A 56-year-old man with fever, ascites and abdominal pain
Michael S. Donnenberg, M.D.
Associate Professor of Medicine
University of Maryland
PRESENTATION OF CASE
The patient was a 56-year-old man who presented with fever and chills associated with ascites, abdominal pain and a hacking cough with scant hemoptysis. The symptoms started two days prior to presentation following an extended trip in an open-air cart during the winter. Respirations were labored due to pleuritic and abdominal pain. The patient had a long history of gastrointestinal problems and childhood asthma. His initial gastrointestinal symptoms, which began at the age of 22, were intermittent abdominal pain and diarrhea. The symptoms progressed and by the age of 31 he complained of abdominal pain associated with alternating bouts of diarrhea and constipation, sometimes progressing to obstipation. Four years prior to the onset of this illness, he had a bout of abdominal pain, vomiting and diarrhea accompanied by jaundice which lasted several months before resolving. Initially alcohol would relieve the pain but later in the course of his disease, alcohol would exacerbate the pain and diarrhea. Two years later, the onset of lower extremity edema was noted accompanied by reports of occasional epistaxis, hematemsis and hemoptysis.
Another dominant feature of the patient’s medical history was deafness which had its onset at the age of 28. Hearing difficulties started in the left, followed by the right ear in association with tinnitus. High pitch tones were lost initially, followed by low tones with the development of total deafness by the age of 44. The impact this problem on the patient’s well-being was magnified by the fact that he made his livelihood as a musician. His loss of hearing was associated with progressive depression, social isolation, self-neglect and frequent inappropriate behavior. Other medical problems included asthma, occasional bouts of “rheumatism” and gout as well as a history of 9 months of a painful eye which required patching. The patient’s younger brother was a pharmacist and frequently supplied him with a broad array of unspecified medications which the patient took in an erratic fashion.
The patient’s father died of complications from alcoholism and his mother and brother died of tuberculosis. The patient was unmarried, and the details of sexual contacts are not clear. He did not smoke but consumed moderate to large quantities of alcohol on a regular basis with a penchant for sweet Hungarian wines and beer.
On examination the patient appeared ill and in moderate respiratory distress. He was lying on a stretcher, groaning in pain. He showed signs of wasting and was febrile with occasional rigors. Icterus with jaundice were superimposed on darkly pigmented skin with erythematous cheeks. Breathing was shallow and rapid. There was dried blood in the nares as evidence of recent epistaxis. The abdomen was markedly distended with obvious signs of massive ascites. Hard nodules were palpated in the liver. The legs were markedly edematous and there were scattered petichiae present.
Over the next two days, the ascites worsened, making breathing difficult. In addition, the patient developed jaundice, rigors and frank hemoptysis. Treatment with a salycilate-based, anti-inflammatory regime provided significant relief, however five days later abdominal pain returned in association with rigors, vomiting, diarrhea, and worsening ascites and edema. A paracentesis was performed which yielded 11 liters of cloudy fluid. This provided a degree of relief but the procedure was complicated by continual seepage from the puncture site and an erysipeloid wound infection. Ascitic fluid eventually reaccumulated and a second large-volume paracentesis which yielded clearer fluid was performed several weeks later. Ascitic fluid continued to accumulate and two additional paracentesis were performed over the next six weeks. A number of unspecified medications, as well as alcohol, were administered in an effort to treat the associated abdominal pain. The patient languished for an additional four weeks becoming progressively more edematous and wasted. Hemoptysis and epistaxis became more frequent and he eventually developed anuria, became comatose and died.
A post mortem examination was performed.
Ludwig van Beethoven died on March 27, 1827, and a post-mortem examination was performed and recorded by Dr. Johann Wagner, who was then an Assistant at the Vienna Pathologic Museum. His findings, originally written in Latin, were lost and rediscovered in 1970. Beethoven’s body was exhumed twice, in 1863 and again in 1888.
Dr. Johann Wagner’s findings:
The corpse was emaciated and covered with petechiae. The abdomen was unusually dropsied and stretched. The auditory nerves were shrivelled and destitute of neuronae. The convolutions of the brain appear deeper, wider, and more numerous than ordinary. The calvarium exhibited great density and thickness throughout, amounting to one-half inch. The chest cavity and its contents were normal. The abdominal cavity contained four liters of greyish-brown turbid fluid. The liver was half the normal volume and greenish-blue in color and beset with knots. The vessels were narrowed and bloodless. The spleen was more than twice its normal size, dark colored and firm. The pancreas was equally hard and firm. Both kidneys were invested by a cellular membrane an inch thick. Every one of their calyces were occupied by a calcaneous concretion of a wort-like shape and as large as a split pea.