Received Sep 11, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| UNK | VACCINE NOT SPECIFIED (OTHER) | UNKNOWN MANUFACTURER | UNK | AW1606B | IM / RA |
| UNK | VACCINE NOT SPECIFIED (OTHER) | UNKNOWN MANUFACTURER | 1 | AW1606B | IM / RA |
11/3/2024 - severely obtunded, brought to hospital. Found to have rapidly progressive lesions in his bilateral cerebral cortices and brainstem. After extensive workup and treatments at facilities, most likely diagnosis is acute disseminated encephalomyelitis (ADEM) per Neurology. Patient was in a coma, now persistent vegetative state without notable neurologic recovery.
Right shoulder labral tear with hill-sachs lesion
None
None
Milk, vancomycin
Cryptococcus Antigen 11/7: Negative CSF Acid fast bacilli 11/6: Negative CSF Viral Biofire 11/4: Negative CSF Cytology with numerous neutrophils, negative for malignancy CSF and blood cultures: Negative CTA Head & Neck/CTP 11/3: No LVO, no acute ischemia MRI C-Spine W WO 11/3: Unremarkable cervical spine. CT C/A/P 11/4: No acute findings Pertinent positive workup: -- See hospital course for catalogue of full workup 11/3 MRI Brain W WO: Large, heterogenous enhancing lesion in the left periventricular white matter, midbrain, and pons; third ventricular mass effect. 11/7 MRI Brain W WO: Unchanged extent of T2 FLAIR hyperintensity with diffusion restriction involving L>R deep and subcortical white matter and extending through the corona radiata, cerebral peduncles, and into the midbrain and pons as well as cerebellum. Mass effect with 5 mm MLS Immune competence: CD3 Absolute 488, CD4 Absolute 270, CD16 Absolute <35) 11/8 EBV Ab: Positive, IgG and IgM: Negative 11/17 MRI Brain W WO: Post surgical changes of L DHC, small multifocal intraparenchymal hemorrhages of the left cerebral hemisphere, re demonstration of extensive L>R edema and diffusion restriction, interval decrease in effacement of the ambient cisterns and downward cerebellar tonsillar herniation with persistent left uncal herniation and left-to-right midline shift 11/13 CSF cytokine panel: interleukin 1 beta (27.4), interleukin 6 (46.5^), interleukin 8 (1011.5^), TNF (35.0) 11/23 MRI C-spine with T2 hyperintense lesion at C1-2 favored to be sequelae of intracranial process 12/26 MRI MRA VWI Interval development of new foci of enhancement in the right parietal lobe with the remaining foci of enhancement in the left parietal lobe and left basilar ganglia are unchanged. 1/8/2025 MRI WWO: 1. Evolving findings of extensive injury involving the bilateral hemispheres, brainstem, and cerebellum with developing areas of cystic encephalomalacia, overall resolving when compared with 12/02/2024 with residual areas of diffusion restriction and cytotoxic edema in the right corona radiata and left putamen. 2. Increased subgaleal collection in the posterior paramedian craniectomy margin when compared with recent CT 01/05/2025. 3. Developing ventriculomegaly which, at least in part, is likely due to compensatory dilatation associated with the global parenchymal volume loss, however, a superimposed developing communicating hydrocephalus should also be considered. Completed Workup: ESR 104, CRP 16.4, RPR negative, HIV negative, T spot negative 11/4 Sample from COX hospital CSF metagenomic sequencing shows no pathogenic RNA virus detected, DNA sequencing inhibition present, unable to assess for DNA virus, parasite, bacteria, or fungus 11/8 CSF and Brain Tissue sent to CDC for PCR for acanthamoeba, balamuthia and naegleria: Negative 11/7 Amoebiosis CSF: Negative 11/7 MOG IgG 1 (serum): Negative, no informative autoantibodies were detected in this evaluation 11/8 Arbovirus CSF: Negative 11/8 MS profile with reflex to oligoclonal bands serum: Negative 11/8 Cerebrospinal fluid for flow cytometry: No significant B-cell population identified by flow cytometry. Flow cytometry shows no significant CD19+ B- cell population. Too few B-cells are present for meaningful clonality analysis. No significant blast-gated population identified. CD34-positive events are not increased. 11/8 Coccidiodes antibody CSF: Negative 11/8 Toxoplasma PCR: Negative 11/8 CT C/A/P: No evidence of malignancy 11/8 Oligoclonal banding CSF: The oligoclonal band assay detected no unique IgG bands in the CSF, negative result 11/8 St. Louis encephalitis (serum): Negative 11/8 APQ4 serum: Negative 11/18 methylmalonic acid: 0.09 11/18 fatty acids profile: Normal 11/9 Mycoplasma PCR: Negative 11/11 Total CH50 30 (normal) and alternative compliments AH50 <10 (low) 11/15 AFP 8.5^, HCG <5.0, LDH 241, b2-microglobulin was normal 11/16 Testicular exam: Negative for obvious mass 11/16 Scrotal US: Normal, no focal lesions. 11/17 vitamin A 63.3, aluminum 3 (mayo send out), vitamin B1 138, vitamin B6 17 11/17 Leptospira antibody: Negative 11/17 folate 7.9, vitamin B12 551 11/17 vitamin C 0.8, zinc 114 (H), copper 70 (L) , heavy metals panel negative, lead <1.0, chromium 0.3 Homocystine 5.4 Ammonia 36 11/18 CSF: RBC 5717, Nuc 29, protein 7, glucose 114, bedside glucose 152, gram stain negative 11/18 lactate/pyruvate panel: <0.2, 0.04 11/18 chronic granulomatous disease by flow cytometry: Negative 11/18 CSF culture: Negative 11/18 CSF + serum autoimmune encephalopathy panel: Negative 11/18 24 hour urine heavy metals: Negative, 24 hour urine Cr: 3.3 11/19 ANA negative, ENA negative, dsDNA <1.0, ANCA negative, AH50 negative 11/21 muscle biopsy by Neuromuscle: No significant histopathologic abnormality 11/22 Genome Sequencing (Genetics sent): Negative 11/24 CSF culture: Negative 11/27 HLA - B51: Negative 11/27 fecal calprotectin: 168 (H) 12/2 Whole Genome and Mitochondrial Sequencing Result: No pathogenic, likely pathogenic, or uncertain significance variants identified 12/23 LP: nucleated cells 4>9, Protein 65, Glucose 55, RBC 537>0" A limited selection of biopsy results from this admission: "11/8 Brain biopsy: The collective morphologic and immunohistochemical findings, in conjunction with imaging findings, are consistent with white matter with diffuse reactive changes including involvement by a histiocytic inflammatory infiltrate, vasculopathy, and reactive gliosis in specimen A&B; and normal, mildly reactive cerebral cortex in specimen C. No definitive evidence of an infectious process. (Demyelination, unclear whether secondary or primary) d/t foamy macrophages and full of myelin, also saw vasculopathy, immune infiltrates, differential includes ADEM, also changes in neurofilament staining -- neuronal loss, also had ischemia and infarcts likely from all the compressions) 11/21 muscle biopsy: Disorder of endomysial capillaries with increased staining on ATPase and alkaline phosphatase and associated cells on acid phosphatase. Immune stains nondiagnostic."