Dr. Matthew Keller shares a complicated patient case from when he was a junior attending physician that has stayed with him throughout the years.
As dermatologists, we all have patient cases that stay with us throughout our entire careers. And when we asked DermConsult host Dr. Matthew Keller about a memorable patient case, this is what he shared with us.
A Complicated Case in Erythrodermic Psoriasis Care
One of the most complicated cases I have ever taken care of was a patient transferred to my academic hospital with erythroderma. He had a prior history of psoriasis and had been admitted with erythroderma, hypotension, leukocytosis, and chills to a local community hospital. After a five-day stay where he slowly decompensated, he was sent to my hospital for academic level care.
Upon arrival the patient was still able to give me a history, but within eight hours, he was intubated. He was a bit disoriented and had the obvious appearance, physical exam, and lab values of an erythrodermic psoriasis patient. He had significant lower extremity and abdominal edema and hot skin with the common chills of a patient with far too much blood flow in his skin.
We talked about his prior history of psoriasis, his liver issues from past alcohol use, and his prior treatments for psoriasis. The patient was complicated, but it became difficult due to competing concerns. He began showing signs of sepsis, such as low BP, fever, and an elevated WBC count, and the ICU team was concerned he had an infection. They also were very concerned about his kidney failure, which had worsened to almost complete anuria.
I wanted to put him on cyclosporine to control his psoriasis and bring his blood back to his central circulation, thus causing kidney reperfusion and helping reverse his acute tubular necrosis that I felt he had secondary to his acute erythroderma. The team instead put him on high dose Medrol and antibiotics as they were more comfortable with that therapy. He eventually required pressor support and continuous hemodialysis.
Two Steps Forward & Two Massive Steps Back As always it was a Friday transfer, and I was concerned the steroid may not have the desired effect and may increase his risk of infection and worsen his already significant edema especially coming into the weekend. On Sunday, I got a call from the resident on call that the patient had a bruise at the site of an old EKG lead and the team was calling about it.
By the time the resident saw the patient, about an hour later, the lesion had increased in size. I asked her to do a frozen to rule out mucor or other serious infection and the diagnosis was confirmed by the on-call pathologist as mucor. The patient was sent to the OR within an hour of the pathologist’s read, and the diseased skin removed.
Luckily, that was the end of it as we caught it early diagnosed it quickly and treated him effectively. I had a long discussion with his family about the need to be aggressive and my recommendation that we start cyclosporine. They were concerned but trusted us to make the best decision.
In order to bring comfort for the primary team I asked an older transplant nephrologist to come and see him and let us know if cyclosporine was an option, and if so, how to dose it. I’ll never forget their words as they told the primary team: “If the patient dies, then so do the kidneys. You keep the patient alive and then I will worry about his kidneys.”
They were the real heroes. Within five days of stating the cyclosporine, his skin was significantly improved, he was off pressors, weaned from the ventilator, and continuous dialysis was stopped.
His edema slowly improved in his lower extremities, but his liver continued to be an issue and his abdominal edema was significant. But after several more weeks, he was stabilized on his cyclosporine dose and sent to rehab with a significant number of follow-up appointments with dermatology, hepatology, primary care, and nephrology.
Unfortunately, the patient never followed up with me or any of the physicians from our hospital. He was readmitted six weeks later with worsening abdominal edema and hepato-renal failure. Though his psoriasis was under control, his liver had suffered too much damage from his prolonged hospitalization and multi-organ failure and he passed during that admission.
Lessons Learned from the Frontline
I learned so much from this case about the importance of being forceful and getting the right people around you to give the best care we can to these most ill patients. Also, I make sure to do what I can to assure follow up with these types of patients to increase the chance of follow-up. In this case it may not have made a difference, but it was a lesson I learned.