December to Remember

So, what happened? why did Roy take on the golden shade again?

Liver Incident 2.0 began in late December. In the weeks prior to Christmas, Roy visited Fort Stockton to see his Dad and had a crown done at the dentist (which because of his hip replacement involves taking antibiotics). He wasn’t feeling great, but both driving to and from west Texas and going to the dentist can be stressful, so a little holiday time off would surely put things right. By the 24th, he was officially sick and fatigued – he thought maybe he was having an allergic reaction to cheese (mistakenly on a take-out burrito) with hives, throat constriction, itching and swelling. Holidays are not a good time to need a PCP; they like to go on vacation too!

On December 26, Roy went down to Brenham to see a PCP that he has seen before. While he was there, they did an ultrasound on his leg (no clots) and an EKG; both were clear. They also took blood for labs as he was itchy, but not jaundiced, and a bit puffy. The rash on his legs was getting worse. The PCP referred him to gastroenterology and dermatology.

The late December labs came back with elevated bilirubin (8.2! which is supposed to be between 0.2-1.3) and other liver function red flags. By the time he got the results on December 28, he was turning yellow. I began making calls to gastroenterology. The nurse helped tremendously and conferred with the doctor on call who scheduled Roy for an MRI on December 31. Because we hit another holiday, results didn’t come back until after Roy’s rash had gotten worse, he was puffier, and itching, and more yellow.

On January 2, he saw another PCP. The rash on his legs had spread to cover them completely and he now had a rash on his belly, back and arms. The doctor decided that Roy had cellulitis and gave him a new antibiotic prescription to address the rash as well as a second referral to gastroenterology. In the meantime, the GI doc put Roy on Ursodiol to help bring the bilirubin level (now at 8.5) down (based on the 2004 experience) and stated that the MRI results were good – everything seemed clear although the report noted that Roy no longer had a left lobe on his liver. Roy continued to be itchy, was definitely swelling and jaundiced.

On January 6, I took Roy to the Emergency Room around 10 pm. He was feeling nauseous and when they weighed him, he was about 30 pounds heavier than he had been on December 26. While in the ER, they did an ultrasound (to confirm Ascites), took lots of blood for labs, did a chest xray, and did an EKG. He was admitted to the hospital with a bilirubin of 10.3. Over the course of a week, the hospitalists and gastroenterologists decided that Roy had chronic liver damage. They needed to get the excess fluid off his body (ascites and edema) and correct his sodium levels before he could go home. He had severe hyponatremia at 119 which means he was well below the low-normal sodium level of 135. A referral to the Liver Consultants in Dallas seemed to be a fairly certain outcome.

During his stay at Baylor Scott & White, Roy received care from hospitalist Dr. Rahman among others. Dr. Rahman reviewed everything in Roy’s medical history (one benefit of having been in the same healthcare system for so long is it was all there) and he determined that the likely trigger for the cascade of blood imbalances, edema/ascites, and jaundice was an undiagnosed but life-threatening allergic reaction to amoxicillin and the associated class of drugs. Essentially, the second antibiotic for the rash “threw gas on the fire.”

Roy left the hospital with a diagnosis of “cholestatic hepatitis.” His instructions included medications and follow-up with his own doctor (he’s now in Dr. Sterling’s practice – my PCP who is a DO) and gastroenterology, as well as the Liver Consultants in Dallas. After two weeks at home, he is still puffy, itchy and jaundiced, but not quite as much as before. He’s shed about half of the water weight so far. However he was getting low in Potassium so that was added to his medications this past week. He is walking a bit at home to move the water off his body. He is eating a restricted diet. Unfortunately he is unable to sleep at night.

Baylor Scott and White Liver Consultants in Dallas had a cancellation on Friday February 1 so we were able to go up and see his new hepatologist Dr. S. K. Asrani. Dr. Asrani explained that Roy’s liver had a smaller than expected left lobe in 2004 and that it has now atrophied so he does not have a left lobe. The right lobe of his liver is also smaller now than expected and there is some level of cirrhosis present. We are awaiting lab results and further instructions to get Roy as healthy as possible.