt from critical

illness myopaty or polyne,ropaty3

A common ca,se of diff,se 4ea%ness is critical illness polyne,ropaty. an

axonal disorder tat occ,rs 4it sepsis3

(ypotonia is often te presenting sign for many systemic diseases and

diseases of te nero,s system3 Te a/dominal m,scles feel ''soft anddo,gy''. also a sign of gastropareses in clinical dia/etes. 4ic also can

rapidly progress to intestinal o/str,ction3

"tomac paralysis. formally called gastroparesis. is a medical condition in

4ic te m,scle of te stomac is paralyFed /y a disease or condition of

eiter te stomac m,scle itself or te neres controlling te m,scle3 As a

conse7,ence. food and secretions do not empty normally from te stomac.

and tere is na,sea and omiting3 Te most common ca,se of gastro-

paresis is dia/etes mellit,s3


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m,scles3 ter diseases s,c as encepalitis. sepsis. 4o,nd /ot,lism.

a,toimm,nity disorders. meta/olic disorders. central nero,s system

dysf,nction. incl,ding infections. ,illian-!arre syndrome and cere/ellar

lesions can also ca,se ypotonia3

(ypotonia in ,illain-!arre syndrome for example. is common and can /eo/sered 4it significant 4ea%ness3 It is caracteriFed /y Hdiminised

resistance of te a/dominal m,scles. 4it diminised tone of te s%eletal

m,sclesC3 Tis syndrome is actiated /y an infection. and res,lts in te

progressie 4ea%ness of te lim/s. and eent,al partial or complete

paralysis /y reason tat te /rain and neres are no longer controlling te

m,scles3 +elayed diagnosis inites catastropic conse7,ences3

(ypotonia as seeral 4ell-defined symptoms. te most prominent amongtem /eing Hred,ced m,scle definitionC3 ,scle tone and moement inole

te /rain. spinal cord. neres. and m,scles 3 (ypotonia may /e a sign of a

pro/lem any4ere along te pat4ay tat controls m,scle moement 3

+iseases s,c as encepalitis. sepsis. meningitis. poisons or toxins and

/ot,lism can also ca,se ypotonia3

eningitis can prod,ce mild symptoms 6 s,c as eadace. lo4-grade

feer and tiredness lasting t4o to tree days 6 in some patients3 In oterpatients. te symptoms can /e seere and /egin s,ddenly 4it feer.

eadace and stiff nec% accompanied /y some com/ination of oter

symptomsM decreased appetite. na,sea. omiting. sensitiity to /rigt ligt.

conf,sion and sleepiness3 Te classic meningitis triad of feer. eadace.

and n,cal rigidity deelops oer o,rs or days3 (o4eer. tere are

different types of meningitis and tey don't al4ays present te same 4ayG

alto,g feer is almost al4ays present. tere ae /een instances of

meningitis 4ito,t feer3 No, can start off 4it a ig feer and /y te timeyo, get meningitis yo,r temperat,re may /e Hlo4 gradeC3 In many cases.

symptoms ae a /ipasic patternG te nonspecific fl,-li%e symptoms and

lo4-grade feer may sometimes precede ne,rologic symptoms3

any cases of infectio,s meningitis /egin 4it a ag,e prodrome3 A

common pattern is lo4-grade feer in te prodromal stage. and may also /e


38/123

seen in early onset forms of meningtis3 People often conf,se te early signs

and symptoms of meningitis 4it te fl,3 eningitis may come on te eels

of a fl,-li%e illness or infection3 Infectio,s ca,ses of meningitis and

encepalitis incl,de /acteria. ir,ses. f,ngi. and parasites3

At te time of er admission to te ir%land and +istrict (ospital. Arlene!erryJs /lood press,re 4as doc,mented at :115>0 /pm. 4it a p,lse of >?

and reg,lar:. as eidenced at A-Q3 *ormal /lood press,re is defined as a

systolic 8top9 press,re of less tan 120 mm(g. and a diastolic 8/ottom9

press,re of less tan @0 mm(g3

n examination. te pysician 4o sa4 er doc,mented positie :/o4el

so,nds:. eidenced at A-Q3 (yperactie /o4el so,nds proide te most

immediate indication of persistent ,pper I /leeding or I emorrage3 Anaccompanying crampy a/dominal pain can also s,ggest ac,te /leeding 3


39/123

contact 8fits te time-line /et4een mid an,ary and mid ay. 200093

P,lmonary amoe/iasis 4ito,t lier inolement occ,rs sporadically as a

res,lt of aematogeno,s spread from a primary site. s,c as te a/domen.

or colon3 It can occ,r from epatic lesion /y aemotageno,s spread andalso /y perforation of ple,ral caity and l,ng3 It can ca,se l,ng a/scess.

p,lmono-ple,ral fist,la. empyema l,ng and /ronco-ple,ral fist,la3 It can

also reac /rain tro,g /lood essel and ca,se amoe/ic /rain a/scess and

amoe/ic meningoencepalitis3 P,lmonary amoe/iasis as also /een

Hmista%en for /roncial carcinomaC3

According to te medical record at *-Q Arlene !erry 4as admitted to te

ir%land and +istrict (ospital at 1@M5 o,rs and ad spent >5 min,tes in

te E 3 In all tat time. te E+ pysician 8+r3 "piller9 ad o/io,sly done

ery little 8if anyting at all9. as eidenced /y te record seen at A-3 At te

time of tis assessment 81@M5 ($R"9. Arlene !erry 4as fo,nd to /e :alert

and oriented:. 4it :*


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te symptoms of !" /egin3

In te iller


41/123

f,rter assessment3 )learly te etiology of te na,sea and omiting ad

neer /een esta/lised. apart from +r3 "piller's :a 7,estion as arisen 4it

respect to metastatic )A of te /rainC. as eidenced at A-Q3

A diagnosis inoles detailed assessment and eal,ation of a toro,g.

detailed and complete medical istory of te person3 No,r patient medicalistory incl,des foods yo, ae eaten in te past fe4 days3 It also incl,des

any recent c,ts or oter 4o,nds. incl,ding s,rgical 4o,nds. medical

proced,res. etc3. tat may ae /een exposed to iral. /acterial. or parasitic

patogens3 +,ring te pysical exam. te ealtcare proider 4ill loo% for

signs of m,scle 4ea%ness or paralysis. s,c as drooping eyelids3 !lood and

fecal tests so,ld also /e ,sed3 )learly. 4it te exception of a noted

Hdiff,se 4ea%nessC and a noted Hleft l,ng pne,monectomyC. tere 4as no

detailed assessement3

*ot diagnosing a condition is one of te most common forms of medical

negligence3 Anoter is 4en tey :dismiss: te presenting symptoms as

temporary. minor. or oter4ise not 4orty of treatment3 Premat,re clos,re is

te fail,re to consider oter pla,si/le or differential diagnoses after an initial

4or%ing diagnosis is reaced3 It is one of te most common clinical

reasoning errors constit,ting negligence made /y clinicians3 Tis sit,ation

may res,lt in an exacer/ation of te ,nderlying condition or inj,ry. ca,singf,rter arm. or een deat3

* diagnosis or differential diagnosis 4as made follo4ing te patientJs

admission at tat time. or at all. according to te record3 )ertainly. *

protocols 4ere follo4ed as eidenced /y te record3 )learly. from te record

as a 4ole. tis patient 4as deli/erately made to deteriorate 4o so m,c

as a diagnosis of er stomac pain3


42/123

and ,se for erself te %idney /asin at er /edside ta/le. as se occasioned

to omit more of te same fl,-li%e :yello4is li7,id: tat se ad done so

many times on te days /efore. and in fact ,sed it for erself in te presence

of er family. at 4ic time a cool clot 4as proided /y te n,rses. as

eidenced at *-Q3 It seems clear tat generally a cool clot is proided

4en a mild or lo4 grade feer is present3 Te patient's ery last 4ords 4ere

tat se 4as Hery tiredC. /,t feeling a little /etter. as eidenced /y :"tates

ery tired: and :"tates feels a little /etter:. also seen at *-Q3 Te same

record doc,ments :*ot comm,nicatie. a/le to follo4 simple commands3

oements ery slo4:3

Te same record seen at *-Q also doc,ments :emesis of V 100cc yello4is

fl,id: at 1?15 o,rs on ay 2rd of 2000. 4at I ta%e to /e H/ilio,s emesisC

or fran% /ile3 Ben ed !lood )ells 8R!)s9 /rea% do4n in te /ody teyprod,ce yello4 pigment 4ic is ten passed to te lier and excreted into

/ile3 !illio,sness is a symptom of a disordered condition of te lier ca,sing

constipation. eadace. loss of appetite. and omiting of /ile3

Te 4ord :/ilio,s: comes from te 4ord colera3 Te 4ord colera is ;atin

for /ilio,s disease and as come to indicate a seere intestinal infection3

Te clinical difference /et4een /ilio,s and non-/ilio,s omiting 8ie. omiting

yello4 or green9 is critical in disting,ising life treatening a/normalities3Ben a person is omiting /ile. it is pointing to4ards te fact tat te

intestine is /loc%ed. meaning intestinal o/str,ction or gastroenteritis3

astroenteritis. or :stomac fl,: is not act,ally ca,sed /y an infl,enFa ir,s.

/,t /y oter ir,ses. as 4ell as many /acteria and parasites3 !acteria. f,ngi

and ario,s protoFoa may also /e responsi/le3 Parasites can ca,se

pro/lems tat often mimic oter disorders and are not correctly diagnosed

as /eing parasite related3

Tro4ing ,p yello4 /ile can /e ca,sed /y a n,m/er of different

circ,mstances. incl,ding a malf,nctioning pyloric ale. a respiratory

infection or excessie deydration3 Ac,te symptoms incl,de /ilio,s

omiting. diff,se a/dominal pain. and /loody stools3 Alto,g stomac fl,

is /y far te most common ca,se. intestinal o/str,ction is also te most


43/123

serio,s and is considered a s,rgical emergency and treating te patient at

te earliest is a m,st to aert any complications3

Intestinal o/str,ction is typically mar%ed /y seere a/dominal pain3 $nli%e

oter inflammatory /o4el diseases 4ere te pain is tolera/le. in tis case

te discomfort is tort,ring alto,g it may s,/side intermittently3 Ben teintestine is /loc%ed. a/dominal pain is typically accompanied /y fre7,ent

/o,ts of /ilio,s omiting3 ost importantly. te person feels constipated

and tere is a/sence of /o4el moement3 Ben te /o4el stops 4or%ing.

te /ody gets toxic3

Intestinal o/str,ction. especially of te proximal small /o4el. prod,ces

mar%ed na,sea and omiting of /ilio,s material3 +istention may /e lac%ing.

/,t intermittent cramping a/dominal pain is caracteristic3 People 4it/o4el o/str,ction may repeatedly omit yello4. or green colored /ile and a

istory of fre7,ent /ilio,s omiting in te presence of a/dominal pain so,ld

ae /een a :red flag: s,ggesting intestinal o/str,ction. 4ic so,ld ae

/een treated emergently. /,t 4as neer een considered. or ignored

altogeter3

*a,sea and omiting are common feat,res of many I infections3 A

eadace tat is present 4it an intestinal infection may also indicate signsof deydration. 4ic so,ld ae raised a red flag s,ggesting te possi/ility

of intestinal o/str,ction3 Instead. tis patient 4as p,t on a regimen of

opioids and proclorperaFine tat 4ere g,aranteed to exascer/ate er

condition3

According to +r3 "piller. tere 4ere :no focal deficits:3 A focal deficit is a

specific area in 4ic normal f,nction isn't present3 A-2 doc,ments a

:sl,rred speec: as eidenced /y a ☑ in te ,pper left corner of tat

doc,ment. 4ile A-Q doc,ments Hdiffic,lty am/,lating:3 A Hsl,rred speecC

8apasia9 can s,ggest a ne,rological deficit.G 4ile Hdiffic,lty am/,lating:

s,ggests a motor deficit3 Tese are examples of focal deficits3 A reasona/le

E+ pysician o,gt to %no4 4at constit,tes a focal deficit. especially 4en

doc,mented on te face of a patient's medical record3


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*-Q of te record doc,ments tat te patient ad stated se 4as :ery

tired:. 4ere,pon se 4as assisted to /ed3 "e also complained of /eing

:cold: 8se ad te cills9 and so te n,rses proided er 4it extra

/lan%ets3 also eidenced at *-Q3 Periods of feeling cold often occ,r d,ring

illnesses. /,t in fact te cills can often /e a sign of infection tat as

spread tro,go,t te /ody3

Te symptoms of a /rain a/scess incl,de sl,rred speec3 In te majority of

cases signs and symptoms contin,e for no more tan t4o 4ee%s /efore te

patient is ospitaliFed. as in tis case3 "ymptoms of cere/ral a/scess res,lt

from increased intracranial press,re and mass effect3 (eadace. na,sea.

omiting. letargy. personality canges. papilledema. and focal ne,rologic

deficits deelop oer days to 4ee%s3


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Te record at *-Q doc,ments :telepone orders: receied /y te ospital

from +r3 ordan at 200 o,rs for :"temetil 10mg: /y I=. x daily ''for

control of na,sea''. gien /y te *. as f,rter eidenced /y te pysicianJs

orders seen at A-11 of te record3 )learly. +r3 ordan ad elected to treat

tis patient oer te telepone. :,nseen:. 4ile sitting at ome 4atcing T=3

"temetil is a /rand name for :proclorperaFine: 3 ProclorperaFine /elongs

to te gro,p of medications %no4n as antipsycotics. and specifically to te

family of antipsycotics called penotiaFines3 ost dr,gs in tis category

are ,sed as anti-psycotics. commonly referred to as Hne,rolepticsC3

*e,roleptic means :nere seiFing:. and descri/es te paralyFing effect tese

dr,gs ae on te /rain and nero,s system3 Increased sedation is a serio,s

side effect of tis type of agent3

ProclorperaFine 8"temetil9 as ne,rom,sc,lar /loc%ing effects33 !y /loc%ing

ne,rom,sc,lar transmission. tese agents ca,se paralysis ,ntil tey are

meta/oliFed3 *e,rom,sc,lar /loc%ade 8paralyFes all of a /odyJs ol,ntary

m,scles. incl,ding te l,ngs and diapragm9 4ic may mas% distress and

res,lt in a Hgasping syndromeC3

"temetil so,ld *T /e ,sed 4ere na,sea and omiting are /elieed to /e

eidence of intestinal o/str,ction or /rain t,mor3 Te dr,g is igly plasma

protein /o,nd 8?1-??D9 and as a d,ration of actiity from to Q o,rs3

$nder normal circ,mstances. a typical single dose of "temetil for a small

4oman 4it lo4 /ody 4eigt is 5 mg3 Arlene !erry 4as gien 10mg. x te

recommeded dosage. togeter 4it oter medications33 *ota/ly. "temetil 10

mg 4as added to te I= at 200 o,rs3 Te dr,g is sedating and a potent

asodilator. 4ic also crosses te /lood-/rain /arrier3 Patients are ,s,ally

:ol,me expanded: prior to its ,se. res,lting in ne,rologic derangement3"temetil can also lead to canges in te /lood-/rain /arrier 8!!!9. allo4ing

an infectio,s agent to gain entry to te /rain and prod,ce letal )*"

8central nero,s system W /rain and spinal cord9 infection3

Te )*" incl,des te spinal cord and /rain 4ile te periperal nero,s

system 8P*"9 incl,des tose neres tat extend into te /ody and are not


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protected /y /one3

"temetil is 4idely distri/,ted into /ody tiss,es and fl,ids 3 It ,ndergoes

meta/olism in te gastric m,cosa and on first pass tro,g te lier 4ere

it enters te enteroepatic circ,lation and is excreted ciefly in te feces ia

te /iliary tract3


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type of dr,g3 Te contraindications are p,t in place /y te parma ind,stry

for a reason3 In tis case. all of tem 4ere ignored3

In terms of te " )ontin. te /iggest ris% of any opioid medication ,se is

respiratory depression tat can lead to seere ypoentilation. apnea and

deat3 ost opiate oerdose deats occ,r in people 4o ae j,st4itdra4n or detoxed3 !eca,se opiate 4itdra4al red,ces yo,r tolerance to

te dr,g. tose 4o ae j,st gone tro,g 4itdra4al can HoerdoseC on a

m,c smaller dose tan tey ,sed to ta%e3 In tis case * close monitoring

or toxicological screening 4as done3

Ac,te 4itdra4al symptoms can /e seere if morpine is stopped s,ddenly

after reg,lar ,se3 Be already %no4 tat te patient 4as gien 0 mg po /id

" )ontin /y *,rse c)ran% at 2000 o,rs. only one alf o,r prior toadministration of "temetil3

orpine can slo4 or stop yo,r /reating. especially 4en yo, start ,sing

tis medicine or 4eneer yo,r dose is canged3


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ca,sing seere ypotension3

Ac,te oerdosage 4it morpine is manifested /y respiratory depression.

somnolence progressing to st,por or coma. s%eletal m,scle flaccidity. cold

and clammy s%in 8cold dry s%in if patient is deydrated9. constricted orpinpoint p,pils. and. in some cases. p,lmonary edema. /radycardia.

ypotension. and deat3

"ymptoms of1" )ontin

oerdose may incl,deM )old s%in. flaccid m,scles.

fl,id in te l,ngs. lo4ered /lood press,re. pinpoint or :dilated: p,pils.

sleepiness leading to st,por and coma. slo4ed /reating. slo4 p,lse rate3

(ypoxic /rain inj,ry. 4ic is ca,sed /y a lac% of oxygen to te /rain. is an

,nder-reported medical conse7,ence of morpine oerdose3 Tese /raininj,ries can ca,se coma. seiF,res and. in 4orst case scenarios. /rain deat3

Te long-term conse7,ences of ypoxia depend on o4 long te /rain is

4ito,t ade7,ate oxygen s,pply3 !asically. te longer a patient is not

/reating. te more potential damage is /eing done to te /rain 3 In many

ospital oerdose cases s,c information is deli/erately omitted from te

record3 (ealt o,tcomes depend on te s,ccess of damage control

meas,res. te area and extent of /rain tiss,e depried of oxygen and te

speed 4it 4ic oxygen 4as restored to te /rain3

2 to ?Q o,rs /,t can last for 1 days or more3 piate4itdra4al can also res,lt in deat for ,nealty patients3

According to te record at A-1. Arlene !erry 4as gien 0 mg po /id "

)ontin /y *,rse c)ran% at 2000 o,rs on ay 2rd of 2000 8te eening

/efore er deat9. in te face of ,ndiagnosed and ,ndifferentiated


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conditions associated 4it :seere a/dominal pain:. incl,ding HeadaceC3

" )ontin is a /rand name for orpine ",lfate3 :)ontin: is a parma-

ce,tical ind,stry /,FF4ord for :contin,o,s: release3 " )ontin is a medicine

,sed to treat moderate to seere. aro,nd-te-cloc% pain3 " )ontin as

4idespread effects in te central nero,s system on smoot m,scle andprod,ces respiratory depression /y direct action on /rainstem respiratory

centers3 Te administration of morpine can only sere to :o/sc,re: te

diagnosis or clinical co,rse in patients 4it ac,te a/dominal conditions3 "

)ontin oerdosage may res,lt in apnea. circ,latory collapse. cardiac arrest

and /reating pro/lems tat can lead to deat3

pioids correctly titrated to proide symptom relief 4ill not ca,se respiratory

depression3 In fact. morpine-related toxicity 4ill /e eident in se7,entialdeelopment of somnolence. mentall d,llness or /l,nting3 Te amo,nt of

morpine tat can ca,se an oerdose or deat depends on 4at a personJs

/ody is ,sed toG in tis case it 4as 10mg "tatex prior to stopping te dr,g3

espiratory system

• +iffic,lty /reating

• "lo4 and la/ored /reating

• "allo4 /reating

•*o /reating

A morpine oerdose can /e treated 4it a medication called naloxone

8*arcanX93 *aloxone. a medicine 8antidote9 to reerse te effects of te

poison -- m,ltiple doses may /e needed3 ItJs ,s,ally gien intraeno,sly. as

tis is te 7,ic%est 4ay to get te medication into te /loodstream3

*aloxone acts almost immediately to co,nteract te morpine3 In some

cases. actiated carcoal is also gien3 In tis case. since no protocols 4ere

follo4ed. no s,c interentions 4ere implemnted3

+r,g interactions and 4arnings incl,deM aoiding concomitant ,se of oter

)*" 8central nero,s system9 depressants incl,ding sedaties or ypnotics.

general anestetics. penotiaFines. tran7,iliFers. and alcool as tese

may prod,ce additie depressant effects3 Te a/dominal cramps and pain

tat are seen as morpine side effects can /e especially dist,r/ing 4en


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morpine is ,sed to treat a/dominal pain3

$s,ally opioid ind,ced constipation needs to /e treated 4it a com/ination

of a gentle stim,lant laxatie li%e senna and a stool softener li%e doc,sate3

Te additie effects of orpine ",lfate in com/ination 4it stool softeners

can only sere to exascer/ate motility3 In tis case. Arlene !erry 4as gien0 mg orpine ",lfate after a one and one alf 4ee% 4itdra4al from a

10 mg regimen of prescri/ed "tatex3

According to family. te reason tat Arlene ad :stopped: ta%ing te

morpine 4as d,e to increasing seerity of :constipation re7,iring extra

laxatie and tap-4ater enemasC to assist 4it stool eac,ation. and also

d,e to HdiFFinessC. mar%ed /y a sense of ,neasiness progressing to

,nsteadiness3 Res,lting decreases in I motility from antidiarreal medications may also contri/,te to constipation and /o4el o/str,ction3

"eere morpine side effects can incl,de /o4el pro/lems incl,ding toxic

megacolon and paralytic ile,s3 Toxic megacolon is a a potentially letal life-

treatening complication of ,lceratie colitis3 It ca,ses 4idening 8dilation9 of

te large intestine 4itin 1 to a fe4 days3 orpine is contraindicated3

Te allmar%s of toxic megacolon 8toxic colitis9 is non-o/str,ctie colonic

dilatation larger tan Qcm and signs of systemic toxicity3

Te diagnostic criteria are as follo4sM

• Radiograpic eidence of colonic dilatation - Te classic finding is more tan Qcm

in te transerse colon 8* Bor%,p +*E9

• Any of te follo4ing -


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s,/stantially decreased respiratory resere:3 Patients 4it only one l,ng

ae a decreased respiratory resere d,e to a :diminised l,ng capacity:. as

in tis case3


52/123


53/123

r,led o,t3 Ben fo,nd d,ring an x-ray examination te gran,loma of

sarcoidosis is often :mista%en for cancer:3 *ota/ly. /ot sarcoidosis and

amoe/iasis ae /een reported as /eing :mimic%ers of m,ltiple p,lmonary

metastasis:3

ran,lomas in te l,ngs or else4ere are not considered malignant gro4ts3m;9 as electrolyte-free 4ater and

renders te sol,tion extremely ypotonic3 Te patient 4ill s,ffer a decrease

in te osmotic concentration of te plasma 4ic is no4 ypo-osmolar to

red /lood cells and so 4ater enters freely /y osmosis and te cells s4ell and


54/123

eent,ally /,rst. res,lting in lysis of many red /lood cells and te ina/ility to

oxygenate te /rain. etc3


55/123

m,c or too little9 or incorrect type of fl,id3 Ins,fficient fl,id administration

is readily identified /y signs and symptoms of inade7,ate circ,lation and

decreased organ perf,sion 8ypoperf,sion3 Administration of te 4rong

type of fl,id res,lts in derangement of ser,m sodi,m concentration. 4ic. if

seere eno,g. leads to canges in cell ol,me and f,nction. and may res,lt

in serio,s ne,rological inj,ry3

If tere is reason to /e concerned a/o,t impaired f,nction of te /rain.

eart. or %idneys. it is al4ays pr,dent to reydrate more slo4ly3 Tis

empirically-deried approac minimiFes te cere/ral dist,r/ances s,c as

seiF,res. or cere/ral edema ca,sed /y fl,id sifts tat can occ,r if fl,id is

inf,sed too rapidly3

Te record at *-Q doc,ments :I= inf,sing 4ell: at 20 o,rs. s,ggesting apossi/le more rapid I= inf,sion. as opposed to a slo4 drip3 Tere are no

f,rter I= related entries. eidenced /y te last entry made at 0200 o,rs.

seen at A-15. 4it noting to indicate 4en or if te I= 4as discontin,ed. or

to so4 tat te rate of administration 4as /eing acc,rately monitored. or

modified. s,ggestie of iatrogenic neglect3

!e a4are tat rapid administration of ypotonic I= fl,ids can ca,se s4elling

of te /rain cells and I)P 8increased intracranial press,re93 (ypotonicsol,tions so,ld neer /e gien to patients 4o are at ris% for increased I)P

/eca,se of a potential fl,id sift to /rain tiss,e. 4ic can ca,se or

exacer/ate cere/ral edema3


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)irc,latory oerload can occ,r if I= is not reg,lated properly and I= fl,ids

inf,se too rapidly for te patientJs /ody to andle3 Too m,c 4ater in too

sort of time period 4ill act,ally flood yo,r nero,s system and %ill off /rain

cells3 "igns of fl,id oerload incl,de :tacycardia. eleated /lood press,re.

dyspnea 8diffic,lty /reating9 and oter signs of respiratory distress:3 "eeral

late signs of fl,id oerload incl,de seere edema 8s4elling9. ig /lood

press,re. decreased ematocrit and emoglo/in. and p,lmonary

congestion3 All of tese signs and symptoms form a part of tis patient's

record3

)orrection of ser,m sodi,m tat is too rapid can precipitate seere

ne,rologic complications as a res,lt of intracere/ral osmotic fl,id sifts and

/rain edema3 Tis ne,rologic symptom complex can lead to tentorial

erniation 4it s,/se7,ent /rain stem compression and respiratory arrest. res,lting in deat in te most seere cases3 Te primary ca,se of mor/idity

and deat is /rainstem erniation and mecanical compression of ital

mid/rain str,ct,res3

*-? of te n,rsesJ notes doc,ments a preca,tion for a :resistant /acteriaC.

eidenced /y a ☑ in te ,pper rigt and corner of tat doc,ment. ,nder

te s,/eading for :I*


57/123

*-5 doc,ments :P,pils dilated at approx 5mm: and :ery little reaction to

ligt:. at 000 o,rs3 Te E+ pysician 8+r3 "piller9. 4as ,p to assess te

patientJs condition at 0055 o,rs3 Te same record doc,ments :+r3 ordan

poned re pt condition *o cange in orders:. at 0100 o,rs o4eer. /y

010 o,rs te same record doc,ments : esps /ecoming more soaring in

nat,re3 *o cange in p,pils & completely ,nresponsie:. only one alf o,r

later3

*-5 also doc,ments te respirations as :deep and soaring: tat /y 0220

o,rs /ecame :,rgly:. a sign of constriction s,ggestie of toracic tra,ma

8patients are often in soc%9G follo4ed /y H esps3 +eep snoring 4ito,t

constant ja4 liftC. s,ggestie of o/str,ctie sleep apnea3 "leep apnea means

cessation of /reat3 It is caracteriFed /y repetitie episodes of ,pper air4ay

o/str,ction tat occ,r d,ring sleep. ,s,ally associated 4it a red,ction in/lood oxygen sat,ration. incl,djng p,lmonary dysf,nction3 /str,ctie

sleep apnea syndrome is te allmar% of dr,g-ind,ced sleep3 It occ,rs 4en

someting o/str,cts /reating in te ,pper air4ay3 /str,ctie sleep apnea

and analgesia is a potentially dangero,s com/ination 6 o,rnal of )linical

Anestesia. =ol,me 1. Iss,e 2. Pages @-@5 +3 ),llen3

Te same record at *-5 doc,ments a eart rate in te 1Q0's 8sin,s

tac%ycardia9. incl,ding a pysician doc,mented :assessments ,ncanged: at025 o,rs. despite te fact tat te patient ad already gone into

respiratory distress at tat time. eidenced /y :)eyne-"to%es respsC and

Hperiods of apnea lasting 5-@ seconds:3 Te same record doc,ments

HP,pils fixed & dilatedC3

Alto,g opiates 8morpine9 ,s,ally ca,se constriction of te p,pils of te

eyes. for te record. :prolonged depressed /reating may res,lt in extremely

lo4 /lood press,re and dilated 8enlarged9 p,pils:3


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state of soc%3

A-2Q doc,ments a /lood press,re of 1Q2@0 /pm 4it an "a2 8arterial

oxygen sat,ration9 of @0D at 0220 o,rs follo4ed /y a potentially letal

drop in /lood press,re to :>@>0 /pm: /y 025 o,rs. s,ggestie of clinical

ins,lt3 Ben /lood press,re drops. te entire /rain /ecomes iscemic for a/rief time3 "ystolic /lood press,re K@0 mm ( is te allmar% of

aemodynamic insta/ility3

Te term :emodynamic insta/ility: is most commonly associated 4it an

a/normal or ,nsta/le /lood press,re. especially ypotension. or tra,ma d,e

to clinical ins,lt or inj,ry3 (emodynamic insta/ility as also /een defined

more /roadly as glo/al or regional perf,sion tat is not ade7,ate to s,pport

normal organ f,nction 8ypoperf,sion93 If te ypoperf,sion is prolonged formore tan t4o min,tes irreersi/le /rain damage /egins to occ,r3

A-12 of te medical record doc,ments a /lood press,re of 1Q11> at

0M20 o,rs tat /y 0M5 o,rs ad dropped to @55@. and again to @552

/y M52 o,rs. oer a span of > min,tes. as eidenced at *-2 of te *,rses'

*otes3

;o4 /lood press,re. or ypotension. occ,rs 4en /lood press,re d,ring and

after eac eart/eat is m,c lo4er tan ,s,al3 Tis means te eart. /rain.

and oter parts of te /ody are not getting eno,g /lood3

* A; !lood Press,re is 120@03

Te same record at A-2Q doc,ments :


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dyspagia3

+yspagia is te medical term for te symptom of Hdiffic,lty in

s4allo4ingC3


60/123

s,/siding3

Bat )a,ses "eiF,resR

any conditions can proo%e seiF,res. incl,dingM

• "tro%e

• !rain t,mor or A/scess

• (ead inj,ries

• Electrolyte im/alance

• =ery lo4 or ig /lood s,gar

• edications. s,c as antipsycotics and some astma dr,gs

• Bitdra4al from medications. s,c as narcotics. or alcool

• $se of cross-reacting dr,gs

• )ancer

• !rain infections. s,c as meningitis

+r,g-related factors

• ,ltiple medicationsM dr,g interactions

• $se of dr,gs %no4n to ind,ce seiF,res

•


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generaliFed tonic-clonic seiF,re3

(yperreflexia is defined as oeractie or oer-responsie reflexes3 Ben te

reflexes are extremely /ris%. tey're called yper-reflexes3 Examples of tis

can incl,de t4itcing or spastic tendencies. 4ic are indicatie of ,pper

motor ne,ron disease3 Te most common ca,se of yperreflexia 8/ris% deeptendon reflexes9 is spinal cord inj,ry. or pyramidal tract dysf,nction3 !ris%

reflexes can also /e ca,sed /y many oter tings. s,c as medications. or

stim,lant side effects. anxiety. electrolyte im/alance. serotonin syndrome

and seere /rain tra,ma3

A generaliFed tonic-clonic seiF,re. sometimes called a grand mal seiF,re. is

a dist,r/ance in te f,nctioning of /ot sides of yo,r /rain3 Tis dist,r/ance

sends o,t electrical signals to yo,r m,scles. neres. or glands3 Tese

signals can ma%e yo, lose conscio,sness and ae seere m,scle

contractions3

I ad as%ed te patient t4ice. in te presence of er foster /roter. if se

co,ld ear me to :4iggle: er toes. and indeed se did. not once /,t Ht4iceC.

to /e a/sol,tely certain3


62/123

passie extension of te %nee 4ile te ip is flexed 8ernigJs sign93 *ec%

stiffness and !r,dFins%iJs and ernigJs signs are termed meningeal signs or

:meningism,s:G tey occ,r /eca,se tension on nere roots passing tro,g

inflamed meninges ca,ses irritation. 4ic may /etter explain te lo4er lim/

leg contractionsflexing as descri/ed erein as yperreflexia3

)A=EATM

,illain-!arre syndrome 8!"9 may present 4it a 4ide range of clinical

pict,res3 Te symptoms of !" and its ariants can affect eac patient

differently and 4it arying intensities. so eac patient can ae a ,ni7,e

case istory3 In te initial stages. te patient is li%ely to ae fe4 if any

symptoms 8(,ges. 1??593 "ome cases may /e so mild tat medical

attention is neer so,gt. and tere are case reports of patients 4it neartotal or total paralysis and some 4o 4ere only a/le to moe a fe4 fingers

andor 4iggle some toes. retaining only a little motion in some fingers or a

foot3

A-1 of te record doc,ments HPlantars ,pgoing /ilaterallyC3 ",/mit tat te

plantar reflex is a allmar% of te !a/ins%i sign. a test for signs of disease

process in te motor ne,rons of te pyramidal tract3 !a/ins%i's sign is also a

prominent finding in !ic%erstaff's /rainstem encepalitis 8!!E9. a ariant ofte ,illain !arre syndrome 8!"93 !!E and


63/123

!a/ins%i's sign is a prominent finding in te iller-


64/123

na,sea 8,pset stomac9. and omiting3

Amoe/ic lier a/scess 8A;A9 4it or 4ito,t ja,ndice. and 4it or 4ito,t

epatic encepalopaty as /een reported in te medical literat,re3

Encepalopaty as also /een reported in association 4it cere/ellar

toxicity caracteriFed /y ataxia. diFFiness. and dysartria3 All of tese signs.mar%ed /y Hdiffic,lty am/,lating. diFFiness and a sl,rred speecC form a part

of tis patient's record3

(epatic encepalopaty may /e triggered /yM deydrationG electrolyte

a/normalities 8especially a decrease in potassi,m9 from omitingG /leeding

from te intestines. stomac. or esopag,sG infectionsG lo4 oxygen leels in

te /odyG and medications tat s,ppress te central nero,s system3

*ota/ly. seere forms of epatic encepalopaty lead to a 4orsening leel of

conscio,sness. from letargy to somnolence and eent,ally coma3 In te

intermediate stages. a caracteristic jer%ing moement of te lim/s is

o/sered 4ic disappears as te somnolence 4orsens 3 In te tird stage.

ne,rological examination may reeal clon,s and positie H!a/ins%iC sign3

)oma and seiF,res represent te most adanced stageG cere/ral edema

8s4elling of te /rain tiss,e9 leads to deat if left ,ntreated3

Amoe/ic a/scess commonly presents as an ac,te entity. /,t it can also

present as a cronic type 4ere it is coered /y a caps,le tat remains

dormant for a gien peroid of time3 If te infecting organism inades te

lier. it ca,ses formation of te typical :reddis /ro4n ancoy paste-li%e

fl,idC of li7,efied lier cells 4it no odor3 *ormal lier f,nction tests do not

excl,de te diagnosis3 ;ier f,nction tests may /e mildly a/normal or

normal3 )ase reports incl,de lier f,nction tests aing normal /ilir,/in and

lier enFymes3 A patient may present 4it minimal symptoms despite aing

lier a/scesses and intra-toracic infection d,e to amoe/iasis3

Ame/ic tropoFoites also ca,se :lier a/scesses: 4it 4ell circ,mscri/ed

lesions containing dead epatocytes and cell,lar de/ris 4ic can rapidly

spread to te /rain 4ito,t a preceding pase of epatitis 3 A rim of

connectie tiss,e. some inflammatory cells and a fe4 ame/ic tropoFoites


65/123

s,rro,nd te lesion. 4ereas te adjacent lier parencyma is ,s,ally

completely normal3

Amoe/iasis can ca,se or mimic epatic encepalopaty. 4it or 4ito,t

ja,ndice3 Te disorder may also /e triggered /y any condition tat res,lts

in al%alosis 8al%aline /lood p(9. lo4 oxygen leels in te /ody. ,se ofmedications tat s,ppress te central nero,s system. infections incl,ding

/ile d,ct o/str,ction. or any coincidental illness3 Any red,ction in lier

f,nction may trigger encepalopaty3

Te mildest form of epatic encepalopaty is diffic,lt to detect clinically.

/,t may /e demonstrated on ne,ropsycological testing3 It is experienced

as forgetf,lness. mild conf,sion. and irrita/ility3 Te first stage of epatic

encepalopaty is caracterised /y an inerted sleep-4a%e pattern 8sleeping/y day. /eing a4a%e at nigt9. 4ic pretty m,c fits Arlene !erry's sleep

pattern on te 4ee% or so prior to er deat3 Te second stage is mar%ed /y

letargy and personality canges3 Te tird stage is mar%ed /y 4orsened

conf,sion3 Te fo,rt stage is mar%ed /y a progression to coma3 +isorders

tat mimic epatic encepalopaty. to,g not incl,sie. incl,de sedatie

oerdose. s,/d,ral amatoma. and meningitis3


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imics of encepalopaty incl,de meningitis.

encepalitis. meta/olic a/normalities. s,/d,ral

amatoma and sedatie oerdose3

Amoe/ic lier a/scess is an enigma as it as /een o/sered in people 4it

no eidence of preio,s amoe/ic colitis or istory of tropical trael3 Te

only contact te patient ad 4it anyone from an endemic area 4as te

toracic s,rgeon 4o performed te left l,ng pne,monectomy. namely +r3

)la,dio +e ;a oca3


67/123

color. ence te name le,%ocytes3

;e,%ocytes form te main part of te imm,ne system of te /ody3 Te

n,m/er of le,%ocytes increase 4en te /ody is figting a disease3 Te

presence of an eleated B!) co,nt is called le,%ocytosis3 ;e,%ocytosis. is

a common la/oratory finding. most often d,e to relatiely /enign conditions8infections or inflammatory processes93 ;e,%ocyte recr,itment is te

allmar% of te inflamatory response3 B!)Js are te /odyJs primary defense

against infection and also reflect te degree of pysiologic stress3

Patopysiologic mecanisms of le,%ocytosis incl,de infection.

inflammation. stress. dr,gs. tra,ma. anemia. and le,%emoid reactions3

;e,%ocytes incl,de fie /asic types of cells - ne,tropils. eosinopils.

/asopils. lympocytes and monocytes3 Tese are /roadly gro,ped intoagran,locytes and gran,locytes. /ased on te a/sence or presence of

specific staining gran,les3 Agran,locytes incl,de lympocytes and

monocytes. 4ile gran,locytes incl,de ne,tropils. eosinopils and

/asopils3 ;ympocytes are f,rter diided into ! cells. T cells and nat,ral

%iller 8*9 cells3 onocytes gie rise to macropages. 4ose main f,nction

is to ingest and destroy foreign particles and organisms3

Tere are t4o /asic *-Qypes of le,%ocytes3 Te pagocytes 4ic are cells tat ce4 ,p inading organisms. and te lympocytes. 4ic are cells tat

allo4 te /ody to remem/er and recogniFe preio,s inaders 3

An increase in B!)s may occ,r in many conditions. incl,ding infection 8iral.

/acterial. f,ngal. and parasitic9. allergy. le,%emia. emorrage. tra,matic

tap. encepalitis. and ,illain-!arre syndrome3 B!)Js are also eleated 4it

deydration. and yperiscosity secondary to deydration3 !eca,se te

/lood as /ecome more concentrated and tic%er. it is more diffic,lt to

effectiely circ,late3 Bit deydration. /lood /ecomes tic%er and sl,ggis.

and terefore. more prone to clotting3 +eydration interr,pts /lood flo4

4ic ca,ses clots. c,tting off te s,pply of oxygen to ario,s parts of te

/ody3 A ig B!) may also indicate tat tere is inflammation of te central

nero,s system as in meningitis3 An increase in te B!) co,nt is also a


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typical response to noxio,s stim,li3

Bite /lood cells 8B!)s9 are categoriFed into fie distinct typesM ne,tropils.

monocytes. lympocytes. eosinopils and /asopils3 Eac type plays its o4n

role in figting iral. f,ngal. /acterial and parasitic infections3 Te relatie

fre7,ency of eac ca,se ,s,ally relates to te clinical setting3 Eosinopilsare 4ite /lood cells tat participate in imm,nologic and allergic eents and

are are responsi/le for figting against infections or inflammations33

An increase in eosinopil co,nt is called eosinopilia3 "eeral ca,ses are

%no4n. 4it te most common /eing some form of allergic reaction or

parasitic infection3 *ota/ly. te gastrointestinal 8I9 tract typically as te

igest n,m/er of eosinopils relatie to oter organs3

+r,g reactions commonly ca,se an increased eosinopil co,nt in

ospitaliFed patients3 +ermatologists fre7,ently find eosinopilia in patients

4it s%in rases3 Eosinopils also secrete cemical mediators tat can ca,se

/ronco-constriction in astma and in tose aing a diminised l,ng

capacity3 P,lmonologists often see eleated n,m/ers of eosinopils in

conj,nction 4it p,lmonary infiltrates and /roncoallergic reactions3 ter

conditions tat can ca,se a rise in eosinopils incl,de ,lceratie colitis. and

sarcoidosis3

An a/normal increase in te n,m/er of eosinopils in te /lood is

caracteristic of allergic states and ario,s parasitic infections3


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presence of P*; is also noted in gastroenterocolitis ind,ced /y iscemic

8aing inade7,ate /lood flo49 conditions. and /y ario,s toxic cemicals or

dr,gs3


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perforations occ,r in te left colon. commonly in te sigmoid colon3

Perforations tend to occ,r more often d,ring first episodes of colitis3

Perforations m,st /e treated s,rgically3

Among te possi/le enironmental factors. no specific foods ae /een

identified as a ca,se of ,lceratie colitis 8$)93 Possi/le ris% factors incl,deimm,nologic factors. infectio,s agents 8s,c as /acteria. ir,ses. or

amoe/ae9. and dietary factors incl,ding cemicals and dr,gs3 To,g it is

important for eeryone to drin% plenty of 4ater. it is essential tat tose 4it

ame/ic colitis remain 4ell-ydrated3

Te opposite of le,%ocytosis is called le,%openia 8or le,%ocytopenia93

;e,%openia is defined as a decreased B!) co,nt3 It is a /lood disease in

4ic te n,m/er of circ,lating 4ite /lood cells diminises to a greatextent3 ;e,%openia is ,s,ally ca,sed /y a decrease in te gran,locyte

n,m/ers. partic,larly te /lood ne,tropils3 Tat is *T te case ere3

Ben te n,m/er of B!)s in yo,r /lood increases. s,c as in tis case. tis

is a s,re sign of infection some4ere in yo,r /ody3

n te 4ee% /efore er deat. Arlene ad /ecome seerely constipated

leading to a massie stool to te point of clogging te toilet. s,ggestie of

megacolon3 egacolon is ,s,ally caracteriFed and preceded /y seereconstipation3 Tere is a potential for )*" 8central nero,s system9 toxicity3


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red,ces te ris%. to,g 4at component of to/acco as a /eneficial effect

on te colon lining is not entirely clear3 "mo%ers ae only a/o,t 0 percent

of te ris% of deeloping ,lceratie colitis of nonsmo%ers 3 ,illain-!arre and

iller 30->>30 9. 4it an A/sol,te *e,ts of 2030 ( aing a

normal of 13-Q3>13 *e,tropilia 8or ne,tropil le,%ocytosis9 is te condition

4ere a person as a ig n,m/er of ne,tropil gran,locytes in teir /lood3

*ormally. ne,tropils acco,nt for 50->0D of all le,%ocytes3 A/o,t 55 to >5

percent of te total B!) co,nt in te /lood is made ,p of ne,tropils3 Tey

play a cr,cial role in figting infection3 *e,tropil acc,m,lation in tiss,e is

te allmar% of inflammation and is associated 4it a ariety of patologicalconditions3 Inflammatory diseases of te /rain incl,de a/scess. meningitis

or cere/rospinal meningitis. encepalitis. and asc,litis 3

Te most common and important ca,se of ne,tropilia is infection. and

most infections ca,se ne,tropilia3 Te degree of eleation often indicates

te seerity of te infection3

Ben an infection occ,rs. ne,tropils traeling in te /lood essels close tote site of infection are attracted to te site /y cemicals released /y te

micro/e as 4ell as /y oter imm,ne cells3 After reacing te site.

ne,tropils s,rro,nd and ingest te micro/e3 Te gran,les present in

ne,tropils contain seeral cemicals. mostly enFymes. for destroying

ingested micro/es3

*e,tropils. are also %no4n as :segs:. :P*s: 8polymorpon,clears9. or

:poly's:3 P*s are te primary effector cells in te innate imm,ne response

against infection3 *e,tropilia may /e d,e to a n,m/er of ac,te and cronic

ca,ses s,c as infection. inflammation. emotional stim,li. dr,gs. meta/olic

ormonal. and endocrine dist,r/ances. incl,ding ematologic a/normalities3

*e,tropilia facilitates te :inflammatory response:. 4ereas 4en

ne,tropenia 8te opposite of ne,tropiia9 is present. te inflammatory


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response to s,c infections is ineffectie3 Te end res,lt is an a,toimm,ne

reaction3 A ig ne,tropil /lood co,ntt is a sign tat someting in yo,r

/ody as triggered an imm,ne response3 Te imm,ne system fails to

properly disting,is /et4een self and non-self. and attac%s part of te /ody3

*e,tropils are also associated significantly 4it te density of :parasites:.s,c as seen in ame/ic infection and as /een s,ggested tat te damage

o/sered in inasie ame/iasis is related to interactions /et4een

polymorpon,clear le,%ocytes 8P*9 and Entamoe/a istolytica3 If te total

B!) is ig d,e to a rise in ne,tropils and eosinopils. ten an allergic. or

parasitic process is most li%ely3

Polymorpon,clear le,%ocytes 8gran,locytes9 ,s,ally represent te

predominant cell type in an inflammatory response acting as te first line ofdefence against inading organisms3 P* infiltration intensity as

conse7,ence of Entamoe/a istolytica density in ame/ic colitis is reported

in P,/ed. ",rgical Infect3. 2M ?1-?>3 ,errant et al3 81?@19 st,died te

interaction /et4een E3 istolytica and P* pagocytes3 A iger density of

P* infiltration as /een o/sered in seere cases3


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responsi/le for eosinopilia3 !asopils are commonly associated 4it

immediate imm,ne reaction against foreign particles in te /loodstream3

+r,g reactions commonly ca,se an increased eosinopil co,nt in

ospitaliFed patients3 "eeral ca,ses are %no4n. 4it te most common

/eing some form of allergic reaction or parasitic infection ter conditionstat can ca,se a rise in eosinopils incl,de ,lceratie colitis. and

sarcoidosis3 *ota/ly. te gastrointestinal 8I9 tract typically as te igest

n,m/er of eosinopils relatie to oter organs3

An a/normal increase in te n,m/er of eosinopils in te /lood is

caracteristic of allergic states and ario,s parasitic infections3 Tey are

actie against nematodes and oter parasites as 4ell as against protoFoa.

s,c as te amoe/ae3 Eosinopils protect te /ody %illing /acteria andparasites. /,t can ca,se pro/lems 4en tey react incorrectly and ca,se

allergies and oter inflammatory reactions in te /ody3 "ince parasitic

infestations proo%e strong allergic reactions in te /ody. tey are

associated 4it ig Imm,noglo/,lin 8Ig9 n,m/ers3

+ermatologists fre7,ently find eosinopilia in patients 4it s%in rases3

Eosinopils also secrete cemical mediators tat can ca,se /ronco-

constriction in astma and in tose aing a diminised l,ng capacity3P,lmonologists often see eleated n,m/ers of eosinopils in conj,nction

4it p,lmonary infiltrates and /roncoallergic reactions3

Interestingly. eosinopils can also secrete s,/stances 4ic t,rn off

cemicals tat mediate infections. and can destroy cancer cells3 Alto,g

/ot te eosinopils and /asopils are an integral part of te )!)s. in tis

case. tey 4ere omitted from te te record altogeter 8not co,nted at all9.

giing rise to a false impression tat peraps tere 4ere none3

*e,tropilic le,%ocytosis 8ne,tropilia9 is also ig on te order of ac,te

/acterial infections. especially pyogenic or p,s prod,cing infections 3 ter

ca,ses of an increased ne,tropil co,nt incl,de :cere/ral a/scess:3

Amoe/iasis is ig on te order of :mixed infection:. incl,ding /rain

a/scess3 !rain a/scesses are ,s,ally mixed infection3 Entamoe/a istolytica

http://en.wikipedia.org/wiki/Allergic_reactionhttp://en.wikipedia.org/wiki/Parasitosishttp://en.wikipedia.org/wiki/Allergic_reactionhttp://en.wikipedia.org/wiki/Parasitosis


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and Toxoplasma gondii are t4o of te commonest protoFoa ca,sing a/scess

in te /rain3 !rain a/scesses can ca,se /rainstem erniation and can

r,pt,re into te e

the arlene berry story

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