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A Not S o Simple UTI

A Not S o Simple UTI. Case Conference November 20 th , 2012 Jiten Patel & Alisha Lacour. Chief Complaint. Headache X 1 week. HPI. 49 year old woman with history of COPD and nephrolithiasis (first diagnosed 2011) 4 Weeks ago:

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A Not S o Simple UTI

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  1. A Not So Simple UTI Case Conference November 20th, 2012 Jiten Patel & Alisha Lacour

  2. Chief Complaint • Headache X 1 week

  3. HPI • 49 year old woman with history of COPD and nephrolithiasis (first diagnosed 2011) • 4 Weeks ago: • She presented to an outside hospital with urinary symptoms, nausea, vomiting and flank pain.  

  4. HPI • 4 Weeks ago: • Urine cultures showed mixed flora • Sent home on ciprofloxacin • Follow-up with urology. • She presented to the urology clinic 2-3 days later • Clinically looked poor so she was admitted from the clinic for: • IV antibiotics • Placement of stents for hydronephrosis. • She was sent home with ciprofloxacin and clindamycin • Urine cultures drawn prior to discharge were negative.  .  

  5. HPI Continued • 2 Weeks ago: • Followed up with urology • Had successful laser ablation of the kidney stone • 5 days ago: • She presented to the an outside hospital complaining of a headache • Constant and aching • Fluctuated in intensity from 8/10 to 10/10 • No radiation • Diffusely throughout the head • No alleviating factors • Worsened by light and sounds

  6. HPI Continued • 5 days ago (cont.): • CT showed a possible subarachnoid hemorrhage • She was transferred to UH for neurosurgical evaluation. • She was admitted by neurosurgery and observed in the ICU. • A repeat head CT showed a stable subarachnoid hemorrhage • She was discharged home with follow-up.

  7. HPI Continued • 3 days ago • After being home for a few days she presented to UH with persistent headache. • Also complained of: • Mild dysuria • No increase in frequency or incontinence • No flank pain • Low grade fevers

  8. Past Medical History • Kidney Stones • ESWL 2011 • COPD

  9. Past Surgical History • Cystolithotomy 2005

  10. Medications • Ciprofloxicin 500mg PO BID • Oxycodone-Acetaminophin 5-325mg PO Q4-6 hours • Tamsulosin 0.4mg PO QDay

  11. Allergies • Penicillin – swelling of extremities

  12. Family History • Father passed away from cardiac disease – 70’s • Mother passed away from lung cancer – 60’s • Siblings healthy • Several family members with kidney stones

  13. Social History • Smokes 1-2 packs per day for 35 years • Quit 3 weeks ago • Denies any current alcohol use • Denies any illicts • Lives with her fiancé

  14. Health Maintenance • Up to date on influenza immunization • Up to date on pneumococcal immunization • Up to date on Tetanus immunization • Up to date on PAP • Up to date on Mammogram • No colonoscopy

  15. ROS • Gen: No weight changes • HEENT: no visual changes, sore throat, rhinorrhea • CV: Per HPI • RESP: Per HPI • GI: no N/V/D/C/melena/BRBPR • Neuro: No dizziness, numbness, seizure • Skin: no new rashes • GU: Per HPI

  16. Physical Exam • Vitals • Triage • BP 110/60 P 68 RR 18 T 99.2 O2 100% on RA • 5’6” 77kg BMI 27 • Exam • BP 125/79 P 61 RR 16 T 98.8 O2 98% on RA

  17. Physical Exam • GENERAL: Awake, alert, and oriented. No acute distress. • HEENT: The patient does have a hyperpigmentation over her left eyebrow. Normocephalic, atraumatic. Mucous membranes are slightly dry. No papilledema. • CARDIOVASCULAR: Regular rate and rhythm. No murmurs • RESPIRATORY: Mild expiratory wheezing bilaterally. • ABDOMEN: Bowel sounds present. Soft. Nontender. Nondistended. • EXTREMITIES: No clubbing, cyanosis, or edema.

  18. Physical Exam • NEUROLOGIC: • Mental: Awake, alert, and oriented x4. • Sensation intact to light touch. • Reflexes are 2+ in biceps, triceps, patellar, ankle • Strength is 5/5 bilaterally in the upper and lower extremities. • Cerebellar function intact to finger to nose and heel to shin • CN II-XII: EOMI intact, PERRLA, sensation intact to light touch, raises eyebrows, closes eyes tight, symmetric smile, tongue midline, good palate elevation, phonation/cough intact, shoulder shrug appropriate

  19. Labs OSH(Day prior) 93 13.3 40.0 134 98 13 131 (4.5-11.0) 18.0 224 3.8 29 0.93 (24-32) 13.3 N 92 L 4 M 3 Ca 8.2 (8.4-10.3) Mg 1.6 P 2.1 UA: Sg pH Prot Glu Ket Bili Blood Nitrite Urobiligin LE 1.010 7.0 25 Neg Neg Neg 25 Pos 4.0 500 TP Alb TB AST ALT ALP 7.2 2.71.6 20 20 61 (3.5-5.0)(<1.3) Received dose of Gentamicin RBC 6-10 WBC >100 Sq 20-100 Bact Many Casts 3-5 Hyaline

  20. Labs Admit 93 12.6 36.2 134 102 13 150 (4.5-11.0) 13.9 224 4.0 26 0.9 13.3 Ca 8.5 Mg 1.6 P 2.1 Blood Cultures drawn N 96 L 3 M 1 UA: Sg pH Prot Glu Ket Bili Blood Nitrite Urobil LE 1.011 7.0 25 Neg Neg Neg 25 Neg 8.0 500 RBC 0-2 WBC 3-5 Sq 1-2 Bact negative Casts 0

  21. CT Head 2/18

  22. CT Head 2/18

  23. CT Head 2/18

  24. CTA Brain (2/19)

  25. CTA Brain (2/19)

  26. CT Brain (2/24)

  27. CT Brain (2/24)

  28. Labs • LP • CSF Clear • Glucose 12 • Total Protein 100.4 • WBC 198 • SEGS 67% • LYMPHOCYTES 33% • RBC 0 • Gram Stain: • Many WBC’s • Few Gram negative rods

  29. Gram Stain

  30. Gram Stain

  31. Gram Stain

  32. Hospital Course • She was admitted: • Placed in respiratory isolation • Treated with: • Dexamethasone • Vancomycin • Imipenem due to her penicillin allergy. • Her headache improved.

  33. Hospital Coarse • Day 2: • Urine Cx from OSH: • E. Coli >100,000 • Resistant to Ciprofloxacin • Susceptible to ticarcillin/clavulinate, ampicillin, gentamicin, nitrofurantoin, piperacillin/tazobactam, ampicillin/sublactam, tetracycline, cefazolin • Intermediate to cephalothin • Blood Cxs and CSF Cxs with • Gram negative rods

  34. MRI Brain

  35. MRI Brain

  36. MRI Brain

  37. MRI Brain

  38. MRI Brain

  39. MRI Brain

  40. MRI Brain

  41. MRI Brain

  42. MRI Brain

  43. MRI Brain

  44. MRI Brain

  45. MRA Brain

  46. MRA Brain

  47. Hospital Course • Day 3 of hospital course • She had a seizure sending her to the ICU • Cause due to the carbapenem or meningitis • Neurology was consulted • EEG done • Mild to moderate abnormality • Diffuse slowing • Excessive beta activity • Imipenem stopped and treated with gentamicin

  48. Hospital Coarse • Repeat LP • Clear • Glu 37 • Pro 64 • WBC 130 • N 9% L 89% M 2% • RBC 0 • Gram Stain: • No Organisms

  49. Hospital Course • Hospital Day 4 • Initial Blood and CSF cultures : • E. Coli • CSF sensitive to aztreonam, ampicillin, piperacillin/tazobactam, imipenem • Blood sensitive with above and gentamicin, bactrim, cefazolin • Blood resistant to ciprofloxicin, moxifloxicin • Antibiotics changed to aztreonam • Somnolent from seizure • Hospital Day 6 • Clinically improved • Reported feeling the best she had in weeks • Stepped down to the floor

  50. Hospital Course • Hospital Day 7 • Became more lethargic • On call intern notified • Evaluated patient, noted papilledema • STAT CT head Ordered

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