2020:
Conference title: Patient centred clinical problem solving 2020Workshop Title: Urosepsis in presence of comorbidities and clinical complexityGuest faculty: Dr Ambarish Bhattacharya sharing his patientActive participants:Ambarish Bhattacharya -Consultant at Nightingale Hospital,Kolkata, Consultant (medicine) at Spandan Hospital and Consultant at The Apollo Clinic, Saltlake
Tarun Chakrabarti, Consultant Medicine, Apollo Gleneagles, Kolkata
Pankaj Pant, Consultant Physician, Kathmandu
Boudhayan DM, Asst professor, Medicine, AIIMS, Deoghar
Aadipta Ghosh, MBBS Student, IQ City Medical College Durgapur
Rakesh Biswas , Prof Medicine, KIMs, NarketpallyPassive participants: 1800 asynchronous online global participants consisting of MBBS and MD students, senior residents, independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, AustraliaConversational learning outcomes:Dr Ambarish Bhattacharya presents the patient data:"70 yrs lady. T2DM, IHD, COPD, Obese with H/o # lower end of femur and hence bedridden for more than a month.Presented with off and on drowsiness and loss of appetite. Outside reports showed poor sugar control, fluctuations from Hypo to 400. Urine shows plenty of pus cells and growth of Staph. Aureus. Hb 9, TLC 16000, CRP 151, Creatinine 1.5, Na 125. Samples repeated after admission. Now culture growth Enteroccus. All others similar.Treated with Basal bolus insulin, Tolvaptan, Meropenem + Linezolid, Clexane. After 5 days CRP 45, Creatinine 0.9, TLC 12500, Na 134, Sugar well controlled. Planning for discharge.After 2 days patient has hematuria. CRP increased to 121, Creatinine 1.2, INR 2.3, aPTT > 100, Platelet 190,000, TLC 10,000, Hb 7.7. BT, CT normal. Now urine growing Candida sensitive only to Caspo & Micafungin. Caspo started, antibiotics changed to Tiecoplanin and Moxiflox, FFP given. TLC now 9500, PT, aPTT normal, Hb/Platelet/Na/K all stable but CRP now 150. Clinically other than pallor and few bedsore there is nothing. Blood cs no growth, Amylase/Lipase/RF normal, CXR normal, USG chronic cystitis.Reports of D-Dimer, FDP, ANF awaited.What should be the next line of management?Active participants inputs:
Inputs from Tarun Chakrabarti
"Discharge her with narrow spectrum oral antibiotics (according to sensitivity report) for at least 2weeks.put a catheter.Repeat urine c/s after 2weeks.
This is a case of urosepsis with metabolic encephalopathy.At this age isolated raised CRP has not much significance.Instead can do PCT.What is LFT report?why ANF,RF,amylase,lipase done?"
AB reply
Tarun Chakrabarti Only low Albumin. All others normal.
Even Procal normal.
Inputs from Pankaj Pant:
Any underlying conditions like multiple myeloma
AB reply
Pankaj Pant Pending reports: ANF, D-Dimer, FDP, Protien electrophoresis
Input from Boudhayan DM:
What is ESR ?
AB reply
Boudhayan Dm 80. But Hb is 7. Microcytic hypochromic
Input from Rakesh Biswas
Interesting urine culture fluctuations. First staph then enterococci then fungi. What was the enterococcus susceptible to?
Sanchita Das, Biswaroop Chatterjee, Dipmala Das, would you like to comment
AB reply
Rakesh Biswas More problematic is the sudden rise in CRP with rise in INR and aPTT along with fall in Hb, Tc, Dc and Albumin. And Hematuria. But Bilirubin, ESR, Platelets remains same. No rash or arthralgia. All lines changed. Daily UB wash with saline. New sets of Blood cs, Urine cs, stool cs sent. Reports of C. Diff toxin, ANF, Protein eletrophoresis, FDP, D Dimer still awaited
RB reply below
I guess as long as the WBC counts and clinical symptoms are holding well we can breathe easy? Will be keen to see how the current abnormal markers evolve.
Input from Aadipta Ghosh
You can do a lipid profile. CRP rises with increased LDL. Rule out underlying malignancies, inflammatory bowel disease and do an autoimmune panel.
RB reply
Please share links to the utility of lipid profile in correlation with CRP
RB reply after Aadipta shares links :
Thanks Aadipta. Can you quote the relevant portions that suggest that it helps in further management.
Aadipta reply:
Quote "In conclusion, our data show that Ox-LDL and hs-CRP levels correlate positively in ACS patients, supporting the hypothesis that Ox-LDL and CRP may play a direct role in promoting the inflammatory component of atherosclerosis in these individuals. We suggest that Ox-LDL/CRP elevated levels may serve as markers of the severity of the disease in evaluation and management of ACS patients."
RB reply:
They suggest they could be markers but that's a long way away from being useful in such a case scenario?
Two days later inputs from Pankaj Pant
Any updates or diagnosis?
AB reply Pankaj Pant Pyelonephritis
Update two more days later by AB
TLC came down from 17500 to 13400 but now again increased to 15200.
CRP down from 235 to 144, but BP dropping. Needs Norad but urine output holding. No growth in any cultures
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