2020 Ecofriendly regular asynchronous case conferences

 2020:

Conference title: Patient centred clinical problem solving 2020

Workshop Title: Urosepsis in presence of  comorbidities and clinical complexity 

Guest faculty: Dr Ambarish Bhattacharya sharing his patient 

Active 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, Narketpally 

Passive 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, Australia

Conversational 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