NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Shella Saint Fleur-Lominy, PGY2 12/06/2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 86 year-old woman presents with decreased urine output and somnolence for two days.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Two months later, the patient was readmitted from the NH for septic shock from multilobar pneumonia treated with vancomycin/meropenem/azithromycin and foley catheter-associated cystitis from multi-drug resistant Klebsiellapneumoniaetreated 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.

5. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

6. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

7. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

8. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

9. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

10. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

11. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

12. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: atrial fibrillation at the rate of 63 • Chest X-Ray: bilateral hazy opacities consistent with edema, small bilateral pleural effusion

13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnoses • Urinary tract infection • Congestive heart failure

14. 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

15. 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

16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Cystitis from multidrug resistant Klebsiella pneumoniae and E. coli