Bedridden 70F T2DM, IHD, COPD, Obese

 

Ambarish Bhattacharya

4tS cpoinsgohrJuneed sorSh2S0h2oi0  · 

Requesting for your kind opinions:

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?

2Vivek Poddar and 1 other

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• 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 dome?

  

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  •  · 39 w
  • Ambarish Bhattacharya

    Tarun Chakrabarti

     Only low Albumin. All others normal.

    Even Procal normal.

    Thanks

    

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    •  · 39 w

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• Pankaj Pant

  Any underlying conditions like multiple myeloma

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  •  · 39 w
  • Ambarish Bhattacharya

    Pankaj Pant

     Pending reports: ANF, D-Dimer, FDP, Protien electrophoresis

    

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    •  · 39 w

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• Boudhayan Dm

  What is ESR ?

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  •  · 39 w
  • Ambarish Bhattacharya

    Boudhayan Dm

     80. But Hb is 7. Microcytic hypochromic

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    •  · 39 w

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• Rakesh Biswas

  Admin

  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

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  •  · 38 w
  • Ambarish Bhattacharya

    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

    

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    •  · 38 w
  • Rakesh Biswas

    Admin

    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.

    

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    •  · 38 w

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• 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.

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  •  · 38 w
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  • Rakesh Biswas

    Admin

    Please share links to the utility of lipid profile in correlation with CRP

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    •  · 38 w
  • Aadipta Ghosh

    https://pubmed.ncbi.nlm.nih.gov/21947962/#:~:text=Elevated%20levels%20of%20oxidized%20low%2Ddensity%20lipoprotein%20correlate%20positively%20with,patients%20with%20acute%20coronary%20syndrome.&text=Ox%2DLDL%2Fhs%2DCRP,in%20SAP%20patients%20and%20contro… 

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    PUBMED.NCBI.NLM.NIH.GOV

    Elevated Levels of Oxidized Low-Density Lipoprotein Correlate Positively With C-reactive Protein in Patients With Acute Coronary Syndrome - PubMed

    Elevated Levels of Oxidized Low-Density Lipoprotein Correlate Positively With C-reactive Protein in Patients With Acute Coronary Syndrome - PubMed

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    •  · 38 w
  • Aadipta Ghosh

    https://www.amhsr.org/.../association-of-lipid-profile...

    

    AMHSR.ORG

    Association of Lipid Profile Parameters with High-Sensitive CÃ

    Association of Lipid Profile Parameters with High-Sensitive CÃ

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    •  · 38 w
  • Ambarish Bhattacharya

    Aadipta Ghosh

     My bad. IHD patient. Already on Atorvastatin 40mg. So not sure whether this will help. Ferritin has been sent though

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    •  · 38 w
  • Rakesh Biswas

    Admin

    Thanks 

    Aadipta

    . Can you quote the relevant portions that suggest that it helps in further management.

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    •  · 38 w
  • Ambarish Bhattacharya

    Ferritin 1020. CRP 218.

    CT abdomen: shrunken kidney right with possible Pyelonephritis left. Cholelithiasis with mildly dialated CBD. Chronic cystitis. Amylase, Lipase normal

    

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    •  · 38 w
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  • Rakesh Biswas

    Admin

    Suggestive of ongoing inflammation possibly pyelonephritis

    

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    •  · 38 w
  • Aadipta Ghosh

    Yes

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    •  · 38 w
  • Aadipta Ghosh

    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 su… 

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    •  · 38 w
  • Rakesh Biswas

    Admin

    They suggest they could be markers but that's a long way away from being useful in such a case scenario?

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    •  · 38 w
  • Aadipta Ghosh

    Yes sir

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• Pankaj Pant

  Any updates or diagnosis

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  •  · 38 w
  • Ambarish Bhattacharya

    Pankaj Pant

     Pyelonephritis

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    •  · 38 w

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• Ambarish Bhattacharya

  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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