A bad outcome

It’s ironic—yesterday I was planning to write about this really fascinating patient I admitted on my last call 3 days ago, a 40-year-old man with newly diagnosed HIV/AIDS with a CD4 T-cell count of 3 (yes, three—and I thought my last guy with a CD4 count of 79 was bad) who came in with headaches/nausea/vomiting, whom we diagnosed with Cryptococcal meningitis, a fungal meningitis that only people who are extremely immunocompromised (i.e. AIDS patients) get. I was going to talk about how cool it was that I got to do his lumbar puncture, and that his lumbar puncture opening pressure was 37 (which represents a very high intracranial pressure—no wonder he was vomiting), and how we saw the encapsulated yeast cells on the India Ink stain of his cerebrospinal fluid that is classic for Cryptococcal meningitis. And how after we started treating him with aggressively with amphotericin B (a super strong antifungal agent) he was starting to get better. But instead of posting yesterday afternoon I decided to take a nap with plans to write all about it today…but then this morning I found out that he died last night, so now my story has changed completely—I am extremely depressed, shocked, and full of guilt.

It’s impossible to know what happened exactly—the patient was actually looking much better yesterday morning than on admission, and I honestly thought he would do fine overnight. Which he was, until around 11pm after he got his daily dose of amphotericin, when he went to into respiratory distress and became severely hypoxic, which was followed by cardiac arrest. Full resuscitative efforts including chest compressions and intubation were done to no avail, and he died soon afterwards. The cause of his respiratory failure was most likely just overwhelming disseminated Cryptococcal infection (he was growing Cryptococcus from his blood, his CSF, his urine…everywhere), but other causes such as pulmonary embolism, ARDS, or brainstem herniation (which is not unusual in Crypto meningitis cases) can’t be ruled out except via autopsy (which I just found out cannot be done at our facility because we don’t have the infectious precautions necessary to perform autopsies on HIV+ patients; the only option would be to send the patient to an outside private autopsy facility which would cost the family $5000 out-of-pocket, which is not really an option for them, so basically we will never the know his immediate cause of death). The mortality rate of Crypto meningitis is pretty high to begin with, and that in conjunction with his T-cell count of 3 put him in pretty bad shape prognostically, but looking back on his hospital course today, I feel like I could have done more to prevent this outcome. I won’t go into specifics, but basically I feel like I could’ve been more vigilant, and should’ve been more vigilant. I honestly just didn’t have a sense of how dangerous the first 48 hours of Crypto meningitis treatment are, not just from the infection itself but from the treatment of it (amphotericin is an awful drug in terms of side effects, both cardiorespiratory and neurological—it’s called “amphoterrible” in the ID world), and I am just kicking myself for not preemptively transferring the patient to the step-down unit or the ICU for closer monitoring. The thing is he looked good throughout the day yesterday, but of course that’s the one major caveat with younger patients—they compensate pretty well until they crash, unlike older patients who show more signs and symptoms of impending respiratory failure before they actually go into it. So both the ID fellow and I were falsely reassured by how well this guy looked as well as by his lack of subjective complaints, so we probably didn’t monitor his vitals and respiratory status as closely as we could’ve. I was in all sorts of distressed states myself this morning, and was repeatedly told by everyone that even if he had been in the ICU, even if he had been intubated prophylactically, that that would probably not have changed his outcome at all—he likely would’ve ended up succumbing no matter what to the severity of his underlying infections that were just too much for his 90-pound body to handle.

But now we’ll never know, and that fact will haunt me for a long time. If he survived this bout of Crypto meningitis, he theoretically could’ve lived for decades longer—I mean that’s why I like the field of infectious disease in the first place, because infectious diseases are generally curable, or at least very treatable (in case of HIV). But I suppose on the flipside, that makes all the treatment failures that much more depressing. This is my first patient whose death I feel could’ve potentially been prevented (despite my attending feeling otherwise), and I feel awful. I guess every resident has his or her first such memorable case right? But I guess in the end, whether or not any mistakes were truly made, the most important thing is that I’ve learned some good lessons from this case—about myself, about system-based patient care loopholes, and of course about HIV/infectious disease medicine.