Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Shella Saint Fleur-Lominy, PGY2
12/06/2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 86 year-old woman presents with
decreased urine output and somnolence for
two days.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Four months prior to this presentation, the patient
who had chronic bilateral lower extremity edema
worsening over two months with skin breakdown
was admitted for cellulitis and treated with
vancomycin and piperacilin-tazobactam.
•Hospital course was complicated by septic shock
from hospital-acquired pneumonia requiring
meropenem and discharge to a nursing home
facility.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Two months later, the patient was readmitted from the NH
for septic shock from multilobar pneumonia treated with
vancomycin/meropenem/azithromycin and foley catheterassociated cystitis from multi-drug resistant Klebsiella
pneumoniae treated with polymixin b (MIC = 1.5).
• Hospital course was complicated by vancomycin-resistant
enterococcal central line bacteremia treated with linezolid,
and acute tubular necrosis secondary to sepsis and
requiring hemodialysis for two weeks.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Three days after discharge, the patient was
brought back to the hospital with family
complaining of the patient making very little urine
and observed to be increasingly somnolent since
the day before.
•no other urinary symptoms or fever noted
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Coronary heart disease
•Congestive heart failure
•Insulin dependent Diabetes Mellitus
•Hypertension
•Hypercholesterolemia
•Paroxysmal atrial fibrillation
•Lower extremity venous stasis
•Past Surgical History:
•Triple-vessel coronary artery bypass surgery in 2000
•Cholecystectomy
•Cataract surgery
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Social History:
•Immigrated from Syria
•Lives in nursing home facility
•No recent travel history
•No history of tobacco, alcohol or illicit drugs
•Family History:
•Non-contributory
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Allergies:
•Codeine
•Medications:
•Amlodipine 5 mg daily
•Metoprolol tartrate 12.5 mg twice daily
•Simvastatin 5 mg at bedtime
•Pantoprazole 40 mg daily
•Quetiapine 25 mg at bedtime
•Docusate 100 mg three times daily
•Bisacodyl 10 mg daily as needed for constipation
•Tramadol 25 mg twice a day as needed for pain
•Acetaminophen 650 mg 4 times a day as needed for pain
•Sliding scale of insulin aspart 3 times daily with meal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: elderly woman, lying in bed sleeping and in
no apparent distress.
•Vital Signs: T:97.2 BP:112/56 HR:64 RR:16 and O2
sat:96% on room air.
•Mental status: lethargic but arousable, oriented only
to self and place, falls right back to sleep during
interview.
•Exam significant for irregularly irregular heart rate,
bilateral crackles at the lung bases, trace bilateral
lower extremity edema, dry diaper on.
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: hemoglobin 9.0 g/dL; hematocrit 30 %
•Basic Metabolic panel: urea nitrogen 67 mg/dL, creatinine
2.8 mg/dL, glucose 128 mg/dL
•Hepatic panel: aspartate aminotransferase 136 U/L,
alanine aminotransferase 72 U/L, albumin 3.1 g/dL
•Erythrocyte sedimentation rate 61 mm/hr (0-20)
•B-type natriuretic Peptide 18000 pg/ml (<300)
•Remainder of the laboratory findings were within
normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Urinalysis:
- yellow and turbid
- moderate blood
- 3+ protein
- positive nitrite
- large leukocyte esterase
- 26 red blood cells
- >100 white blood cells
- 3 squamous epithelial cells
- moderate bacteria
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•ECG: atrial fibrillation at the rate of 63
•Chest X-Ray: bilateral hazy opacities
consistent with edema, small bilateral
pleural effusion
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnoses
• Urinary tract infection
• Congestive heart failure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Days 1-4:
– The patient is started on intravenous vancomycin
and tigecycline. She also received one dose of
cefazolin and one dose of tobramycin.
– Urine culture grows E. coli (sensitive only to
cephalosporins, carbapenems and
aminoglycosides) and K. pneumoniae (sensitive
only to tigecycline; polymixin B MIC= 8)
– Blood cultures remain no growth and vancomycin
discontinued
– The patient is successfully diuresed
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Days 5-10:
– Mental status returns to baseline.
– 10-day course of Tigecycline is completed.
– Urine output returns to normal and remains
stable.
• The patient is discharged to nursing home
on hospital day 11
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Cystitis from multidrug resistant Klebsiella
pneumoniae and E. coli
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS