Hello everyone ..Im first yr resident of internal medicine back with one more intresting case .
Thrusday was my opd and night duty , so around 5 pm ,I got a call from casualty .
A 48 yr old female patient was brought to emergency with complaints of
Loose stools ,vommitings ,fever since 4 days .
Patient is a home maker by occupation and resident of Nalgonda was apparently alright 4 days ago..doing her routine activites of cooking ,washing clothes , although she had mild history of pain abdomen and uneasiness since 10 days..which patient ignored .
So pt was bought to casualty with complaints of
- Vomitings -6 to 8 episodes / day ,non bilious ,no history of blood in vomitus ,immediately after ingestion of food .
-Loose stools - 8-10 episodes / day , watery ,non mucoid ,non bloody and no history of black stools , associated with pain abdomen.
No history of outside food ingestion and no history of meat consumption prior to loose stools.
-Fever high grade ,intermittent ,not associated with chills and rigors .
- Pain abdomen which was diffuse and associated with abdominal distension .
- Patient even gave history of decreased urine output since past 4 days . But there is no history of pedal edema .
History of shortness of breath since 1 day - grade 3 . But no history of palpitations and chest pain.
Pt had no history of cough ,burning micturation ,Orthopnea and pnd .
No history of yellowish discoloration of sclera , no history of drug usuage .
No previous history of similar episode .
Pt is a k/c/o DM -2 since 5 years on OHA .pt is not using them since 4 days
K/c/o HTN since 1 yr ..but she stopped using medication since 4 months ,on her own .
No h/o CAD ,CVA, EPILEPSY,TB ,ASTHMA,
no h/o previous blood transfusions.
Pt has 4 children , and she is on her first day of menstural cycle when she got admitted .
LMP -11/06/20 .regular cycles ,no history of menorrhagia and dysmenorrhea .
So based on my history my provisional DD was:
- ? Present renal Aki secondary to acute gastro enteritis
K/c/o DM 2 and HTN
.
Then I proceeded with my examination :
Patient was conscious ,but irritated due to severe pain abdomen and coherent and oriented to time p,and person.
Moderately built and nourished .
Patient had no pallor ,icterus ,cyanosis ,clubbing ,lymphadenopathy and edema .
Vitals were at time of admission :
Bp - 140/90 mmhg
Pulse rate -111 BPM
Resp rate - 28/min
Spo2 -98% on RA
Temp - 101 F
Grbs - 333 mg /dl .
Cvs - S1 S2 HEARD . No murmurs
Resp system - NVBS present , clear all areas.
CNS - GCS -15/15
No significant abnormality in CNS.
Per abdomen -
Distended
mild guarding present .
Diffuse tenderness in all areas .
Bowel sounds - Absent.
INVESTIGATIONS :(11/6/20)
1)CBP - HB - 12.2 g/dl ,TLC -10,000 ,platelets - 80,000 . Neutrophils -90 ,lymphocytes - 4 .
2) RFT - Urea - 89mg/dl , s.creat -2.2md/dl
Uric acid - 6 ,calcium -8.7 mg/dl , phosphorus -2.6 mg/dl.
Na -136 meq/l , K - 3.7 meq/l
Cl - 102 meq/l.
3) LFT - TB -1.76 , DB - 0.74 , sgot - 29 ,SGPT - 19 , ALP -199 ,Albumin -2.8 mg/dl
4) CUE : color - pale yellow , clear ,albumin -trace ,sugars -3+ , RBC - 2-4 ,pus cells - 4-6
5) urine for ketones - negative .
6) serology (HIV ,HBSAG,HCV)-negative
7)Pt - 18 sec ,aptt - 33 sec
Inr -1.3
ABG - PH - 7.38 ,pco2 - 25.1 ,po2 - 86 , hco3 - 17.9
Sthco3 - 14.9 ,spo2 - 96.3%
8) USG abdomen - altered echotexture of right kidney - ? right pyelonephritis with mild right hydronephrosis.
9) Xray erect abdomen - no dilated bowel loops .
10) CXR PA view : no significant abnormalities .
11) ECG - no significant changes
12) 2d echo - sclerotic aortic valve ,no Rwma, concentric lvh ,
EF -55 % ,RSVP- 35 mmhg , Moderate AR ,Moderate AS ,good lv systolic function.
So based on initial investigations patient was initially started on treatment:
- NBM TILL FURTHER ORDERS.
-IVF NS/RL @100ML/HR
-INJ PIPTAZ 4.5GM IV STAT FOLLOWED BY INJ PIPTAZ
2.25GM IV QID .
- INJ PAN 40 MG IV PD
-INJ ZOFER 4MG IV TID
-INJ OPTINEURON 1 AMPULE IN 100 ML NS IV OD.
-INJ ZOFER 4 MG IV TID.
- INJ NEOMAL 1G IV BD.
-STRICT I/O CHARTING
-BP,PR,TEMP CHARTING WND HRKY
-GRBS 6TH HRLY
INJ HAI S/C ACCORDING TO GRBS.
Next day morning
Patient had fever spikes upto 101 F
BP- 140/90 mm hg
Pr - 102 bpm
Abdomen was distended and still tender .
BS - Sluggish .
CBS,Rft was repeated . And also cray kub and plain ct abdomen was done.
Plain CT ABDOMEN :
Right kidney - enlarged in size (13.5x7.2x7.4)
Extensive collection of gas within renal parenchyma with more than 50% renal destruction.
No e/o intra renal fluid collection.
Gas is seen extending into perinephric space and right subdiaphragmatic region .
A thin rim of fluid is seen along the retro peritoneal fascial plane's on right side.
Impression - Right emphysematous pyelonephritis
Hong tseng class 3 .
Urology opinion was taken and right per cutaneous nephrostomy was done under LA . (14 F nephrostomy tube was placed )
Same treatment was continued .As bowel sounds returned patient was started oral feeds.
Post nephrostomy mid night around 3 am patient was having sob and had atrial fibrillation
Inj amiodarone 150 mg IV stat was given , followed by Inj amiodarone iv infusion 6ml/hr for 6hrs and 3ml/hr for 18hrs.
Rate and ryhtm became regular following amiodarone
Next day
As patient was not responding and continous fever spikes were present ,so PIPTAZ was withheld and Inj Meropenam 1g IV BD was started.
Repeat xray kub was done which showed increased gas shadow so a subcutaneous nephrostomy tube was inserted.
Nephrostomy drain and subcutaneous drain was being monitored.
- CBP TREND :
Date HB TLC PLATELET
11/06 12.2 10,000 80,000
12/06 11.7 10,700 65,000
13/06 11 10,500 50,000
14/06 11.6 12,000 48,000
15/06 11.1 11,600 76,000
16/06 10.8 14,900 80,000
17/06 10.6 18,200 1.32 lakes
RFT TREND : UREA CREAT
Date
11/06 89 2.2
12/06 96 2.2
14/06 79 1.5
15/06 58 1.3
17/06 54 1.1
LFT Total bilirubin Direct bilirubin
11/06 1.76 0.68
14/06 4.89 1.26
17/06 1.46 0.60
Serum albumin - 2.8 .Resst of the liver parameters were normal .
Fever charting:
Urine culture - Initially candida was isolated which is a colonizer probably. Repeat sample was sent .
-Blood culture- No growth isolated.
-Nephrostomy tube drainage culture-
E. Coli isolated which was sensitive only to gentamicin and resistant to amoxicillin clavulinic acid,ciprofloxacin, ceftazidime,cefuroxime,cotrimoxazole, piperacillin tazobactam ,cefixime .
So patient was now started today on gentamicin adjusted to renal doses.
- Inj Gentamycin 80 mg in 100ml NS IV TID .( 3-5ml/kg/day).
Remaining same treatment was continued.
Emphysematous pyelonephritis :
Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system or perinephric tissue.
A patient infected with emphysematous pyelitis has an excellent prognosis with medical management (MM), whereas EPN deserves special attention because of its life‐threatening potential with either MM or surgical management. Mortality from EPN is primarily attributable to septic complications. EPN was associated with a mortality rate of up to 78% until the late 1970s but, over the last two decades, improvement in management techniques has reduced the mortality rate to 21%.
Diabetes mellitus is the single most common associated factor. Up to 95% of patients with EPN have underlying uncontrolled diabetes mellitus.
Emphysematous pyelonephritis is a severe, necrotizing form of acute bacterial pyelonephritis and Escherichia coli remains the most common causative pathogen; the organism has been isolated on urine or pus cultures in nearly 70% of the reported cases .There have, however, been reports of Proteus mirabilis, Klebsiella pneumoniae , Group D Steptococcus and coagulase‐negative Staphylococcus being the causative agent for EPN . Anaerobic micro‐organisms including Clostridium septicum, Candida albicans, Cryptococcus neoformans and Pneumocystis jiroveci have, in rare cases.
https://bjui-journals.onlinelibrary.wiley.com/doi/full/10.1111/j.1464-410X.2010.09660.x.
Thrusday was my opd and night duty , so around 5 pm ,I got a call from casualty .
A 48 yr old female patient was brought to emergency with complaints of
Loose stools ,vommitings ,fever since 4 days .
Patient is a home maker by occupation and resident of Nalgonda was apparently alright 4 days ago..doing her routine activites of cooking ,washing clothes , although she had mild history of pain abdomen and uneasiness since 10 days..which patient ignored .
So pt was bought to casualty with complaints of
- Vomitings -6 to 8 episodes / day ,non bilious ,no history of blood in vomitus ,immediately after ingestion of food .
-Loose stools - 8-10 episodes / day , watery ,non mucoid ,non bloody and no history of black stools , associated with pain abdomen.
No history of outside food ingestion and no history of meat consumption prior to loose stools.
-Fever high grade ,intermittent ,not associated with chills and rigors .
- Pain abdomen which was diffuse and associated with abdominal distension .
- Patient even gave history of decreased urine output since past 4 days . But there is no history of pedal edema .
History of shortness of breath since 1 day - grade 3 . But no history of palpitations and chest pain.
Pt had no history of cough ,burning micturation ,Orthopnea and pnd .
No history of yellowish discoloration of sclera , no history of drug usuage .
No previous history of similar episode .
Pt is a k/c/o DM -2 since 5 years on OHA .pt is not using them since 4 days
K/c/o HTN since 1 yr ..but she stopped using medication since 4 months ,on her own .
No h/o CAD ,CVA, EPILEPSY,TB ,ASTHMA,
no h/o previous blood transfusions.
Pt has 4 children , and she is on her first day of menstural cycle when she got admitted .
LMP -11/06/20 .regular cycles ,no history of menorrhagia and dysmenorrhea .
So based on my history my provisional DD was:
- ? Present renal Aki secondary to acute gastro enteritis
K/c/o DM 2 and HTN
.
Then I proceeded with my examination :
Patient was conscious ,but irritated due to severe pain abdomen and coherent and oriented to time p,and person.
Moderately built and nourished .
Patient had no pallor ,icterus ,cyanosis ,clubbing ,lymphadenopathy and edema .
Vitals were at time of admission :
Bp - 140/90 mmhg
Pulse rate -111 BPM
Resp rate - 28/min
Spo2 -98% on RA
Temp - 101 F
Grbs - 333 mg /dl .
Cvs - S1 S2 HEARD . No murmurs
Resp system - NVBS present , clear all areas.
CNS - GCS -15/15
No significant abnormality in CNS.
Per abdomen -
Distended
mild guarding present .
Diffuse tenderness in all areas .
Bowel sounds - Absent.
INVESTIGATIONS :(11/6/20)
1)CBP - HB - 12.2 g/dl ,TLC -10,000 ,platelets - 80,000 . Neutrophils -90 ,lymphocytes - 4 .
2) RFT - Urea - 89mg/dl , s.creat -2.2md/dl
Uric acid - 6 ,calcium -8.7 mg/dl , phosphorus -2.6 mg/dl.
Na -136 meq/l , K - 3.7 meq/l
Cl - 102 meq/l.
3) LFT - TB -1.76 , DB - 0.74 , sgot - 29 ,SGPT - 19 , ALP -199 ,Albumin -2.8 mg/dl
4) CUE : color - pale yellow , clear ,albumin -trace ,sugars -3+ , RBC - 2-4 ,pus cells - 4-6
5) urine for ketones - negative .
6) serology (HIV ,HBSAG,HCV)-negative
7)Pt - 18 sec ,aptt - 33 sec
Inr -1.3
ABG - PH - 7.38 ,pco2 - 25.1 ,po2 - 86 , hco3 - 17.9
Sthco3 - 14.9 ,spo2 - 96.3%
8) USG abdomen - altered echotexture of right kidney - ? right pyelonephritis with mild right hydronephrosis.
9) Xray erect abdomen - no dilated bowel loops .
10) CXR PA view : no significant abnormalities .
11) ECG - no significant changes
EF -55 % ,RSVP- 35 mmhg , Moderate AR ,Moderate AS ,good lv systolic function.
So based on initial investigations patient was initially started on treatment:
- NBM TILL FURTHER ORDERS.
-IVF NS/RL @100ML/HR
-INJ PIPTAZ 4.5GM IV STAT FOLLOWED BY INJ PIPTAZ
2.25GM IV QID .
- INJ PAN 40 MG IV PD
-INJ ZOFER 4MG IV TID
-INJ OPTINEURON 1 AMPULE IN 100 ML NS IV OD.
-INJ ZOFER 4 MG IV TID.
- INJ NEOMAL 1G IV BD.
-STRICT I/O CHARTING
-BP,PR,TEMP CHARTING WND HRKY
-GRBS 6TH HRLY
INJ HAI S/C ACCORDING TO GRBS.
Next day morning
Patient had fever spikes upto 101 F
BP- 140/90 mm hg
Pr - 102 bpm
Abdomen was distended and still tender .
BS - Sluggish .
CBS,Rft was repeated . And also cray kub and plain ct abdomen was done.
- XRay kub - right kidney shadow visible - ? emphysematous pyelonephritis
Plain CT ABDOMEN :
Right kidney - enlarged in size (13.5x7.2x7.4)
Extensive collection of gas within renal parenchyma with more than 50% renal destruction.
No e/o intra renal fluid collection.
Gas is seen extending into perinephric space and right subdiaphragmatic region .
A thin rim of fluid is seen along the retro peritoneal fascial plane's on right side.
Impression - Right emphysematous pyelonephritis
Hong tseng class 3 .
Urology opinion was taken and right per cutaneous nephrostomy was done under LA . (14 F nephrostomy tube was placed )
Same treatment was continued .As bowel sounds returned patient was started oral feeds.
Rate and ryhtm became regular following amiodarone
Next day
As patient was not responding and continous fever spikes were present ,so PIPTAZ was withheld and Inj Meropenam 1g IV BD was started.
Repeat xray kub was done which showed increased gas shadow so a subcutaneous nephrostomy tube was inserted.
Nephrostomy drain and subcutaneous drain was being monitored.
- CBP TREND :
Date HB TLC PLATELET
11/06 12.2 10,000 80,000
12/06 11.7 10,700 65,000
13/06 11 10,500 50,000
14/06 11.6 12,000 48,000
15/06 11.1 11,600 76,000
16/06 10.8 14,900 80,000
17/06 10.6 18,200 1.32 lakes
RFT TREND : UREA CREAT
Date
11/06 89 2.2
12/06 96 2.2
14/06 79 1.5
15/06 58 1.3
17/06 54 1.1
LFT Total bilirubin Direct bilirubin
11/06 1.76 0.68
14/06 4.89 1.26
17/06 1.46 0.60
Serum albumin - 2.8 .Resst of the liver parameters were normal .
Fever charting:
Urine culture - Initially candida was isolated which is a colonizer probably. Repeat sample was sent .
-Blood culture- No growth isolated.
-Nephrostomy tube drainage culture-
E. Coli isolated which was sensitive only to gentamicin and resistant to amoxicillin clavulinic acid,ciprofloxacin, ceftazidime,cefuroxime,cotrimoxazole, piperacillin tazobactam ,cefixime .
So patient was now started today on gentamicin adjusted to renal doses.
- Inj Gentamycin 80 mg in 100ml NS IV TID .( 3-5ml/kg/day).
Remaining same treatment was continued.
Emphysematous pyelonephritis :
Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system or perinephric tissue.
A patient infected with emphysematous pyelitis has an excellent prognosis with medical management (MM), whereas EPN deserves special attention because of its life‐threatening potential with either MM or surgical management. Mortality from EPN is primarily attributable to septic complications. EPN was associated with a mortality rate of up to 78% until the late 1970s but, over the last two decades, improvement in management techniques has reduced the mortality rate to 21%.
Diabetes mellitus is the single most common associated factor. Up to 95% of patients with EPN have underlying uncontrolled diabetes mellitus.
Emphysematous pyelonephritis is a severe, necrotizing form of acute bacterial pyelonephritis and Escherichia coli remains the most common causative pathogen; the organism has been isolated on urine or pus cultures in nearly 70% of the reported cases .There have, however, been reports of Proteus mirabilis, Klebsiella pneumoniae , Group D Steptococcus and coagulase‐negative Staphylococcus being the causative agent for EPN . Anaerobic micro‐organisms including Clostridium septicum, Candida albicans, Cryptococcus neoformans and Pneumocystis jiroveci have, in rare cases.
https://bjui-journals.onlinelibrary.wiley.com/doi/full/10.1111/j.1464-410X.2010.09660.x.
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