CASE PRESENTATION

DR DIVYA AJMERA
PATIENT’S IDENTITY
• Name : Madam PM
• Age : 69 years old
• Race : Chinese
• Address : Bukit Beruang, Melaka
• Occupation : retired accountant clerk
• Hypertension
• Ischaemic Heart Disease – 3 vessel disease, CABG done in IJN 2014
• H/O admission in 2017 (5/10/17 – 10/11/17)
• Was treated as splenic abscess and was covered for meliodosis
• Completed 4 weeks of IV Cefepime
• CECT TAP was done on 11/10/17 – multiple splenic lesion representing splenic
abscess
• Subsequent CECT Abdomen done on 7/11/17 – no more splenic abscess
• Meliodosis on 11/10/17 - Negative
HISTORY
• Admitted on 16/7/2018
• Presented with
• Prolonged fever x 2/12
• Documented temperature highest 39 degree celcius.
• Continuous fever
• Occurs more over the nights
• Reduced apetite and loss of weight for 2/12
• LOW 60kg  54 kg in 2 months
• Generalised body weakness associated lethagy
• Otherwise :
• No chest pain
• No abdominal pain
• No myalgia or arthalgia
• No cough
• No shortness of breath
• No vomiting
• No diarrhea
• No UTI symptoms
• No H/O traveling/jungle trekking/swimming in the river
• No known allergies
• H/O taking fiber supplements for 2/12 for constipation. No history of
taking any traditional or herbal supplements
On admission, 16/7/2018
• Well and comfortable under room air • Noted HB 7.2 , WCC 7.1, platelet 294
• Pale, not septic looking • RP, LFT normal
• Vital signs • CXR – clear lung field
• Temperature 39 • No palpable cervical, inguinal and
• BP 111/60 axillary lymph node
• PR 94 • Breast examination – NAD
• GM 7.1
• SPO2 97% RA
• Lungs – clear
• Cvs – systolic murmur over left sternal
edge
• P/A – soft, non tender, no
organomegaly
• Diagnosis
• Treated as TRO Infective Endocarditis

• Plan
• For ECHO urgent
• IV Gentamicin 80 mg STAT and BD ( 3mg/kg/day)
• IV C – Penicillin 2.4 MU STAT and QID
• To transfuse 2 pint packed cell
18/7/18
• ECHO noted
• EF – 77.5%
• No vegetation
• Mild LVH, mild MR, trivial TR
• Diastolic dysfuntion
• Plan
• Off IV Gentamicin and Penicilin ( given for 2 days )
• For USG Abdomen KIV CECT Abdomen TRO deep seated abscess in view of previous
history of splenic abscess
• Started on IV Ceftazidime 2g STAT and TDS
• Impression
• Pyrexia of Unknown Origin
• Cover for Meliodosis
• TRO Recurrent Splenic Abscess
19/7/2018
• Patient developed another temperature spike of 39 degrees
• Proceeded with USG Abdomen urgent
• Report
• No sonographic evidence of splenic lesion or intraabdominal collection
• Mild right hydronephrosis with proximal hydroureter. Cause not demonstrable
in this study
• Cholelithiasis
• Plan
• To request CECT Abdomen urgent cm TRO occult sepsis
20/7/18
• Patient complain having minimal cough, no sputum production
• Still having temperature spike
• On and off vomiting
• WCC 6.8
• However CECT abdomen was not granted as WCC not raised and cultures were pending
• Impression – Cover for Atypical Infection
• Plan
• Add T. Doxycycline 200 mg STAT and 100mg BD
• Trace cultures
• Another temperature spike to repeat septic workout and CXR
• If still having persistent temperature spike despite being on IV Ceftazidime >72
hours, to escalate to IV Meropenem
• KIV CECT TAP
23/7/18
• Patient developed temperature spikes during weekend
• Was escalated to IV Meropenem 1g TDS
• Been having cough with whitish sputum
• Noted HB dropped from 9.1  7.7
• PR – brownish stool
• No blackish stool, no abdominal pain
• CXR repeated on 22/7/18 – no pneumonic changes, clear
• CECT Abdomen and Pelvis was done
• Hepatosplenomegaly with patchy hypodense splenic lesion and new finding in
bilateral adrenal are likely infective. Possible ddx includes tuberculosis and
lymphoma
• Issue
• Treat as Atypical infection
• Cover for meliodosis
• TRO Extrapulmanory Tuberculosis

• Plan
• To continue IV Meropenem
• Trace all pending cultures, tumour markers
• To consult chest physician possibility of adrenal TB and also consult ID
physician
ID REVIEW – 26/7/2018
• TRO Disseminated TB
• In view of constitutional symptoms
• Noted from CT report right lung lymph node
• Increase ESR
• Unlikely meliodosis
• Blood c&s no growth for meliodosis
• Meliodosis serology – pending
• Plan
• To get CECT Thorax to reascess
• Suggest for bronchoscopy
• Need to consider empirical anti-TB
28/7/18
• Patient became hypotensive
• Bp : 73/42 mmHg  132/70 ( run 1 pint NS fast )
• PR : 101 bpm
•T : 38.3 noted HB 7.1
• GM : 9.9
• SPO2 : 92 % RA
• Patient only complaint of generalized body weakness. No other symptoms
• GCS full, lungs clear, p/a soft, non tender, cvs no murmur
• Dx : septic shock secondary to ? Meliodosis / disseminated TB
• DDX ACS
• Plan
• Transfuse I pint packed cell
• Cont IV Meropenem
 • Start IV Fluconazole 400 mg STAT and 200 mg OD
• Withold all anti hypertensive
• Iv drip 3 pint NS/24 hours
• Trace blood c&s and Fungal c&s
• Refer GA for ICU care

• HB 7.9 post 1 pint transfusion

• PR done – yellowish stool
• CXR repeated – opacity over right hilar region
RESPI REVIEW – 29/7/2018
• Case was referred TRO disseminated TB / adrenal TB
• Having cough with whitish sputum
• Mantoux test – 4mm
• MTB C&S – pending
• CECT Abdomen film noted
• Initially patient was responding to treatment as remained afebrile for
3 days, hence planned for CECT Thorax ( 28/8/18 )
• However then developed fluctuating temperature and was planned
for KIV to start anti-tb medication if indicated. To observe
temperature trend
3/8/2018
• Noted patient was gasping
• Very lethargic looking, GCS E3V4M5
• Proceeded with intubation in view of respiratory distress, ETT size 7cm anchored
at 19cm
• T – 39.6, BP 127/51 (supported with Ivi NoRad), PR 121, Spo2 – 100%
• Hb 9.5  6.6, platelet 172  34
• Impression
• Pyrexia of unknown origin – TRO disseminated TB
• Hospital acquired infection with respiratory failure
• Plan
• Refer GA for ICU admission – admit to ICU Orkid
• Continue IV Meropenem 1g TDS (Day 11)
• Update respi and ID team regarding patient – KIV start anti- TB
• IV Ampicillin – Sulbactam 9g STAT & TDS ( cover for Acinobacter MRO in view of prolonged
hospitalization)
• Transfuse 2 pint packed cell
ID REVIEW – 3/8/2018
• Reviewed post intubation
• Continue high dose ampicillin-sulbactam
• Continue meropenem
• KIV descalate antibiotics if C&S no growth
• To get earlier CECT thorax
ICU Progress
• Patient was subsequently transfuse total of 6 pints pack cells, 4 units
of platelets and 4 units of FFP
• Started in Ivi Insulin as GM was not controlled, not in DKA
• Patient then developed UGIB
• Had coffee ground in ryles tube free flow ~ 210 cc  500 cc
• Referred to surgical – not for scope yet. To stabilize platelet. For Ivi
Pantoprazole infusion
• Respi team started on anti-tb medication on 6/8/2018
• KIV to refer hemato TRO ? HLH (Hemophagocytic lymphohistiocytosis)
and KIV BMAT
• Noted RP worsening, Urea 22.8, Creatinine 212. VBG metabolic acidosis ( pH 7.29,
HCO3 12.6 )
• Had a family conference and explained patient requires dialysis. Right IJC inserted
for HD
• However on the 8/8/2018, noted on cardiac monitor patient developed
Ventricular Tachycardia, HR 150-160 bpm and also hypotensive despite being on
inotrope
• Eventually PEA and CPR commenced for 15 minutes with total IV Adrenaline of 2
mg given and IV Calcium Gluconate. Patient ROSC. Subsequently developed
Pulseless VT, Debfibrillation 200J x 1, CPR commenced for another 10 minutes
• Patient persistent hypotensive despite being on 2 inotropes. Eventually patient
pronounced death at 0835 H.
• COD : Septicaemia with Multiorgan Failure
Date 16/7 18/7 21/7 28/7 3/8 4/8 6/8 7/8
WCC 7.1 9.1 7.7 7.1 6.6 10.1 10.1 9.8
HB 7.2 6.8 6.8 6.9 9.2 14.0 10.0 11.9
PLT 294 207 185 161 34 58 36 31
UREA 4.7 4.8 3.6 9.5 14.3 15.0 21.8
NA 133 135 128 135 131 137 133
K 3.8 3.1 3.5 2.8 3.9 3.6 4.3
CREAT 54 63 49 53 138 129 212
TP 68 65 62 61 61 56
T.BIL 14.1 14.4 20.4 32.9 68.5 82.4
ALP 86 121 104 274 189 227
ALT 27 64 63 92 62 55
ALB 30 27 25 21 22 20
CRP 90.8 138.5 221.6
ESR >120 115
INR 1.21 1.53 1.39 1.31
LDH 628 700 3070
• Sputum AFB x 3 – Negative
• Sputum Tibi C&S – Negative
• Urine C&S – No Growth
• Blood C&S – 16/7,17/7,18/7,22/7, 27/8 – no growth
• Leptospira – inconclusive x 3
• Mycoplasma serology (19/7) – negative
• ANA – Negative , Rheumatoid factor - negative
• Infective screening – non reactive
• Serum fibrinogen (7/8) – 2.46 ( normal)
• FBP – anaemia secondary to acute blood loss , u/l infective, thrombocytopenia
secondary to peripheral consumption
• Tumour markers
• AFP - <1.1
• CEA – 0.7
• CA 125 – 37.8
• Meliodosis Serology – Negative
• Blood Fungal C&S – No growth
Antibiotics Summary
ANTIBIOTICS DURATIONS INDICATION

IV C-PENICILIN 4 MU 4 HRLY 2 DAYS INFECTIVE ENDOCARDITIS

IV GENTAMICIN 80MG BD

IV CEFTAZIDIME 5 DAYS SPLENIC ABSCESS

T. DOXYCYCLINE 100 MG BD 5 DAYS ATYPICAL INFECTION

IV MEROPENEM 1G TDS 14 DAYS OCCULT SEPSIS

IV UNASYN 9G TDS 5 DAYS COVER FOR ACB MRO

PYREXIA OF UNKNOWN ORIGIN (PUO)
• Petersdorf and Beeson defined pyrexia of unknown origin (PUO) in
1961. It is defined as:
• A temperature greater than 38.3°C on several occasions.
• Accompanied by more than three weeks of illness.
• Failure to reach a diagnosis after one week of inpatient investigation.
Causes of PUO
• Abscess – Intraabdominal ( liver, spleen, renal )
• Tuberculosis – disseminated, extrapulmanory, pulmanory
• Infective endocarditis
• Virus – Cytomegalovirus, Ebstein-Barr Virus
• HIV – AIDS / Lymphoma
• Fungal infection / Parasitic
• Neoplasms
• Autoimmune disease – Rheumatoid arthritis, SLE
• Hyperthyroidism