Another case for Sepsis week.
67 yo. male traveller. Recently been on vacation in Scotland, then spent a week in Singapore, flew into Perth (WA) then up to Broome to sit on the beach. Spent all his time in metro areas, no farm / rural / jungle exposure.
Presents to the ED with a 2 day history of fevers, sweats and feeling generally miserable. This case occurred in the midst of the Aussie swine flu pandemic – so he was fully loaded with Tamiflu as soon as he hit the front door! However, this man had no respiratory symptoms at all – not even a sniffle. Actually he had no good localizing symptoms at all. No cough, rash, diarrhea, no headaches, no abdo pain – nothing…
He had impressive fevers – t > 39, spiking every 3 – 4 hours. But his other numbers remained relatively normal. Examination was not really helpful – no ENT, chest, abdo or skin signs. His urine was clean on dipstick. A CXR was done in ED – normal, nothing to see.
UECr = normal,
LFTs: alb = 34, ALT and GGT just up, bilirubin = 16
CRP = 67
Cultures sent, rapid malaria kit / films Negative for malaria. Serology sent for flu / respiratory panel
So – what to do? Well the thinking was that he had likely early viral illness – and he was admitted for observation and not given any antibiotics. ”Reculture if febrile” The next day his obs chart showed ongoing impressive fevers – spiking up to 40 every 4 hours. Still no good signs. He felt a bit nauseated and was dry from the sweats.
UECr = slight bump in urea, Cr now 110 (up end of normal)
LFTs = albumin 29, ALT and GGT now about double normal ALP a bit up, bilirubin = 37
CRP now 189!
OK – what do you want to do next?
Ok, all you fever hunters – what is your next move?
So my next move…. go back and take the history again. I didn’t take the original history in ED, so I went back to the bedside and probed a bit more into what had been going on over the past few weeks, months etc. All this whilst the nurses were making up a batch of broad-spectrum bug poison!
He got better, and didn’t really think about it until asked… Oh, actually, he had still been getting some mild lower abdo “aches”, “nothing he’d take a pill for though”. And when pushed on history, the fevers, well, they had been intermittent for a few weeks, only became “troublesome” in the past few days!
So, I thought. BINGO – he has a diverticular abscess, partly treated by the ABs, and still causing fevers. Lets scan him.
At this point I was feeling pretty smart – I thought I had found a fever source and could carry on with the ABs, call a surgeon, and he would be OK.
History remains one of our best weapons. It would be easy to order a batch of tests and cover with ABs until we get the results, but I am still constantly surprised in my practice how often the patient will tell you the answer if you probe with a careful history. Sometimes you need to ask questions in differents ways to get the info you need. and remember patients are human – they forget, overstate, get distracted and sometimes even lie!
So what happened – this man got tazobactam / pipperacillin on advice from a Micro guru and flown out for percutaneous CT guided drainage of his liver abscesses – these were polymicrobial, likely stemming from his diverticuitis the weeks before.
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Hi casey
nice work with the sepsis cases.
this guy in this case needs more workup. He needs an echo, serial blood cultures. Q fever serology as well…although less likely given the recent positive BC results
endocarditis till proven otherwise.
…and fill him full of ABs on advice local microbiologist/sensitivities whilst awaiting results of Minh’s more detailed workup.
So I get that he’d need serial BCs if you didn’t already have a positive but what will they change now that you have your bugs? I agree that a TEE/TOE is pretty important here though
you should be careful diagnosing endocarditis on only one set of cultures. when I was doing internal medicine for my advanced skills year, we would hold off on IV ABs until we had three sets of serial BCs over 6-9hrs..if the patient was stable enough to do so!
Sometimes the TOE is inconclusive. Its important to get a good diagnosis as endocarditis therapy is often for weeks if not months.
Hepatic abscesses? Brilliant.
You’re spot on with value of history vs a battery of tests – one of the strengths of rural docs is that we HAVE to rely on, as Sir Lancelot Spratt said “eyes, ears and hands foremost”