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.