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This case history is available online at Case Report of Mr.

This case history is available online at

at Case Report of Mr. Amulokbhai Patel In Nadiad A 72 year old

Case Report of Mr. Amulokbhai Patel

In Nadiad

A 72 year old Hindu male Amulokbhai Patel of Nadiad who was previously in healthy condition started complaint of high grade fever with rigors with associated generalized weakness on Aug 20th 2004. For the same, he was taken to family physician where clinical & lab. findings suggested Malarial Fever (P. Vivax positive on 20th) & Hb found to be 4.2 gm % associated with Microcytic, Hypo chromic RBCs on Peripheral Smear (PS) with Total WBC Count (TC) 11400/cmm & Differentials : P 80 ; L 20. Treatment for Malaria was started & after two days of Chloroquine, high grade fever disappeared with no Malarial Parasite on Peripheral Smear (PS MP). Pateint's relative has given history of single episode of Generalized tonic clonic convulsion on Aug 26th for which CT Scan (Head) taken on next day showed no abnormality.

However, patient had intermittent fever of 99-101 ºF every day, he was shifted to Dr. C G. Shah (Surgeon ?!) by their relatives on 24th Aug where laboratory workup showed Hb of 5.0 gm % & S. billirubin : 4.2 (direct : 3.0) [with mild icteric tinge clinically]. He received two units of whole blood (post BT Hb was 6.9 gm %) & transferred to Physician Dr. B L. Bhatt on 27th Aug where further Liver Function Tests showed ALT of 28 IU/L & Alk.PO 4 297 IU/L (mild increase) s. Albumin 2.2 gm % / Globulins : 4.8 gm % with decreased A:G Ratio: 0.46 ( N: >1.2). Prothrombin Time was 14.2 compared to control of 12.0 & INR being 1.22. His Total WBC Counts (TC) were 22100/cmm mainly

Polymorphs-83 %.

Serial Blood Counts & Liver Functions showed WBC counts


persistently ranging between 17000-27000 /cmm with predominant Polymorphs

averaging 80 % of total WBC count.


Mild Renal Function abnormality were detected with Bl.Urea

of 60-80 gm % which returned to normal around 30th Aug (6th day of admission). Meanwhile treatment was given in the form of two additional blood units which raised his Hb up to 8.1 gm % as on Sep 1st. Injectable Empirical (?!) Antibiotics were started on Aug 27th with Inj. Aztreonam 1 gm IV 12 hrly (?) & Inj. ceftazidime 1 gm IV 12 hrly. However, we are not sure of how accurately did dosage schedules been followed for the same antibiotics ! As patient's condition was not improving since admission with continuing fever of 99-101 ºF along with high total WBC counts & abnormal liver functions, the case was referred to senior Gastro Consultant of Baroda -

Dr. Prashant Buch

[D.M. ; AIIMS New Delhi]. Pateint was brought to Baroda on Sep 2nd.

In Baroda


As advised by Dr. Buch, patient has been transferred to Multi Speciality Hospital - Bhailal Amin General Hospital (BAGH) for diagnostic workup & further management. There is no associated specific history related to patient's occupation, personal habits , previous treatment details neither in family.

Patient's Diagnostic Work Up at BAGH uptill now is as follows

Hb : 8.1 gm %

TC : 17600/cmm

DC: P 80 ; L 13 ; Rest 7 Platlets : 279000/cmm

PS : Microcytic, Hypo chromic RBCs & Hypersegmented Neutrophils with No Parasites seen.

ESR : 36 mm/end of 1st hr

CRP : 135 mg/l

Bl. Urea : 46 ; S. Creat : 1.3 HRP II Antigen for P.Falciparum : Negative HBsAg : Negative HCV : Pending

Plain X Ray Abdomen : No Abnormality

USG Abdomen


: Mild Ascitis with Splenomegaly, No evidence of focal liver lesion or surrounding pus

Liver Functions

S. Bil. : 4.0

(Direct : 3.4)

AST : 40 ALT : 20

Proteins : Albumin 2.4 Globulins : 3.5 (increased)

Alk. PO 4 : 387

A/G Ration : 0.69

( N : >0.9)

Ascitic Fluid Analysis : Transudative type with total cell count of 950, impression of SABE

Upper G I Endoscopy : No Abnormality

Mantoux Test : Negative ECG : Within Normal Limit

Blood & Urine Culture & Antibiotic Sensitivity

sent today (Sep 2nd). Meanwhile, empirical

antibiotics are started combining Inj. Aztreonam & Inj. Metronidazole in appropriate dosage. Patient has developed pedal edema & fever of 103 ºF for which he is receiving supportive treatment.

Provisional Impression

? Chronic Liver Disease with superadded infection and SEPSIS

Further Work Up

1. CT Abdomen/Pelvis for hidden septic foci & Liver Parenchymal Disease

2. Search for septic foci or relevant etiological factor anywhere else in the body


Status as on Sep 3rd 2004 13:00 Local Time

Clinically no pyrexia since late night, Vitals & Urine Output : Normal

Ongoing Treatment :

Oxygen Inhalation : SOS

Empirical Aztreonam & Metronidazole

Supportive Therapy

Work Up :

Blood Culture shown growth of organisms - Identification & Antimicrobial Sensitivity are pending (expected to arrive by late night)

Urine Culture : Negative

Blood Samples for LDH , HIV , HCV , IgM Leptospira & Widal for Typhoid sent today morning

CT Scan of Abdomen / Chest & Echocardiography : Pending till Blood C/S Reports.

Status as on Sep 4th 2004 23:00 Local Time

Clinically :

No fresh complaints


Intermittent fever of

99-101 ºF


Pulse/BP/RR : 120 ; 150/90 mm Hg ; 24/min Regular

Mild icteric tinge & pallor present


Pedal edema: Up to shin of tibia

Shifting dullness positive

on per abdomen examination


examination : No Abnormality Detected

Fluid Input/Output : 2500 ml / 600 ml UOP

Work Up :


Blood Culture shown growth of

Staphylococcus aureus - However culture has


been reincubated & to confirm the organism as physicians are suspecting possible S aureus contamination during sample handling.

Urine Culture : Negative after 48 HRS of aerobic incubation.


HIV, HCV, S. Typhi : Negative


Serum : 603 IU/L (N : <400)

Peritoneal Fluid : 431 IU/L

Prothrombin Time:

Control : 12.8

Test : 17.4 (N : 0-15 sec)


INR : 1.4

CRP : 135 mg/L (N :<10)

• • • • • CRP : 135 mg/L (N :<10) Renal Functions: Supportive Therapy Echocardiography

Renal Functions:

Supportive Therapy


see below

Parasite in Peripheral Smear : Not Found

Random Blood Sugar : Avg. <126 mg %

Uric Acid : 3.8 mg % (N : 3.4-7.2)

Serum Sodium : 127 (N : >136)

Serum Bicarbonate : 22.8 ( N : >24)

Anion Gap : 2.2 ( N : 8-18)

Oxygen Inhalation : SpO 2 - 96-99 %


: 7.5 mg % Rechecked (N : >8.1)

Empirical Aztreonam & Metronidazole (Antimicrobial sensitivity for S Aureus is pending, Physicians may add empirical agent to cover up S Aureus by Sunday noon)

S aureus bacteremia (SAB) Management Guidelines

CT Scan of Abdomen / Chest


Ongoing Treatment :

Further Work Up :

S Aureus Bacteremia Cross References :

Current Status as on Sep 5th 2004 13:45 Local Time


No pyrexia since 11:00 PM Sep 4th

Patients has no sleep till 4 o'clock morning last night & history s/o altered sensorium since late night. Since Today Morning, patient is gone into stuporus state. On examination, Asterixis are absent, clinically progressing Jaundice, Ascites with

evidence of Renal Dysfunction - picture favoring

Hepatic Encephalopathy in a

established case of Sepsis due to hidden septic foci &/or ongoing chronic liver disease.

Dr. Prashant Buch reviewed the case & advised to transfer patient in Medical ICU.

Management for Hepatic Enceph. been started with add-on Inj. Linezolid for Gram

Positive Coverage #


Case Prognosis is worse.

Dear Dr Mukesh Sir & Nileshbhai,

I am sorry to inform you that patient has gone into MODS - hepatic coma with hepato renal syndrome with compensatory metabolic acidosis with ? GI Bleed ( Hb went to 6.2 gm % of previous 8.0 gm %) & developed right sided hemi paresis due to ? C V Stroke. Dr Buch has just seen the case ( at 11 PM Sep 5th) & apologize us for his inability to do further favorable in this case. Right now, patient is put on ventilator system.

Please call me on 0265 3126975 as soon as you arrive at Ahmedabad airport.

With Regret, Dr. Samir B. Amin Sep 6 2004 00:00 +0530 Local Time

With no favorable prognosis expected, family relatives decided to take discharge of patient against medical advise. Patient is discharged on Sep 6 2004 1400 HRS. Eventually, patient expired at his home (Pij, Nadiad) by 2100 HRS of Sep 6 2004 leaving involvement of hepatic dysfunction in dilemma.

Sep 6 2004 21:20 +0530 Baroda India


Sep 6 2004 21:20 +0530 Baroda India

India <end> Sep 6 2004 21:20 +0530 Baroda India Disclaimer/Disclosure details :

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S Aureus Bacteremia Cross References


report of even a single positive blood culture for S aureus should prompt a

careful investigation to determine if there is an associated endovascular or metastatic focus of infection. Of S aureus bacteremia cases, 20% to 40% are associated with a metastatic focus of infection, and up to 57% may be associated with endocarditis (3). Risk factors for such complications include community-acquired infection, absence of an identifiable source of infection (eg, cutaneous abscess), presence of an indwelling foreign body, persistence of bacteremia for more than 3 days after initiation of antibiotic treatment, and underlying immunosuppression. Identification of patients with complicated S aureus bacteremia is essential because these patients require a 4- to 6- week course of antimicrobial therapy and may require surgical removal of localized infection

(Original Article at : The many faces of Staphylococcus aureus infection : Recognizing and managing its life- threatening manifestations by Dr. J. John Weems Jr, MD in VOL 110 / NO 4 / OCTOBER 2001 / POSTGRADUATE MEDICINE )

2 patient-specific

the clinical outcome for patients with S. aureus bacteremia


management advice by infectious diseases consultants can improve


PubMed : PMID:


70 • NUMBER 6 JUNE 2003 )

Staphylococcus aureus bacteremia: Using echocardiography to guide length of therapy

ALICE I. KIM, MD Department of Infectious Disease, The Cleveland Clinic KARIM A. ADAL, MD Department of Infectious Disease, The Cleveland Clinic STEVEN K. SCHMITT, MD Department of Infectious Disease, The Cleveland Clinic


S aureus bacteremia has an overall mortality rate of 21% to 34% 4 Search Results

S aureus bacteremia has an overall mortality rate of 21% to 34%


Search Results for Staphylococcus aureus sepsis guidelines