Mrs. Juanita Orozco Gomez is 66 years-old, and lives with her husband, Cesar, and grandson, Jesse, in Angleton, Texas.  Juanita and Cesar have raised a tight-knit family of nine children, and 31 grandchildren.

In August 2011 Juanita Gomez consumed Jensen Farms/Frontera cantaloupe purchased at the Kroger grocery store located at 1804 N. Velasco Street in Angleton, Texas. The blood specimen collected from Juanita Gomez in August 2011 cultured positive for Listeria Monocytogenes.  Test results were confirmed by Laboratory Services at the Texas Department of State Health Services, which also conducted Pulsed Field Gel Electrophoresis (PFGE) on Mrs. Gomez’ isolate.  Results of genetic testing showed that Juanita was infected by strain GX6A16.0029/GX6A12.0069, one of the strains associated with contaminated cantaloupe.

During the summer of 2011, Juanita (or as her husband Cesar like to call her, Juany) was eagerly anticipating the end of August.  Juanita and Cesar’s 50^th wedding anniversary was August 27, Juanita’s 66^th birthday on August 25^th and exactly two weeks later on September 8, Cesar would be celebrating his 71^st birthday.

Cesar recalls:

The summer of 2011 was one of the hottest and driest summers that I can recall.  Juany and I would sit out in the shade on the front porch every day and weekends were especially important for us to sit outside because our kids and grandchildren would often visit us and we enjoyed seeing their smiling faces as they came up the driveway.  On some of these hot summer days we decided to enjoy some cantaloupe while we waited for our family’s arrival.  I never imagined that the deliciously sweet cantaloupe would almost send my wife to her deathbed.

On August 19, 2011, Cesar performed his morning ritual by rising around 8 AM and having breakfast ready around 9 AM.  Cesar gave Juanita her usual eggs and corn tortillas, but instead of her usual healthy appetite she just picked at the food.  A short while later she complained of nausea and lack of appetite.  Cesar didn’t worry at the time, thinking she was just tired of his breakfast eggs.  Juanita decided to rest a bit more and Cesar left to run an errand at the post office.

When he returned, Juanita was still sleeping so he kept himself busy by gardening in the yard, tidying up the house, and starting the laundry.  By noon she was still sleeping, therefore Cesar gently woke her up.  She made her way to the living room and watched a little TV while Cesar cooked rice and chicken for lunch.  With his encouragement she ate most of her meal, but again complained of nausea afterwards.  Cesar made a mental note to bring up the nausea at Juanita’s next check-up at the doctor’s office, thinking her regular medication might need to be adjusted.

After lunch they sat in the living room and watched some TV shows.  Juanita got up a few times and headed to the restroom mentioning that she had an upset stomach.  Cesar tried to get her to drink some water when she returned but she refused it.  At dinnertime Cesar fixed tamales, which Juanita ate, but she again mentioned the nausea.  She also mentioned feeling dizzy.  Later that evening, as the dizziness worsened, she started having trouble walking.  Cesar was now very worried.  He helped her to bed around 11 PM.  She fell asleep quickly and he read his bible until around midnight.

Sometime during the middle of the night, Cesar became aware of Juanita repeatedly getting up and going into the bathroom.  She was suffering from increasingly worsening diarrhea and vomiting.

She was doubling over in pain constantly and I knew at this point Juany was very sick. I felt anxiety and I wanted the clock to hurry up and turn hands so one of our daughters might show up because I was afraid and confused as to what I should do for her. I was too distraught to think clearly.

At around 3 AM neither had slept a wink.  Juanita was distraught with tears having soiled and wet her clothes, the bed sheets and having to be carried to sit on the toilet.  In a rush Cesar removed all the sheets and piled them in a corner and ran back to the bathroom to help her.  Juanita sat using the toilet with her clothes still on, while simultaneously leaning over to vomit in the bathtub.  Cesar—himself scared and helpless—could only console her and rub her back.  They were both exhausted and she kept collapsing into his arms.  Finally he could wait no longer.  Around 4 AM he called his daughter, Rosa.  As she recalls, “My father sounded very nervous as he told me my mother was really sick and he didn’t know what to do. I asked him what was the matter with her and he said she had been vomiting and had very bad diarrhea and that she was burning up with fever.”

For Cesar, he did his best to keep calm while talking to his daughter:

I tried to hide the crying and fear from my voice when I spoke with my daughter. Rosa said she would be right over and after hanging up I tried to bring Juany some water but she was not drinking. When I tried asking her questions her answers were unrelated to the subject. I got her up onto her feet and held her from under her arms to help her walk but she was shaking too hard as if she were having a seizure.

When Rosa walked in and saw her dad struggling, she hurried to help him drag Juanita, who was completely unresponsive at that point, into the bedroom.  “I stopped in front of the restroom in the hallway where I found my father dragging my mother out of the restroom. I immediately grabbed her legs and assisted him in getting her in the bed.”  After about a minute of their pleading, she opened her eyes again.

Fear struck me as I took in my mother’s appearance. She was shining with sweat and her skin from head to toe was burning to the touch. Her entire body was violently shaking as if she was either at an advanced stage of Parkinson’s disease or having a seizure. I asked her several questions as I held her face in my hands so she could look at me. Her responses were simply “Uh huhh” to every question and her eyes were glassy. She looked at me as if she was looking through a window. Then she became limp and her eyes closed she was not responding at all for a while. I turned to my dad and yelled at him “We have to get her to a hospital now!”

Once they arrived at Angleton Danbury Medical Center, Cesar and Rosa placed Juanita in the chair and pushed her into the lobby.  It was slow going as she shook so much that she slid out of the chair several times.  She continued to be ill in the lobby and they waited for what seemed hours until finally a room became available.  After what seemed an eternity they called her in and took her temperature, which recorded 105.6 °F.

They provided Juanita’s history to the ER physician, Roger Collins, MD.  Her blood pressure was 167/74 and her oxygen saturation was 96%.  An IV was started to push fluids (normal saline), and she was given oral Tylenol to bring down her significant fever.  Dr. Collins examined her, not finding any obvious acute pathology.  She was put on oxygen by nasal cannula, and both urine and blood samples were sent to the lab for culture and blood studies. She had good oxygen saturation and continued to be stable in the ER.

Throughout this ordeal, Rosa calls: “I have never seen my father so afraid in my entire life. The man was on the brink of tears which I know he was fighting because I was there and I was doing the same for him as well.”

By 7:12 AM, her fever had come down to 103.6º F, her oxygen saturations remained in the 90’s, and her vital signs remained stable.  An emergency CT scan was done at 7:40 AM, which showed no acute intracranial findings, and a chest x-ray showed no signs of pneumonia or cardiopulmonary disease.  An EKG was normal if tachycardic.  After another half hour of observation, she was discharged from the hospital at 8:10 AM with a prescription for Zofran to treat her nausea.

On August 21, 2011, the cultured blood sample taken in the ER was showing growth, and a gram stain showed gram positive cocci in the aerobic culture bottle.  A lab report indicates the anaerobic culture bottle contained beta hemolytic strep.  Given the blood culture results, the hospital attempted to reach Juanita that same day in order to bring her back to the ER.  Late in the evening, her daughter returned the hospital’s message and the triage nurse, Patricia Milligan, asked her to bring her mother into the ER.  As instructed, Juanita was taken back to the emergency room, arriving just after midnight.

As we entered the emergency department I told them the situation and how I was asked to bring her back. We were asked to wait in the lobby and it took 5 hours for them to call her in. I had been taking her to the restroom every 10 to 20 minutes with my father’s help.  I also notified my siblings of the situation at that point.

At this time she was complaining of increasingly painful stomach cramps and severe diarrhea.  Her temperature was 100.9º F.  She was again started on IV fluids and given Zofran and Demerol by intramuscular injection for nausea and pain.  A CT scan was taken of her abdomen and pelvis, which showed diffuse generalized mucosal thickening of the entire colon.  The radiologist felt it was likely infectious colitis, but that the possibility of Clostridium difficile colitis should be considered.

Dr. Kalyani Koduri admitted Juanita to the hospital for continued IV hydration and treatment of acute kidney failure.  She reported having abdominal cramping and watery diarrhea for three days, with occasional vomiting.  The cramping was worse before a bowel movement, and improved somewhat afterward, but the cramping would not go away.

Dr. Koduri ordered Ciprofloxacin and Flagyl, and had stool samples sent to the lab to be cultured and tested.  He continued her insulin, but held her oral diabetic medication and anti-hypertensive because of the acute renal failure, which he thought was likely due to dehydration from the diarrhea.  He also placed her on Lovenox for DVT prophylaxis. While his wife was being tended to, Cesar could only sit by and pray:

We had nine children and never did we experience such a traumatic event before. The hospital could not, at that point, tell me what was wrong with my wife. Doctors out ruled the stomach virus and I asked constantly what was wrong with her and the only reply was that they were running tests. It was very frustrating not to have an answer.

On the afternoon of August 23, 2011, Dr. Koduri came in to see Juanita.  She was still having some abdominal pain and diarrhea, but these were improving.  Her fever had stayed down.  He continued to diagnose acute colitis, and continued her current regimen of antibiotic therapy.

Dr. Nizar Charafeddine came in to do a gastroenterology consultation in the early afternoon, requested by Dr. Koduri.  He reviewed the history of this illness and examined Juanita.  He found her abdomen to be soft but mildly distended, and tender in both lower quadrants.  The stool samples had come back negative for C. Difficile, and the blood cultures were so far negative.  Her white count was 9.9 and her platelets were 261,000.

Dr. Charafeddine concurred with a diagnosis of acute colitis, ongoing for two or three days without any blood, agreeing that it was likely infectious in etiology, despite negative stool cultures so far.  He agreed with the plan to give IV fluids, IV antibiotics, and a full liquid diet.  He also wanted to do a colonoscopy soon.

Cesar stayed by his wife’s side throughout, only going home when the doctors and hospital staff told him he should go and rest.  This only brought him more distress:

Sometimes I would go home because they insisted I go. I felt so much shame and sadness that I didn’t want them to know I was running out of gas in my car and had no money.  The little money I had I spent on food and personal hygiene items for Juany.  We are not able to put money into savings. We do okay every month but live on a fixed income and this illness not only devastated us physically and emotionally but financially as well.

 On the morning of August 24, 2011, the nurse making rounds noted that Juanita was still having loose, green stools.  Dr. Koduri came in to see her.  He thought she was stable enough to go home, but wanted Dr. Charafeddine’s recommendations first.

Dr. Charafeddine came in to see Ms. Gomez later in the afternoon, and he agreed that she was doing better and was stable enough to go home.  Dr. Koduri wrote a discharge summary, and she was discharged home that afternoon around 5:30 PM.  She was advised to avoid greasy and spicy food, follow her diabetic diet, and to follow-up at St. Thomas Clinic in one to two weeks.

After her discharge from Angleton Danbury Medical Center, Juanita went home with her family by her side.  She was incredibly weak and barely able to care for herself.  The planned celebration of their 50^th wedding anniversary was effectively ruined, as was Juanita’s own birthday.

When they learned the reason Juanita had become so ill, it was a complete shock.  “We were migrant farm workers ourselves for many years and adhered to strict rules of hygiene and never once had we, or any of our nine children, or 30 grandchildren become ill with Listeria. I pray that we never experience this again.”

Frances Elizabeth Mostiller Gilbert loved to travel.  She, her husband Allen Ray Gilbert (“Ray”) and their children, Kathleen and James, spent countless trips exploring the beaches of Florida.  Frances was certainly in her element while near the shoreline.  She was a science teacher and she brought that knowledge and thirst for learning to every family outing.  Her character traits must have rubbed off on her two children, and she now has a microbiologist son and her daughter became a registered nurse.  Given her strong ties to science, her daughter Kathleen states:

It has not gone without notice that my mother would, in fact, be fascinated with the details of her own death.

Frances was a very strong woman.  She endured two major back surgeries in the past five years, while also dealing with the symptoms and treatment of Leukemia and attending to her 92-year-old sister.  She also meticulously cared for Ray, to whom she was steadfast in her devotion.  Ray has suffered two strokes as well as other health issues in the past decade.  When he had a long ICU stay a little over a year and a half ago, Frances was there for every visit and refused to be anything but positive, even when the outlook was grave.  She visited him daily while he was in a rehabilitation hospital for months and lovingly cared for him on his return home, in spite of her own cancer struggles and related oncology appointments.

Cancer: A Battle with Leukemia Fought and Conquered

Frances had Chronic Lymphocytic Leukemia and was scheduled to begin treatment in the Spring of 2011.  She started chemotherapy right after the family’s celebration of her 80th birthday, on March 4, 2011.  Her husband of 60 years, Ray took great joy in all of the planning and effort going into her party.  There was nothing he loved more than making his wife happy.  All four of her beloved granddaughters were there.  The family gave her a small diamond cross necklace to wear as a symbol of hope when embarking on the journey of chemotherapy.  Kathleen wore an identical cross during the months to come.  It was a symbolic gesture to show that the Gilbert family was in this fight together, much like it was with Kathleen’s own cancer battle years ago, when Frances supported her and her young children with love and prayers.

Although chemotherapy for anyone, let along an 80-year-old, is difficult at best, by far it was a battle that Frances had won.  Although weakened from the fight, Ray and the family were optimistic.  While still seeing her doctors every Friday morning, Frances was making plans for moving forward and enjoying the upcoming year.  She had seen an orthopedic surgeon and planned to have knee surgery so that she could increase her mobility—enjoying her remission from cancer even more.

Listeria: A Battle Frances Could Not Win

On Saturday, September 3, 2011, the Gilbert family was together again.  The four granddaughters with their three husbands arrived along with James and Kathleen and their spouses.  Ray had been concerned with the details of this celebration for months—it was his and Frances’s 60th wedding anniversary.

All the plans were in place for a beautiful luncheon at the family’s favorite place.  Fresh flowers, place cards and praline favors were matched by color—Frances’s favorite.  Frances and Ray’s wedding photos were framed for each couple to have as a keepsake and James’s wife, Minette, took pictures during the party that she would later make into a book to give Ray and Frances as an anniversary gift.  None of the family could have ever believed that, on this happy and joyful day, Frances would never live to see those pictures as they sat next to her bed in the intensive care unit, a little more than ten days later.

It was on September 15 that Kathleen was packing to make the trip that afternoon to Louisiana, prior to her mother’s Friday appointment with her oncologist.  As she packed, Ray called to find out exactly when Kathleen would arrive.  As they talked, it became clear that something was wrong—he was becoming increasingly concerned about Frances.  He explained that she had become ill the day before with vomiting and diarrhea, and it had become worse through the night.  But most shocking of all, Frances was unable to speak.  She could not even hold the phone.  Kathleen quickly called her brother, James.  He rushed over to his parents’ home and called an ambulance immediately upon arriving. At first James thought his mom had suffered a stroke.  She was in her bedroom chair slumped to the side, unable to move her limbs or her body.

When the paramedics arrived, they checked Frances immediately and found her severely dehydrated.  She was transported to WK Pierremont Health Center, noting that she had an altered state of consciousness. Although Frances was answering their questions, she could only muster one word responses.  James—trying to avoid what he knew would be a long and stressful night—suggested Ray remain at home.  He agreed after James promised he would call him with updates when something was known about Frances’s condition.

Kathleen arrived in the emergency room while her mother was still waiting for a room.  She recalls her shock upon entering:

I was stunned by her lack of facial expression.  She looked nothing like herself.  Her face appeared slack and the most prominent feature was the look in her eyes.  She looked confused and scared.  There was an awkward attempt at barely a smile when she recognized me and it was the last hint of recognition that I would ever see from her.  She looked so scared and I have never seen my mother look scared of anything.

Frances and the family spent the next hours with a series of revolving doctors and nurses.  Kathleen and James tried to remain calm, but the barrage of emotion made it difficult.  An emergency room nurse said repeatedly, “She’s the sickest person we’ve got in here,” and a doctor said, “She’s the sickest person we’ve seen in some time.”  Once Frances was transferred to the Intensive Care Unit, however, everyone took some small comfort in the prospect that the intravenous fluids and antibiotics she was receiving would result in a big improvement in the morning.  The staff convinced Kathleen and James to go home and get some rest.

The next morning, however, brought no good news.  The prognosis was dire enough that the infectious disease specialist called Kathleen while en route to the hospital stating, “She is the sickest person I have seen in a long time!”  Kathleen was growing increasingly upset at just hearing those words repeated, yet again.  It was later that day that Frances stopped communicating with even simple eye contact.

In shock and disbelief, all of the extended Gilbert family, including Frances’s devoted granddaughters and their husbands, camped out at the ICU and hung on every terrible word from the doctors, each one with their own horror story of Frances’s decline.  Frances started making abrupt, jerking movements with her arms, straightening them out violently and then dropping them to the bed.  These episodes continued at random.  The family could only watch helplessly as their beloved Frances declined.

By the next day, her eyes were becoming crossed, also a neurological sign of the infection that was ravaging her brain by now.  Ray was stunned to near silence as the sight of his wife of 60 years, but he knew she was in there.  He sat in the chair beside her bed, whispering loving words to her while gently stroking her hand.

The focus now was on Frances’s escalating fever of 104°F.  The staff managed to get it down under 102°F, but it would only start right back up again.  This battle continued for days.

The family stayed in shifts.  Kathleen was at her bedside for many of the most unbearable moments as Frances began seizing—just the first of many such episodes to come.  She describes one:

If you haven’t seen a grand mal seizure, the worst and most significant of seizures, then you can barely imagine what it would be like to see your precious, 80-year-old mother who has been fairly motionless for hours begin to flail her arms and arch her back and violently jerk as her head rears back and all the while her eyes are wide open because they have been for days, she is clamping her teeth as she grimaces sucking air in and out as her mouth begins to foam.

All I could do as the nurses ran in was try to touch her jerking shoulder as I cried, “I’m here, mom” and the tears flooded my face and I could hear my own sobbing.  When I thought it was finally over after minutes of this agony, I realized that she was still arched and still sucking in the air with her teeth clamped and it was an eternity before her breathing finally slowed and she relaxed back into the sheets.

After Sunday afternoon, Ray never returned to the hospital.  He said his goodbyes to the woman he had loved nearly all his life, and had shared the last 60 years as husband and wife.  It was simply too hard to see her.

The next days were a progressive blur of more morphine to reduce the body thrashing, followed by less morphine to keep her breathing from becoming too shallow.  Every doctor seemed to have an idea of what Frances needed, whether it was a different antibiotic or simply stopping them altogether because it was pointless.

A feeding tube was started, but it caused unstoppable and constant diarrhea.  Luckily, one of the doctors discontinued the feeding tube completely and after a few hours more, at least, that nightmare was over.  Through all of this Frances’s eyes remained open—a terrified gaze fixed around the room.  She was unable to blink, causing her eyes to dry out.  Eventually they became so dry that her cornea began to tear away from her eye.

Frances was connected to a breathing mask, which eventually became sprinkled throughout with visible blood droplets being exhaled by each breath.  Her mouth and throat started bleeding and weeping steadily, causing the bottom of her mask to fill with a thick, blood-tinged liquid.  Her breathing had become almost systematic—labored, but at a predictable pace.

On the September 21, Dr. Padilla, the infectious disease specialist overseeing her care, came to the family with the news that they had been longing for—the cause of Frances’s infection was certain.  She was infected with Listeria.  The causal link between Frances Gilbert’s Listeria infection and the contaminated cantaloupe grown at the Jensen Farms facility is clear.  In August and September 2011, Frances consumed Jensen Farms/Frontera cantaloupe purchased on numerous occasions at Kroger store #412, located at 4100 Barksdale Blvd, Bossier City, Louisiana.

At 2:25 AM, with her family steadfast at her bedside, Frances Gilbert quietly took her last breath.

“She is far more precious than jewels and her value is far above rubies or pearls.”  Proverbs 31:10

Frances’s memory will be cherished by her loved ones: husband of 60 years, Allen Ray Gilbert; son, James Robert Gilbert and wife Minette; daughter, Kathleen Gilbert Buchanan and husband Buck; grandchildren, Marianne Buchanan Hawkins and husband Michael, Margaret Buchanan Barker and husband Brett, Mary Margaret Gilbert Edmonson and husband Andy, Meredith Kathleen Gilbert and sister, Pauline Mostiller.

Frances Gilbert from Marlerclark on Vimeo.

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.

Continue Reading Being Immune Compromised was Big Risk for this King Sooper Cantaloupe Shopper