Transcript A Not So Simple UTI - LSU School of Medicine

Case Conference
October 1st, 2013
Phuong Dinh, Ben Triche & Alisha Lacour
Chief Complaint

 Headache X 5 days
HPI

 63 year old male with a PMH diverticulitis and Hepatitis B
 8 days prior to presentation: has non-bloody, watery diarrhea
that lasted for 2 days and resolved spontaneously.
 5 days prior to presentation: Pt developed a sharp, stabbing
left-sided frontal headache, that gradually worsened.
 Headache was centered over Left temple and radiated up to his
scalp.
 Pt admitted to fevers, chills, blurred vision, arthralgias, and
myalgias.
 He denied shortness of breath, cough, neck stiffness, confusion,
N/V, or any other symptoms.
Past Medical History

 Diverticulitis
 Hepatitis B (1971)
 Chronic Lower Back Pain
Past Surgical History

 Lasik
 Back Surgery
Allergies

 NKDA
Medications

 Celecoxib 100mg PO BID
Family History

 Mother died of heart disease
 Father died of Alzheimer’s Disease
 2 Brothers with Heart disease
Social History

 Smokes 1 pack per day for 50 years
 Rarely drinks on special occasions
 Denies any illict drug use
 Lives at home alone
 Retired massage therapist
Health Maintenance

 Not up to date on influenza immunization
 Not up to date on Tetanus immunization
 No colonoscopy
ROS

 Constitutional: Positive for fever and chills.
 HEENT: Negative for hearing loss, ear pain, facial
swelling, neck pain, neck stiffness and ear discharge.
 Eyes: Negative for pain, discharge, redness and itching.
 Reports of blurriness of vision and mild photophobia
associated with his headache.
 Respiratory: Negative for apnea, shortness of breath and
wheezing.
 Cardiovascular: Negative for chest pain, palpitations, leg
swelling and syncope.
ROS (cont’d)

 Gastrointestinal: Positive for diarrhea. Negative for
abdominal pain.
 Genitourinary: Negative for dysuria and hematuria.
 Musculoskeletal: Positive for back pain.
 Neurological: Positive for headaches. Negative for
dizziness, speech change, focal weakness, seizures, loss
of consciousness, facial asymmetry, weakness and
numbness.
 Psychiatric/Behavioral: Negative for memory loss and
altered mental status.
Physical Exam

Triage Vitals
 Temperature 98.0° F
 Blood Pressure 145/80
 Pulse 96
 Respiratory Rate 16
 O2 Sat 93% on RA
 Height 5’8”
 Weight 79 kg
 BMI 26
Exam Vitals
 Temperature 101.7° F
 Blood Pressure 107/79
 Pulse 88
 Respiratory Rate 16
 O2 Sat 96% on RA
Physical Exam

 GENERAL: Awake, alert, and oriented. Squinting in pain.
 HEENT: PERRL, EOMI, Left temporal artery more prominent
than right. No tenderness to palpation. Decreased visual
acuity of left eye (20/200- left vs. 20/100- right).
 NECK: supple, no nuchal rigidity
 CARDIOVASCULAR: Tachycardic, Regular rhythm. No
murmurs. 2+ radial and DP pulses.
 RESPIRATORY: No increased work of breathing. No crackles,
rales, wheezes
 ABDOMEN: Bowel sounds present. Soft. Nontender.
Nondistended.
 EXTREMITIES: No clubbing, cyanosis, or edema.
Labs

134
100
12
3.4
25
1.02
Ca 8.5
Mg 1.6
168
Phos 2.1
TP Alb TB AST ALT ALP
6.9 3.2 0.7 101 110 92
(<45) (<46)
11.1
14
93
191
41.9
13.5
N 92 L 4 M 3
HIV – nonreactive
U/A - WNL
ESR - 72 (0-20)
CRP – 23.96 (<0.90)
Electrocardiogram

ER Course

After initial workup, differential diagnosis
were:
 Trigeminal Neuralgia
 Temporal Arteritis
Given his elevated ESR and CRP he was
started on prednisone 60mg
Medicine was consulted for admission
ER Course (cont’d)

 After Medicine Oncall Team had finished evaluation
of patient and were writing admission orders, the
patient spiked a temperature of 105.3, which
prompted further workup.
 Patient was empirically started on Vancomycin,
Ceftriaxone, Ampicillin, and Ciprofloxacin for
suspected meningitis
 The Medical ICU was consulted
 Lumbar Puncture was performed
Lumbar Puncture Results

CSF Clear
Glucose 90 (40-70)
Total Protein 49.6 (15-45)
WBC 0
RBC 2
Additional Lab Orders

 Additional Lab Orders placed:








Blood cultures
Urine culture
Legionella Antigen
Hepatitis Panel
T spot
Rheumatoid Factor
ANA
Cryoglobulin
CXR

CTA Chest

CTA Chest

CT Head

Hospital Course

The patient was admitted to the ICU with
the following active problems:
Sepsis secondary to pneumonia
 Continued on Vancomycin, Ceftriaxone,
Ampicillin, and Ciprofloxacin
Temporal headache
 Continued on Prednisone
Hospital Course – day 2

 The patient was afebrile and was stable for transfer to the
floor.
 Ophthalmology was consulted for evaluation due to
concern of Temporal Arteritis. A full eye exam was
performed showing sharp disc margins, and no evidence
of temporal arteritis.
 Neurosurgery was consulted for temporal artery biopsy.
 Prednisone was continued.
 Antibiotics were changed to Ceftriaxone and
Azithromycin for Community Acquired Pneumonia.
Hospital Course – day 3

 Patient had a temperature of 101.0 overnight.
 Vancomycin added back to cover for potential postviral MRSA pneumonia.
 Neurosurgery planning for temporal artery biopsy.
Recommending an MRI to better workup
abnormality seen on CT imaging.
Hospital Course – day 4

 MRI Brain completed
 Patient’s Legionella Antigen resulted Positive
 Antibiotics were changed to Ciprofloxacin 400 IV q12
 This was selected secondary to cost of medication
MRI Brain

MRI Brain

MRI Brain

MRI Brain

Hospital Course

 Films reviewed with Neurosurgery. Pt has
cavernous malformation in Left basal ganglia. This
could not be removed safely because of its location in
eloquent brain. It was recommended to repeat MRI
in 3 months and follow up in Neurosurgery clinic for
follow-up.
 Neurology evaluated the patient who believed that
the patient has Trigeminal Neuralgia and
recommended Carbamazepine.
Hospital Course

 Patient was continued on IV Ciprofloxacin for 2
more days and then discharged on Ciprofloxacin
750mg PO BID x 14 days.
 He continued Carbamazapine outpatient for his
headaches and was given follow up with Neurology.
 Repeat MRI scheduled for 3 months from discharge.
Diagnosis

 Legionella Pneumonia
 Trigeminal Neuralgia

Thank You