A 66-year-old North African male with no past medical or family history consulted for the management of a left iliac fossa pain evolving over the course of two months. He was retired and did no smoke nor consume alcohol. He was not undergoing any medical treatment. The patient’s chief complaints included an alternation of diarrhea and constipation, as well as asthenia.
On admission, it was found that the patient was underweight (BMI = 17) with an average general condition (PS = 2) and pale conjunctivae.
Physical examination found no fever (Temperature = 37,3 °C), normal blood pressure (120/80 mmHg) and normal pulse (80 bpm). Neurological examination was normal (GCS = 15/15).
Abdominal examination found a tenderness in the left iliac fossa with no obvious palpable mass. There was no evidence of hepatomegaly nor splenomegaly.
The lymph node areas were free. The digital rectal exam was normal, with no rectal bleeding and no identifiable intra-rectal mass.
The biological assessment showed:
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Blood Group: B ( +) positive
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CBC: WBC = 10,40 × 103/ μL, #Neu = 4,82 × 103/ μL, #Lym = 3,18 × 103/ μL, #Mono = 0,72 × 103/ μL, #Eos = 0,29 × 103/ μL, #Baso = 0,05 × 103/ μL, RBC = 3,57 × 106/ μL, Hb = 12 g/dL, HCT = 33%, MCV = 84 fL, MCH = 28,9 pg, MCHC = 31,8 g/dL, RDW = 14,2%, Platelet = 235 × 103/ μL, MPV = 9,5 fL, Na+ = 146 mmol/L, K+ = 3,8 mmol/L, Urea = 5,4 mmol/L, Creatinine = 70 μmol/L, Alanine aminotransferase = 45 IU/L, Aspartate aminotransferase = 43 IU/L, Gamma-Glutamyl Transferase = 70 IU/L, Alkaline Phosphatase = 93 IU/L, Total bilirubin = 17 μmol/L, Conjugated bilirubin = 5 μmol/L, Albumin = 55 g/L.
The patient had an abdominopelvic computed tomography (CT) scan which showed a 12 cm long axis, stenosing sigmoid tissue mass associated with left pelvic adenopathy of 1,7 cm.
A colonoscopy showed an ulceroburging process of the sigmoid, the biopsy of which revealed a moderately differentiated Lieberkuhnian adenocarcinoma. The locoregional and distance extension assessments were negative. The patient underwent surgery.
Per-operatively, a 20 cm long axis invading tumor was found at the sigmoid colon complicated with a peri-neoplastic abscess. However, several adhesions did not allow exploration of the liver. There was neither ascites liquid nor carcinosis nodules.
The patient had a monobloc resection of the sigmoid colon and invaded hail with end-to-end hail-to-hail anastomosis with the confection of a double Bouilly Walkman stoma.
During the first post-operative week, the patient was on alternate infusions of saline and glucose serum. On day seven post-operatively, we introduced oral feeding, which was not well tolerated by the patient.
The postoperative period was marked by installing soft white edema of the lower limbs keeping the cup associated with ionic disorders such as hyponatremia (Na+ = 130 mmol/L) and hypokalemia (K+ = 2,9 mmol/L) associated with hypo-protidemia (Protein = 44 g/L) and hypo-albuminemia (Albumin = 26 g/L). The patient was fully conscious Neither tachycardia nor arterial hypotension were noted.
After regulating ionic disorders, and given the patient’s undernourished condition, he was placed on exclusive parenteral nutrition on day thirteen post-operatively. On day sixteen post-operatively, the patient presented a sudden worsening of his neurological state with a fluctuating GCS between 10–11/15 without convulsions. Physical examination found no fever and no infectious signs (clear urine, no veinitis, clean surgical wound).
The biological report found no metabolic disorders.
The patient’s altered neurological status was accompanied by a drop in blood pressure and worsening of edema in the lower limbs which required sedation, intubation, and vasoactive drugs.
A cerebral and thoracic-abdominal-pelvic CT scan were performed with no abnormalities.
The patient had a cerebral magnetic resonance imaging (MRI), which showed a hyper signal of the mammary bodies (in FLAIR coronal section) (Fig. 1) and a hyper signal of the mammary and peri-aqueductal bodies (in FLAIR axial section) (Fig. 2).
This aspect was compatible with Gayet-Wernicke’s encephalopathy and a right anterior frontal juxta-ventricular lesion measuring 1,5 cm long axis, corresponding to a cavernoma or a secondary hemorrhagic lesion.
The patient underwent vitamin B1 1000 mg/day intravenous (high dose) for three days starting on day eighteen post-operatively.
On day twenty-four post-operatively, even under high doses of vasoactive drugs, patient was 80/50 blood pressure and desaturated at 92% SpO2. He then experienced a cardiorespiratory arrest which did not respond to adequate resuscitation. No precipitating condition for the cardiorespiratory arrest could be formally identified, but high output failure remains the most likely cause.
