Figure 3: Brain MRI showing chronic periventricular demyelination and no acute intracranial pathology.
During the hospitalization, he was found to have a UTI based upon the results of his urinalysis. His urine culture grew extended spectrum beta-lactamase Escherichia coli. Infectious disease was consulted, and they started the patient on intravenous piperacillin-tazobactam 3.375g every 8 hours for 7 days followed by oral fosfomycin 3g every 48hours for a total of 3 doses. Blood cultures collected at the time of discovering the UTI grew gram-positive cocci in one bottle that was later determined to be contaminant.
Due to severe dysphagia, the patient was ordered to have nothing by mouth (NPO), and a speech-language pathologist conducted a barium modified swallow with fluoroscopy study. The assessment showed profound oropharyngeal dysphagia with gross aspiration of nectar thick liquids. No cough response was appreciated during an aspiration event. Patient was unable to clear significant pharyngeal residue despite multiple swallows. He was determined to be a severe risk for aspiration with all oral consistencies. Their recommendations were to find a permanent method of alternative feeding or to proceed with oral feeds as a means of comfort care.
Neurology was consulted to investigate for reversible causes of dysphagia. Based upon neurology’s evaluation they did not believe that the patient’s symptoms were related to an MS flare or any type of cerebrovascular event because of gradual progression of symptoms and the remainder of the neurologic exam. They recommended discontinuing carbamazepine due to the possibility of this medication was leading to increased sedation with subsequent impaired neuromuscular coordination and oropharyngeal dysphagia.
Palliative care was also consulted to address goals of care. After a discussion with the family, the decision was made to place a percutaneous endoscopic gastrostomy (PEG) tube. Thus, an interventional radiology consult was placed on day 3 of admission. Given the patient’s NPO status since admission, all oral medications were held. Interventional radiology postponed placement of the PEG tube until day 4 of admission due to the active UTI and single positive blood culture, which had yet to be ruled a contaminant.
On day 4, the patient’s mentation significantly improved. His secretion burden had completely resolved and his frank aspiration on oral secretions also resolved. He was able to participate in simple conversation and communicate in short sentences. Interventional radiology delayed placing the PEG tube to monitor symptom progression. On day 5, the patient’s speech and enunciation continued to improve, and he began to produce a more forceful cough that allowed him to better clear secretions. Thus, a second fluoroscopic swallow study was ordered and demonstrated significant improvement in oropharyngeal dysphagia. The patient was cleared for soft pureed diet with medications administered in apple sauce. All his home medications were resumed on day 6 except carbamazepine, and he was subsequently monitored until completion of intravenous antibiotics on day 9. The patient continued to show improvement in dysphagia, speech, and swallowing capabilities until they returned to baseline upon discharge.