Morbidity & Mortality Case Conference 00776886-4

1. Morbidity & MortalityCase Conference00776886-4 John C. Araujo MD, Ph.D.

2. CC: Nausea and Diarrhea • HPI: • Mr. S. is a 62 year old male who presented to the ED at DHMC with one day of nausea and profuse watery diarrhea.

3. HPI Continued: • Symptoms began yesterday AM. (12hrs after eating at a local restaurant.) • Non-bloody diarrhea, 6-7 x a day. • + abdominal cramps relieved with BM. • No associated fevers or sweats. + Chills. • No jaundice. • No recent travel. • No sick contacts.

4. HPI Continued: • L inner thigh pain. Started yesterday. • Came on suddenly while sitting at his work bench. • Describes pain as a “deep ache.” • No antecedent injury. • No Leg swelling, redness, or warmth. • No recent prolonged immobility. • No personal or family history of blood clots.

5. PMHx: • Obstructive Uropathy: • Incontinence 1995. • Urodynamics --> Atonic bladder. • BPH. • Treatment recommendation: intermittent straight catheterization. Obstructive Uropathy • Admitted with uremia and renal failure 1997. • Self discontinuation of catheterization. • BUN/CR 176/17 • Renal U/S: severe hydronephrosis with marked cortical thinning. • D/C with indwelling foley --> straight cath. • Baseline Cr 3.4 -3.7 Range. • H/O recurrent UTIs. • Cx + multiple organisms: E. Coli, MSSA, Citrobacter.

6. Medications: None Allergies: Sulfur and Penicillin -- Rash Social Hx: Married. Lives in Lebanon. Employed as a machinist in a local factory assembling motion detectors. Non smoker. Occasional beer with dinner. No illicit drug use.

7. Family Hx • Father died of a MI at 79. • Mother died of CHF at age 90. • No family history of cancer or DM. ROS • No hematuria. • No dysuria. • No flank pain. • Continues to straight cath.

8. Physical Exam: • Gen: Ill appearing man laying in bed, NAD. • VS: T: 37.6 C HR 98 BP 112/64 RR 14 • No orthostatic BP or HR changes • HEENT: NCAT, sclera anicteric, OP- clear, dry MMM. • Neck: supple, no LAD, CVP not visualized. • Lungs: CTA B/L. • CV: RRR, Nl S1S2, no MGR, strong distal pulses. • ABD: Active BS, soft, non-tender, no HSM.

9. Physical Exam: • Back: No CVA or spinal tenderness. • Ext: No C/C/E. L medial thigh diffusely tender to palpation. No erythema, warmth, swelling, fluctuance, or crepitus. + shotty inguinal LAD B/L. • Neuro: A&Ox 3, strength 5/5 throughout, sensation intact to L.T. • Derm: No rash. • Rectal:NT, nontender, symmetrically enlarged/smooth prostate, heme positive.

10. Laboratory Tests: 10.0 \ 15.0 / 157 / 44.6 \ N45 B51L4 141 | 106 | 47 CK 202 4.2 | 19 | 3.8LFTs WNL UA: SG 1.019, pH5.5, no ketones, no NIT, trace leuk EST, 39WBC, 21 RBC. Blood Cx and Urine Cx sent

11. LLE Duplex - U/S • No evidence of DVT. • No fluid collection or abscess. • No gas visualized.

12. Assessment:62 yo man with a h/o obstructive uropathy presenting w/ nausea, diarrhea, and L thigh pain out of proportion to exam. Laboratory examination remarkable for a significant bandemia w/o fever or leukocytosis, heme + stool, an abnormal U.A and a normal LE duplex. • DDX: • UTI or early Pyelonephritis. • Possible Gastroenteritis. • Muscle strain vs. focal myositis vs. DVT

13. 6 hour ED Course: • IVF: 3L NS. • Compazine 10mg IV x1. • Percocet 5/325mg PO for pain x1. • Pt reported marked improvement after the IVF. Leg pain persisted but improved. • Nursing note: “I feel great.” • Able to drink clears while in ED. • Unable to give stool sample.

14. Discharge Medications: • Ciprofloxacin empiric therapy for UTI. • 250 mg PO BID x 10 days. • Oxycodone for pain. • 5mg PO Q 4-6 PRN pain. • Immodium PRN diarrhea. • 4mg initially and 2mg after each loose stool to max 16mg QD. • Compazine suppositories PRN nausea. • 25mg PR BID PRN.

15. Discharge Instructions: • Stay well hydrated. • Drink at least 2 liters of water a day. • Call PCP in AM for follow-up appointment. • Return to the ED with worsening pain, increased diarrhea, fever, or if unable to keep down liquids.

16. How Useful is the Differential WBC Count for Predicting Bacterial Infection?Wasserman, M. et al. “Utility of Fever, White Blood Cells, and Differential Count in Predicting Bacterial Infections in the Elderly.” Journal of the American Geriatrics Society. 37(6) 537-543, 1989. • 420 patients between 65-99 y.o. evaluated in a community ED for fever, leukocytosis, and bandemia as a screening method for predicting bacterial infection. • Fever >37.5, leukocytosis > 14,000, bandemia > 6%. • All patients who had a CBC (220/420) included. • Bacterial infections defined as: • + blood Cx • + urine Cx and Pyuria • + sputum Cx and CXR with an infiltrate.

18. Return to the ED: • New rash over his face, neck, and now trunk. • No urine output over the last 24 hours. • Leg pain now much worse. • No oral intake x 24hrs despite improvement in his nausea and diarrhea.

19. Exam: • Gen: well developed, well nourished man, NAD. • VS: T 36.7C HR 124BP73/44RR 22 Sat 97% RA • Derm: diffuse, confluent, erythematous rash over his face, neck, chest, back, extending to the inguinal region. • HEENT: sclera anicteric, conjunctiva pink, OP-clear. • Neck: supple. • Lungs: CTA • CV: Tachy, RR, no murmur • ABD: +BS. Soft, NTND, no masses or HSM. • EXT: significant pain in the region of the L thigh adductor with increased swelling. No overlying erythema or bullae. No warmth, fluctuence or crepitus.

20. LABS 6.4 \ 15.1 / 82 N 12 B80131| 99 | 99 / 46.3 \ 5.2 | 9 | 7.6 INR 1.4 Ca 8.0 Phos 7.0 Mg .62 Alb 2.4 PTT 39Tbili 0.4 Dbili 0.2 ALT 73 AST 68 CK 1020Cultures: NGTD EKG: sinus tach w/o ST-T wave changes

22. Problem List: Hypotension Acute on Chronic Renal Failure Bandemia Thrombocytopenia Coagulopathy Transaminitis Elevated CK Hypoalbuminemia Diagnoses: Sepsis Toxic Shock Syndrome Myositis vs. Fasciitis Group A Streptoccoci S. Aureus C.Perfringens Mixed facultative organisms Possible DIC Urosepsis

23. Plan: • Volume Resuscitation • Blood Cx now • Empiric antibiotics • Cefazolin 1gm IV now then 500mg IV Q12hrs • Clindamycin 600mg IV q 12hrs • Gentamycin 160mg IV q 48hrs • STAT MRI of the L thigh • STAT Surgery Consult • Plan for admission to the ICU

26. Arrival in the ICU • Central access obtained. Pulmonary artery catheter and A-line placed for close hemodynamic monitoring. • Initial Readings CVP 7, PAP 35/17, PCWP 15, CO/CI 15.8/7.6, SVR 232. • Surgical evaluation: • Picture c/w septic shock and myositis. • Plan for immediate exploration & debridement if necessary. • Infectious Disease evaluation: • Picture c/w Group A Streptococcal myositis with a toxin mediated syndrome. • Add IVIG 400mg/Kg QD x 5 days.

27. Cochrane Report- IVIG for treating sepsis and septic shock- Cochrane Library, Issue 2, 2002 • RCT’s comparing IVIG to placebo or no treatment • 27/55 studies met criteria • Pooled analysis of 8,856 patients RR 0.91 (CI 0.86-0.96) • Polyclonal IVIG- n=492; RR 0.64 (CI 0.51-0.80) • Mortality was not reduced with use of monoclonal IVIG (anti-endotoxins, anti-cytokines)

28. IVIG for Streptococcal Toxic Shock Syndrome- Clin Inf Dis 1999;28:800-7 • Observational study- Ontario Streptococcal Study Group • 1994-95- during winter months • Tx included IVIG, clinda, PCN and surgery if indicated (or no IVIG) • Historical and observed case-fatality rate 65% • Primary outcome 30 day survival • Cases (21)- 67% Controls (32)- 34% OR 7.7 • Superantigens bind to cells MHC Class II- interact with B chain of T cell receptor to cause massive proliferation of T cells and cytokines • IVIG blocks in vitro T cell activation

29. Intra-operative Report • Edema encountered w/i the subcutaneous tissues. Fascia appeared “viable.” • Underlying adductor muscle described as “pink” and contracted with electrocautery. • Exploration showed no extension of infection. • Penrose drain left in place. • Wounds irrigated and packed with gauze dressings. • Two biopsies were sent for pathology and culture.

31. Hospital Course ICU Day 1 • Patient remains intubated post-op. • Persistent hypotension despite aggressive fluid replacement and support with Neosynephrine and Norepinephrine. • Renal failure with severe acidosis requiring initiation of CVVHD. • Rising oxygen requirements and ARDS develops. • Severe thrombocytopenia w/o true DIC. • No other source of infection identified. • All cultures remained NGTD • Pt. Made DNR per his wife and living will.

32. Hospital Course ICU Day 2 • Milrinone and Vasopressin added for further support. • Oxygen requirements increase. • Clindamycin, Gentamycin and Metronidazole continued. Cefazolin dc’d. • Pt sustains Acute MI with peak CPK of 1263, Troponin rises to 11.8. With ST elevations in the anterior leads.

33. Hospital Course ICU Day 3 • Situation deemed futile. • Wife decides to withdraw support. • Patient expires.

43. Final Anatomic Diagnosis I. Widespread sepsis A. Acute myocarditis B. Early bronchopneumonia C. Difluent spleen D. Acute myositis, left thigh (S-01-4789) E. Deep cutaneous fungal infection of the left thigh. II. Prostatic hyperplasia with focal prostatitis and infarction. A. Chronic obstructive uropathy. B. Chronic pyelonephritis with near end-stage kidneys. C. Focal acute pyelonephritis D. Urinary bladder hypertrophy. E. Chronic renal failure (clinical). III. Other Findings A. Bilateral lower lobe lung collapse and congestion 1. Focal pleural thickening and fibrosis, bilateral 2. Focal osseous metaplasia in lung. B. Coronary artery atherosclerosis 1. Congestive heart failure i. Bilateral pleural effusion, 1.0 liters on each side ii. Generalized organ congestion (liver, spleen, lungs). iii. Pericentral hepatic hemorrhagic necrosis iv. Pedal and scrotal edema C. Gall bladder adenoma

44. Bibliography 1) Wasserman, M. et al. “Utility of Fever, White Blood Cells, and Differential Count in Predicting Bacterial Infections in the Elderly.” Journal of the American Geriatrics Society. 37(6) 537-543, 1989. 2)Kaul, R. et al. “Intravenous Immunoglobulin Therapy for Streptococcal Toxic Shock Syndrome - A Comparative Observational Study. CID. 28: 800-7, 1999.