At the time that he became infected by Listeria monocytogenes in the outbreak, Rodney was 49 years old, and he lived in the Denver suburb called Englewood. He worked as a chef for years, and always maintained a very healthy diet. Rodney’s life, despite his medical history, which is described below, was very normal. He enjoyed many different activities in the outdoors, including rafting and hiking, and also loved to dance and travel. He always tried to keep himself in good shape.
Rodney’s medical history is significant for HIV (diagnosed in October 1996), Hepatitis C (diagnosed in 1998), and past substance abuse. Rodney was in the Kaiser System for antiretroviral therapy for his HIV for several years. In 2011, however, because he could not afford the medications, he was off of the antiretroviral therapy during the first 6 months of the year. He had also not been treated for the diagnosed hepatitis C condition, but by a June 2011 appointment with his primary physician, Dr. Lichtenstein, he had enrolled in the Colorado Indigent Care Program (CICP) and was soon able to get the antiretroviral therapy medication through ADAP (AIDS Drug Assistance Program).
Feeling better by the day, and eating right and exercising, Rodney truly felt like he had a new lease on life in the end of summer 2011. He was eating lots of fruits and vegetables, including cantaloupes that he purchased at a Denver area King Soopers location on August 2, 12, 18, and 31.
Rodney returned to see Dr. Lichtenstein on September 22, reporting some persistent bilateral tinnitus and diminishing headaches. He had fallen at home and incurred an abrasion and small laceration on his right upper arm, pain in his anterior chest, and possibly a fractured rib. Exam of the chest revealed excellent air movement, and vital signs were normal. Physical exam revealed a non-tender abdomen with only mild distention. There was no jaundice, scleral icterus or ascites. Liver and spleen were not palpable and were within normal margins.
Dr. Lichtenstein continued to be impressed with the rapid and positive response to the HIV therapy, but added that he would be much more content when Mr. DeHerrera’s viral load was undetectable. Dr. Lichtenstein wanted to initiate treatment of the chronic hepatitis C, but expressed concern that it would be necessary to determine the options and costs of management before burdening Rodney with bills he could not pay.
Rodney received an influenza vaccine and was encouraged to continue his medications. Vitamin D was increased to 2000 IU twice daily. No additional labs were ordered but Rodney was informed that he would be contacted as soon as the means for managing his hepatitis C were determined. Return visit was scheduled for November 2011.
Around the middle of October 2011, Rodney began to feel ill. He developed a cough, as well as a sore, somewhat bloated abdomen. He called Dr. Lichtenstein’s office on October 19 to report these symptoms, and very soon thereafter began to feel extremely fatigued and dizzy.
I had started to feel so weak that I could not drive or run my own errands, I couldn’t focus or concentrate, even cleaning my apartment became too tiresome. Eventually, the sick feeling was worsening and my cousins insisted on taking me to Denver Health Hospital.
The date of Rodney’s trip to the emergency department at Denver Health was October 23. He presented at 5 PM and reported a week-long history of weakness, significant weight loss, throbbing headache, non-productive cough, abdominal pain and bloating, and diffuse epigastric discomfort. The triage nurse took Rodney’s vital signs, noting mild hypertension, tachycardia, fever, and poor oxygen saturation (88% on room air). Physical assessment was positive for pulmonary rales and crackles and mild abdominal distension.
After triage, Rodney saw John Kendall MD, who was attending in the emergency room and noted jaundice and ascites. Dr. Kendall ordered a comprehensive diagnostic workup and that Rodney begin receiving intravenous fluids. Rodney gave a blood sample for testing and was then taken to the radiology department for x-rays.
Complete blood count (CBC) demonstrated mild anemia with a slightly low hemoglobin and hematocrit. WBC count was normal, and serum electrolytes were normal too except for sodium, which was mildly low. Renal function studies were normal, and liver function tests showed elevated bilirubin and AST. Rodney’s protime (PT) was prolonged at 20.0 sec and INR was high at 1.74. Urinalysis was positive for trace protein, 2+ blood and 1+ bile. Blood and urine cultures were “pending.”
PA and lateral chest x-rays revealed hypoinflation with bibasilar pulmonary opacities, consistent with atelectasis or possible aspiration and pneumonia. A small right-sided pleural effusion was present as well as abdominal distention and possible ascities.
Rodney returned from radiology to the ER shortly after 6 PM, where he again saw Dr. Kendall. His blood pressure was improved, but his respiratory rate was too fast, and he was therefore given 3 liters of oxygen via nasal cannula. He was given morphine for pain control. Dr. Kendall expressed concern about the “new onset ascites” and the possibility of spontaneous bacterial peritonitis (SBP). He ordered paracentesis in order to obtain a peritoneal fluid specimen from the abdomen for further testing. Approximately10 cc of fluid was aspirated during the procedure and sent to the lab for studies, which ultimately showed “cloudy” fluid with 18,140 WBC’s, 91% neutrophils and 0.4 albumin.
Dr. Kendall admitted Rodney to the regular hospital under the care of Medicine Services. His diagnoses included possible pneumonia, and new onset ascites with possible SBP. Empiric intravenous antibiotic therapy was started with Cipro, Ceftriaxone, and Levaquin.
The next day, October 24, Rodney underwent a complete admission assessement on the medical floor by Regina Barela, RN. He was still fevered and hypertensive, but his heart rate and oxygen saturation were normal, or at least adequate. He then saw Sabrina Adams, MD, who concurred with the existing differential diagnoses, but added Zithromax to the antibiotic regimen and Dilauded for pain control. Dr. Adams also requested from Dr. Lichtenstein the most recent report on Rodney’s viral load so that she could coordinate treatment with the antiretroviral therapy.
Blood tests done the morning of October 25 showed worsening anemia with a further decline in the hemoglobin and hematocrit to 10.8 and 32.2. WBC was lower as well, but remained in the normal range, and platelets were still low. Serum sodium, potassium and chloride levels were all low too, and PT and INR continued to be mildly prolonged at 21.9 sec and 1.95.
Joshua Vasquez, MD, a medicine resident saw Rodney later in the day to evaluate him and write orders. Dr. Vasquez ordered the addition of Lactulose to Rodney’s regiment for treatment of hepatic encephalopthy. Ibuprofen was added as needed for fever, discomfort, and inflammation. Acetaminophen for pain and fever control, although in low doses given Rodney’s liver disease. And [hytonadione (Vit K) was ordered for treatment of coagulopathy.
The same morning, Rodney also underwent complete abdominal ultrasound to rule out portal vein thrombosis, followed by Doppler evaluation of the liver. Findings included dilatation of the main portal vein but showed no evidence of thrombosis. Color Doppler showed patent hepatic veins. The gallbladder was distended but without stones; the common bile duct measured 3 mm; there was no intrahepatic biliary ductal obstruction; and Rodney’s kidneys spleen, and urinary bladder appeared normal. The liver was “nodular and echogenic, indicative of cirrhosis.” Final radiologic impression was “limited exam, hepatosplenomegaly and non-quantifiable hepatic flow. However, dilatation of the main portal vein was indicative of portal hypertension. There was a large volume of ascites; simple without debris.” Given the large volume of ascites, a potassium-sparing diuretic called Spironolactone was added to the treatment regimen.
Nursing notes throughout the day indicated that Rodney went through periods of calmness and periods where his emotions escalated considerably. He was in pain due to his distended abdomen and was generally very emotional about his medical circumstances and hospitalization. Family members arrived at his bedside later in the day and were able to calm him some.
Later, after Rodney took some Atripla that he had brought from home, he developed a rapid heart rate of 140 beats per minute, which triggered a “rapid response escalation criteria.” Oxygen saturation at this time was 88% on 2 liters of oxygen. The nurse on duty contacted Dr. Adams, who came to the bedside to find Rodney generally agitated and tearful. She increased the rate of oxygen to achieve better saturation, and performed a portable chest x-ray at Rodney’s bedside, which showed mild progression of medial bibasilar opacities, possibly consistent with atelectasis or pneumonia. EKG showed junctional tachycardia with left anterior fascicular block and possible left ventricular hypertrophy. Rodney was taken to a telemetry bed, and was given Dilaudid on an as needed basis for pain control.
Rodney continued to struggle with his medical circumstances into the next day, October 25. He was described as tearful and “unable to cope” when reassessed around midnight. He denied pain at this point, and his vital signs showed persistent tachycardia with improved blood pressure, no fever, and oxygen saturation at 91% on 4 liters of oxygen. Respiratory assessment was “unlabored but diminished breath sounds.”
Blood tests done the morning of October 25 showed that Rodney’s anemia and thrombocytopenia had resolved, but that his WBC count was now high, as were neutrophil level and absolute neutrophil count. Sodium and potassium were low, and liver function studies showed persistent elevation of bilirubin, alkaline phosphatase and AST. PT and INR remained high as well.
Later in the day, Rodney saw Joshua Vasquez, MD, to whom he denied any shortness of breath or chest pain, but Dr. Vasquez noted crackles in the lung bases. Rodney’s abdomen was noted to be “tympanic and very distended” with mild pain on palpation. Dr. Vasquez believed Rodney’s hyponatremia (low sodium) to be due to chronic cirrhosis. Rodney had also suffered an episode of vomiting and was now constipated. EKG showed persistent tachycardia.
The same day, tests done of the sample of peritoneal fluid secured days earlier were positive for Listeria monocytogenes, thus confirming that the cause of his spontaneous bacterial peritonitis was infection by Listeria. The specimen was sent to the State Health Lab for definitive investigation and evaluation. Rodney continued on Levaquin, and was scheduled for another paracentesis later in the day to remove the large volume of peritoneal fluid that continued to accumulate around the abdomen. Three liters of ascetic peritoneal fluid was removed, and analysis ultimate showed more hazy fluid, and elevated red and white blood cells.
After the removal of the ascitic fluid, Rodney felt a little better but continued to complain of constipation. His vital signs showed persistent tachycardia and mild hypertension. Vancomycin and Ampicillin were soon added to the antibiotic regimen, and Spironolactone was increased. Rodney’s constipation was treated with Fleets enema, Docusate sodium, and Bisacodyl.
Infectious disease consulted next, given the positive Listeria result. The physician agreed with the addition of Ampicillin for treatment of Listeriosis, but discontinued the Vancomycin. The final decision on treatment of SBP was to be determined pending the final results of the blood cultures. Metabolic panel done around 10 PM that night continued to show hyponatremia and hypokalemia with low serum sodium and potassium levels. Rodney received one dose of potassium chloride to treat the hypokalemia.
On October 26, Rodney’s abdominal distention was much improved. He complained of nausea but denied any abdominal pain. Urinary output was also improved, and he reported a bowel movement as well. Vital signs were stable, and Rodney’s oxygen saturation was 94% on room air. Telemetry monitoring was canceled, and he was transferred back to the regular medical ward. New orders included a low sodium diet and subcutaneous heparin for treatment of coagulopathy. Ampicillin therapy was to continue.
That day, Rodney and his cousin Virginia Abeyta met with social worker Robin List to establish a baseline for assistance and long-term needs discharge. Ms. List elicited pertinent information to include medical conditions, medications/treatment, occupation, employment, health insurance, living situation, release of information documents, and financial well-being. Rodney was currently unemployed with an income of $403 per week. He was not qualified to receive social security benefits because his unemployment income placed him in an income bracket that was too high. Further planning for Rodney’s care after discharge was delayed until his medical circumstances improved more.
Rodney remained afebrile but with mild tachycardic heart rates and elevated blood pressures throughout the rest of the day. There were no significant events or changes in his condition.
Early labs on October 27 showed that Rodney was again anemic, but his platelet count remained normal. Dr. Vasquez rounded a few hours after this set of labs was done, noting that Rodney continued to have mild tachycardia and hypertension, but normal oxygen saturation. Dr. Vasquez included on Rodney’s “problem list” SBP secondary to invasive listeriosis, ascites secondary to chronic cirrhosis, tachycardia secondary to SBP/ascites, and hypokalemia.
Dr. Vasquez’s orders included a stat dose of potassium chloride to treat the hypokalemia; stat dose of Spironolactone, with an increase in the daily dose to 100 mg for treatment of ascites, and magnesium sulfate. The doses of oral vitamin K were changed to intramuscular to treat Rodney’s ongoing coagulopathy. Contrast-enhanced CT scan of the chest and abdomen was ordered to evaluate for lung infiltrates and liver nodules. Placement of a central venous catheter (Hohn) was ordered for administration of antibiotic therapy after discharge from the hospital.
Shortly after 6 PM, Rodney was taken to radiology for CT imaging of the chest, abdomen, and pelvis. The study revealed cirrhosis with portal hypertension, splenomegaly, and large volume ascites. Diffuse colonic wall thickening was present, thought to be due to portal colopathy or ongoing infection and inflammatory response. Gallbladder findings were unchanged. The scan also revealed mild bilateral lower lobe bronchiectasis and band-like opacities in the lungs, which most likely represented atelectasis.”
Just after midnight on October 28, Rodney developed a sudden and acute drop in blood pressure to 88/50 and heart rate. He was otherwise asymptomatic; denying dizziness, shortness of breath, or chest pain, and fortunately there was no evidence of fever or new infection. Holly Vonau, MD, ordered a fluid challenge with 1 liter normal saline, which bumped both his blood pressure and heart rate to a safer level.
Blood tests done shortly afterward showed that Rodney was still anemic, though the condition appeared to be stable. His WBC was slightly low, and platelets were normal. Labs drawn at 3:24 AM demonstrated persistent but stable anemia, a slightly low WBC count, and normal platelets. Serum calcium was also low, and PT/INR were 22.0 and 1.96.
Dr. Pisney visited Rodney around 8 AM, and found him tearful and depressed with complaints of increasing abdominal girth secondary to ascites, diarrhea, and lower extremity edema. His heart-rate and blood pressure continued to fluctuate wildly; now he was tachycardic and hypertensive. Plans for the day included Hohn central venous catheter placement and diuresis for removal of the volume overload.
Dr. Pisney thought that the diarrhea was iatrogenic (treatment-related) and suggested stopping Lactulose and Reglan. He ordered stool testing for ova, parasites, WBC’s, as well as cultures for Clostridium difficile, Cryptosporidia, and Giardia. Rodney was also scheduled to receive 2 units of fresh frozen plazma (FFP) for treatment of the hypovolemia and hypotension episode the night before.
The first unit of FFP began flowing at 12:13 PM. Within the hour, Rodney developed hives and erythema (redness). He denied any shortness of breath or fever, but it was clearly an allergic reaction. He was given Benadryl. The second unit of FFP was administered without incident.
Later in the day, Rodney went to the special procedures unit for placement of a central venous line with a Hohn catheter for intravenous outpatient antibiotic therapy. Under ultrasound guidance, the catheter was placed in his right internal jugular vein by Gerard Salame, MD. Post procedural chest x-ray showed appropriate positioning of the catheter tip in the superior vena cava and right atrial junction.
Later in the day, Rodney saw Robin List, the social worker, again, who was to provide supportive counseling and assist with the plan for discharge, which was scheduled for the next day. Rodney agreed that he would need home health nursing for continuation of the intravenous antibiotic therapy. He indicated that he had “lots of support from family and friends.” He planned to continue his care at National Jewish with Dr. Lichtenstein, and possibly move to Pueblo, Colorado where he grew up and had many friends and extended family.
Blood tests on a sample drawn early in the morning showed that Rodney had persistent, mild anemia and a continuing WBC deficiency, but his platelet count, renal function, and serum electrolytes were normal. Stool studies from the day before were negative for Cryptosporidia, Giardia, Clostridium Difficile antigen and toxins, ova and parasites, Salmonella, Shigella, Escherichia coli O157:H7, Campylobacter, and gram negative bacilli. Fecal leukocytes were also absent.
Rodney’s discharge exam occurred at 8 AM. He was afebrile with mild tachycardia and normal blood pressure, and his oxygen saturation was 91% on room air. Physical exam was positive for abdominal distention and lower extremity edema in both legs. Nevertheless, he was stable for discharge home with instructions to continue treatment of listeria-related SBP with intravenous Ampicillin by a home health nurse.
Mark Reid, MD, wrote the discharge summary, noting that Rodney had presented with cough, mental status changes, and acute worsening of his Hepatitis C with “new onset” increasing ascites secondary to culture-confirmed acute Listeria monocytogenes and associated SBP. He was discharged on Ampicillin twice daily via the Hohn catheter, and was to be followed by Dr. Lichtenstein for further management of SBP, HIV/AIDS, and Hepatitis C. Following completion of the Ampicillin, Dr. Reid advised that Rodney continue on oral Levaquin for SBP prophylaxis. Discharge was delayed until 3:35 PM so that Rodney could receive his noon dose of Ampicillin at the hospital. The 6 PM dose was to be done at home with the home health nurse.
On October 31, Rodney saw Dr. Lichtenstein again for the first time since his hospitalization for Listeriosis. By this point Rodney knew that the source of infection was cantaloupe he had eaten 6 to 8 weeks before his illness. Dr. Lichtenstein noted that Rodney had had a good response to the Ampicillin therapy, but would also need weekly Levaquin to prevent SBP. He also noted that the Listeria infection had worsened Rodney’s hepatitis C, causing ascites and necessitating treatment with Spironolactone.
With regard to his present condition, Rodney told Dr. Lichtenstein that he remained very fatigued but was feeling reasonably well with no fever, chills, or abdominal pain. He also indicated that he was planning to move back to Pueblo at the end of the week to be closer to friends and family. He would stay at the home of his close friend and cousin, Virginia Abeyta.
Dr. Lichtenstein’s exam noted some jaundice, occasional nausea, and constipation. Rodney continued to have obvious ascites. Abdominal exam was described as “tense with ascites with obvious fluid shift; liver and spleen not palpable secondary to the ascites.” Lower extremity exam revealed 1-2+ pitting edema. But given the absence of abdominal pain, Dr. Lichtenstein felt that the peritonitis was under reasonable control. He added that the HIV infection was also in reasonably good control.
Dr. Lichtenstein indicated that Rodney did need treatment for hepatitis C sooner than later given his ascites and well-documented cirrhosis. He was willing to manage these conditions from Denver, assuming that Rodney could endure the travel. But if that was not possible, Dr. Lichtenstein instructed Rodney seek care from both an infectious disease specialist and gastroenterologist in Pueblo. He also offered to consult with any new physicians in Pueblo, once care was established there.
Rodney placed a phone call to Dr. Lichtenstein’s office on November 2, reporting that he was having difficulty sleeping. He requested an increase in the dose of his Ambien, a prescription sleep aid. Given his decompensated liver disease, however, Dr. Lichtenstein was reluctant to do this and instructed him to take 50 mg of Benadryl in addition to the Ambien.
November 7 marked the last day that Rodney received his Ampicillin infusion. The home health nurse received a verbal order from Dr. Lichtenstein to discontinue the Hohn central venous catheter line. Of note, however, the line was actually not discontinued and Rodney’s cousin Marilyn Abeyta called to report that she took him to the Emergency Room for this but was told they needed an order. On November 11, the central line was still in place and Marilyn was instructed to call Tana at Amerital to coordinate removal of the line. It is still unclear as to when or where the central line was finally removed.
Rodney’s care was ultimately transitioned to Pueblo Community Health Center, because he was physically unable to make repeated trips to Denver to see Dr. Lichtenstein. The Center referred him to Mark Schwartz, MD, for HIV care, and he was also referred for a gastrointestinal evaluation and CT scan of the head due to complaints of severe headaches.
Rodney saw Dr. Schwartz on December 1, 2011. He was noted to be 100% compliant with his treatment protocol at the time. He reported the ongoing, severe headaches, and was sent to the laboratory for a blood draw. Test results showed that his glucose was elevated, and his hepatic panel was abnormal. Hematocrit was low, and hepatitis antibody tests were “reactive.” Rodney’s PT was also high.
Labs drawn at Centura Laboratory Services on this date revealed normal serum electrolytes except for a slight decrease in serum sodium to 137. Glucose was elevated at 110. BUN and creatinine levels were normal. Hepatic panel was abnormal; total bilirubin 2.6, AST 201, ALT 65, albumin 2.1, alkaline phosphatase 235 and “reactive” Hep B surface antigen. CBC demonstrated normal WBC, hemoglobin and platelet counts; hematocrit was low at 39.3. Hepatitis-C antibody and hepatitis-A antibody tests were “reactive.” CD4 Panel showed a normal WBC count at 5200 (NR: 2900-10500); CD4 T-Cells % was normal at 42.1 (NR: 34-66%); CD3 T-Cells % was elevated at 68.8 (NR: 57-88%); ABD CD4 count was normal at 460 (NR: 302-1604). TB screen was negative. PT was high at 13.6 (NR 10-12 sec); INR was normal at 1.3.
On December 6, due to ongoing headaches, Rodney presented to the St. Mary Corwin Medical Center for CT examination of the brain without contrast. There was prominent hypoattenuation in the subcortical and deep white matter in both cerebral hemispheres, most markedly in the frontal region. Differential considerations included chronic small vessel ischemic change versus demyelinating process. CT was otherwise negative with no acute findings. At the visit, as a result of his SBP, Rodney also underwent another paracentesis procedure, resulting in the removal of 7.5 liters of cloudy yellow fluid.
Rodney had his gastrointestinal evaluation on December 14 with Barbara Niven, PA-C, due to the ascites he had developed as a result of the Listeria infection, and the cirrhosis. She reviewed his recent hospital course for acute onset ascites and SBP secondary to Listeria monocytogenes, and noted that there had been an outbreak this summer from cantaloupe. Rodney’s active problem list included a 15 year history of HIV, chronic Hepatitis C without coma, alcoholic cirrhosis, ascites, listeriosis and hepatic encephalopathy. Note was made that Rodney had “recently under[gone] paracentesis but was complaining of increasing abdominal girth already.” PA-C Niven also noted that Rodney’s cousin, Virginia Abeyta, reported periods of confusion and short term memory loss.
Because of the evidence of hepatic decompensation occurring after his listeriosis infection. Niven did not believe that Rodney was a candidate for treatment of hepatitis C. She added that she would try to make him as comfortable as possible. Orders included comprehensive hepatic workup, abdominal ultrasound with liver biopsy, CT scan of the abdomen with and without contrast, and esophagoduodenoscopy (EGD) to evaluate for esophageal varices.
Once these studies were completed, Niven planned to schedule Rodney for a consultation with Dr. Gibbs at SMC to have him evaluated for TIPs. Additionally, since patients with esophageal varices are at risk for hepatic cellular carcinoma (HCC), she ordered ongoing endoscopic examinations (EGD) for HCC and varices surveillance. If the patient was able to get Medicaid/Medicare coverage she planned to refer him to a tertiary center for evaluation for a liver transplant but added that his HIV will impact this. Lactulose was ordered pending the result of the ammonia level to treat hepatic encphalopathy. MELD score was noted to be 13. Child Pugh Class C (11-12). Prognosis poor. Rodney was instructed to return in 4 weeks.
Over the ensuing several months, Rodney was treated for liver failure as a result of his chronic hepatitis C. He underwent paracentesis on December 6, 14, and 20, each time with the removal of multiple liters of fluid from the ascites. A biopsy was planned December 20, but, after evacuation of the fluid, there was still significant ascites surrounding the liver, which could not be evacuated. Michael Bhagat, MD, indicated that, given the evidence of obvious end-stage liver disease on the prior imaging study, chronic cirrhosis, splenomegaly, multiple varices and large volume ascites, the risks of the procedure out-weighed the benefits and the liver biopsy was not performed.
On December 21, Rodney had his initial evaluation with Mark Schwartz, MD, who has since been his primary physician for management of his care related to HIV and hepatitis C at Pueblo Community Health Center. Rodney reported 100% adherence to anteretrovirals and a 23 pound weight loss since December 1. Dr. Schwartz included a history of “syphylis”(not factual) and indicated he had not received records from Dr. Lichtenstein. Dr. Schwartz also reviewed lab tests results and noted that the liver biopsy had not been done due to an “elevated INR” (also not factual). General examination noted mild abdominal distention but also reported “no obvious hepatoslenomegaly.” Bilateral lower extremity 1+ pitting edema to the knees was noted. EGD was scheduled for the next day, and Dr. Schwartz instructed Rodney to continue his current prescriptions for Ambien, Levaquin and antiretroviral medications. HIV ultrasensitive PCR was ordered in 2 weeks. A trial of Paxil was ordered for treatment of anxiety. MRI of the brain with gadolinium was ordered to further evaluate headaches. Rodney was to followup in 4 weeks.
On December 22, Rodney underwent elective EGD for surveillance of varices under conscious sedation with Fentanyl and Versed. Findings included: (1) varices in the distal third of the esophagus (band ligation was performed to control bleeding); food in the body of the stomach; normal duodenum; no blood loss or complications. Rodney was instructed to resume his regular diet, follow with PA Niven, and repeat EGD in 8 weeks.
Rodney has also continued to experience headaches and memory loss. He was seen for another MRI of the brain at St. Mary Corwin Medical Center on January 18, 2012. Results showed “Fairly extensive white matter lesions  with increased signal on FLAIR imaging and suggestion of post-contrast blush diffusely in the white matter. These findings are nonspecific and could be related to multiple sclerosis although conditions such as infectious or inflammatory etiology or vascularity could be considered.” Dr. Ballenger advised correlation with the patient’s signs, symptoms and history. Rodney then saw Gary Cohen, MD, a neurologist, in March and April, who noted that the headaches were improving some and ultimately diagnosed Rodney with chronic tension headaches beginning with his listeriosis illness.
Due to his liver decompensation, Rodney also had the TIPs procedure done on January 26 at St. Mary Corwin. He stayed overnight in the ICU until he was ready for discharge. Abdominal ultrasound on February 6 showed widely patent flow through the shunt. Rodney also underwent various endoscopies, EGDs, and ultrasounds to monitor the performance of the shunt, as well as continuing ascites and esophageal varices, in the setting of his liver failure.
Rodney passed away on November 14, 2012.