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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.PO4 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.
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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 (N : < 12 Ref.: http://www.haps.nsw.gov.au/edrsrch/edinfo/crp.html ) 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 pocketing

Liver Functions
S. Bil. : 4.0 (Direct : 3.4) AST : 40 ALT : 20 Alk. PO4 : 387 Proteins : Albumin 2.4 Globulins : 3.5 (increased) 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
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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 CNS 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 LDH :
• •

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

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• • • •

CRP : 135 mg/L (N :<10) Parasite in Peripheral Smear : Not Found Random Blood Sugar : Avg. <126 mg % Renal Functions:
• • • • • • • • •

Blood Urea : 46 mg % S. Creat. : 1.3 mg % Uric Acid : 3.8 mg % (N : 3.4-7.2) Serum Calcium : 7.5 mg % Rechecked (N : >8.1) Serum Sodium : 127 (N : >136) Serum Potassium : 4.4 Serum Chloride : 102 Serum Bicarbonate : 22.8 ( N : >24) Anion Gap : 2.2 ( N : 8-18)

Ongoing Treatment :
• • •

Oxygen Inhalation : SpO2 - 96-99 % Empirical Aztreonam & Metronidazole (Antimicrobial sensitivity for S Aureus is pending, Physicians may add empirical agent to cover up S Aureus by Sunday noon) Supportive Therapy

Further Work Up :
• • •

S aureus bacteremia (SAB) Management Guidelines Echocardiography CT Scan of Abdomen / Chest

S Aureus Bacteremia Cross References :

see below

Current Status as on Sep 5th 2004 13:45 Local Time PATIENT IS SHIFTED TO MEDICAL ICU 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 4 Positive Coverage# . ( Ref. http://www.rxpalace.com/DrugBriefs/Zyvox.htm ) 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 <end>
Sep 6 2004 21:20 +0530 Baroda India

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S Aureus Bacteremia Cross References
1. ......The 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 6week course of antimicrobial therapy and may require surgical removal of localized infection....... (Original Article at http://www.postgradmed.com/issues/2001/10_01/weems.htm : The many faces of Staphylococcus aureus infection : Recognizing and managing its lifethreatening manifestations by Dr. J. John Weems Jr, MD in VOL 110 / NO 4 / OCTOBER 2001 / POSTGRADUATE MEDICINE )

2......patient-specific management advice by infectious diseases consultants can improve the clinical outcome for patients with S. aureus bacteremia.......( PubMed : PMID: 9770144)

3...... Original Article at CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 6 JUNE 2003 http://www.ccjm.org/pdffiles/KIM603.PDF ) 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
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S aureus bacteremia has an overall mortality rate of 21% to 34%

4......Search Results for Staphylococcus aureus sepsis guidelines http://www.google.co.in/search?hl=en&ie=UTF8&q=Staphylococcus+aureus+sepsis+guidelines&meta=
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