CASE PRESENTATION

PREPARED BY: ERICK RAFEL ANCA, M.D.

GENERAL DATA

U.C.J
21/M/S
R.C.
Filipino
Pasay City
Admitted for the 1st time at our
institution
CHIEF COMPLAINT

Loose – watery stool

History of Present Illness
4 days PTA

Febrile episode, undocumented

Chills, excessive sweating,
generalized body weakness,
muscle pain all over the body
4 days PTA

No rashes, joint pains, nausea

and vomiting, headache,
changes in bowel movement,
dysuria, signs of bleeding
4 days PTA

Noted wading in the flood after

work a week prior the onset of
fever
Patient claimed to have no open
wound at that time
4 days PTA

Self medicated with

Paracetamol and Mefenamic
Acid which provided temporary
relief
No consult done
3 days PTA

Still with aforementioned

symptoms
Epigastric pain, 8-10/10, burning,
non-radiating, spontaneously
occuring
3 days PTA

No rashes, joint pains, nausea

and vomiting, headache,
changes in bowel movement,
dysuria, signs of bleeding
3 days PTA

Consult at another institution

Given with HNBB and
AlOH+MgOH+Simethicone
(Kremil-S)
3 days PTA

THM: Omeprazole 40mg OD

Diagnosis not disclosed
Home meds taken with good
compliance, provided temporary
relief
1 day PTA

Recurrence of fever and epigastric

pain, muscle weakness and body
pain
5-6 episodes of loose-watery stool,
approximately 1 dipper, non-
mucoid, non-bloody
1 day PTA

Around 8 episodes of non-

projectile vomiting of PIF,
approximately 1 pitcher in
amount, non-bilous, non-bloody
1 day PTA

Patient claimed to have only

eaten home-cooked meal hours
prior to onset of vomiting and
passing of loose-watery stool
1 day PTA

Noted decrease in appetite and

urine output
No rashes, joint pains, headache,
dysuria, signs of bleeding
Persistence prompted consult, and
subsequent admission
Past Medical History
No hypertension
No diabetes mellitus
No bronchial asthma
No prev. PTB treatment
No allergies to foods and meds
No prev. surgical operation
No history of recurrent UTI
Family Medical History
Hypertension - mother
No diabetes mellitus
No bronchial asthma
No prev. PTB treatment
No allergies to foods and meds
Unrecalled kidney disease –
maternal side
Personal Social History
Non-smoker
Occasional alcoholic beverage
drinker
Denies illicit drug use
Works as a service crew in a fast
food restaurant
No history of recent travel
Source of drinking water –
purchased mineral water
Eats home-cooked meal, foods
served at work, and street foods
No incidence of dengue cases in
their neighborhood
House is near the street
Review of Systems
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS
HEART
ABDOMEN
EXTREMITIES
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No weight loss/gain, no
HEART
easy fatigability, night
ABDOMEN
EXTREMITIES sweats
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS
HEART No pallor, jaundice,
ABDOMEN lesions
EXTREMITIES
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN No excessive
HEENT
lacrimation, nasoaural
CHEST AND LUNGS
HEART discharge, throat
ABDOMEN itchiness/sore throat
EXTREMITIES
Noted feeling of dry
GENITO-URINARY
HEMATOLOGIC mouth
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No chest pain,
HEART orthopnea, PND,
ABDOMEN cough episodes,
EXTREMITIES hemoptysis
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS
HEART
No palpitations
ABDOMEN
EXTREMITIES
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No hematemesis,
HEART
hematochezia,
ABDOMEN
EXTREMITIES melena, tenesmus
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No complaints of
HEART
edema on upper and
ABDOMEN
EXTREMITIES lower extremities
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No dysuria, hematuria,
HEART sand-like sensation
ABDOMEN when voiding, penile
EXTREMITIES discharge
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS
HEART No complaints of easy-
ABDOMEN bruising
EXTREMITIES
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No polyuria, polydipsia,
HEART
polyphagia, heat/cold
ABDOMEN
EXTREMITIES intolerance
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS No dizziness, loss of
HEART
consciousness, seizure
ABDOMEN
EXTREMITIES episodes
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
Physical Examination
 GENERAL APPEARANCE
VITAL SIGNS
SKIN
HEENT
CHEST AND LUNGS
HEART
ABDOMEN
EXTREMITIES
GENITO-URINARY/RECTAL
NEUROLOGIC
 GENERAL APPEARANCE
VITAL SIGNS
SKIN
HEENT Awake, not in
CHEST AND LUNGS cardiorespiratory
HEART distress, weak-looking,
ABDOMEN ectomorph
EXTREMITIES
GENITO-URINARY/RECTAL
NEUROLOGIC
 BP: 110/60 mmHg
GENERAL APPEARANCE
VITAL SIGNS HR: 113 bpm
SKIN RR: 24 cpm
HEENT
CHEST AND LUNGS T: 37.1o Celcius
HEART O2 sat: 99%
ABDOMEN
EXTREMITIES Wt.: 55.8 kg
GENITO-URINARY/RECTAL Ht.: 178 cm
NEUROLOGIC
BMI: 17 kg/m2
 GENERAL APPEARANCE
VITAL SIGNS (+) pallor
SKIN
HEENT No rashes, lesions,
CHEST AND LUNGS open wounds,
HEART jaundice
ABDOMEN
Dry skin
EXTREMITIES
GENITO-URINARY/RECTAL Fair complexion
NEUROLOGIC
 Anicteric sclera
GENERAL APPEARANCE Slightly pale palpebral
VITAL SIGNS conjunctiva
SKIN
HEENT Non-sunken eyeball
CHEST AND LUNGS No nasoaural
HEART discharge,
ABDOMEN tonsillopharyngeal
EXTREMITIES congestion
GENITO-URINARY/RECTAL
NEUROLOGIC Moist and pinkish lips,
gums and oral mucosa
 GENERAL APPEARANCE
VITAL SIGNS
SKIN
HEENT No cervical and
CHEST AND LUNGS
HEART
supraclavicular
ABDOMEN lymphadenopathy
EXTREMITIES
GENITO-URINARY/RECTAL
NEUROLOGIC
 GENERAL APPEARANCE Symmetrical chest
VITAL SIGNS
SKIN expansion
HEENT No retractions
CHEST AND LUNGS
HEART Both lung fields were
ABDOMEN resonant
EXTREMITIES No tactile and vocal
GENITO-URINARY/RECTAL
NEUROLOGIC fremitus
 GENERAL APPEARANCE
VITAL SIGNS
SKIN Clear breath sounds on
HEENT all lung fields
CHEST AND LUNGS
HEART No bronchophony,
ABDOMEN egophony, and
EXTREMITIES whisper pectoriloquey
GENITO-URINARY/RECTAL
NEUROLOGIC
 GENERAL APPEARANCE
Adynamic precordium
VITAL SIGNS No lifts, heaves and
SKIN thrills
HEENT
CHEST AND LUNGS PMI heard best at 5th
HEART ICS LMCL
ABDOMEN
EXTREMITIES S1>S2 at apex, S2>S1 at
GENITO-URINARY/RECTAL base
NEUROLOGIC No S3, S4, murmurs
 GENERAL APPEARANCE
VITAL SIGNS Flat
SKIN
HEENT 16 bowel sounds per
CHEST AND LUNGS minute heard on all
HEART quadrants
ABDOMEN
EXTREMITIES (+) tenderness on
GENITO-URINARY/RECTAL epigastric area
NEUROLOGIC
 GENERAL APPEARANCE
Grossly normal
VITAL SIGNS extremities
SKIN Full and equal
HEENT
CHEST AND LUNGS peripheral pulses
HEART No cyanosis
ABDOMEN
EXTREMITIES CRT: 1-2 seconds
GENITO-URINARY/RECTAL (+) Homan’s sign,
NEUROLOGIC bilateral
 GENERAL APPEARANCE
VITAL SIGNS
SKIN No CVA tenderness
HEENT
CHEST AND LUNGS No penile discharge
HEART Pendulous, non-
ABDOMEN
EXTREMITIES edematous scrotum
GENITO-URINARY/RECTAL
NEUROLOGIC
 No external
GENERAL APPEARANCE hemorrhoids
VITAL SIGNS
SKIN Good sphincteric tone
HEENT Non-collapsed rectal
CHEST AND LUNGS
HEART
vault
ABDOMEN No mass appreciated
EXTREMITIES
GENITO-URINARY/RECTAL (+) brownish fecal
NEUROLOGIC material on examining
finger, no blood
 GENERAL APPEARANCE
VITAL SIGNS
SKIN
HEENT
CHEST AND LUNGS Oriented to person,
HEART place and time
ABDOMEN
EXTREMITIES
GENITO-URINARY/RECTAL
NEUROLOGIC
 GENERAL APPEARANCE
VITAL SIGNS Cranial Nerves:
SKIN  I – no anosmia
HEENT
CHEST AND LUNGS  II, III – PERTLA 2-3 mm
HEART  III, IV, VI – intact EOM
ABDOMEN
EXTREMITIES  V – Temporalis and
GENITO-URINARY/RECTAL masseter muscle intact
NEUROLOGIC
 Cranial Nerves:
GENERAL APPEARANCE
 VII – No facial
VITAL SIGNS asymmetry, (+)
SKIN bicorneal reflex
HEENT  VIII – Intact gross
CHEST AND LUNGS hearing
HEART
ABDOMEN  IX, X – Intact gag reflex,
EXTREMITIES uvula midline
GENITO-URINARY/RECTAL  XI – Good shoulder
NEUROLOGIC shrug L=R
 XII – Tongue at midline
 Motor
5/5 5/5
GENERAL APPEARANCE
VITAL SIGNS 5/5 5/5
SKIN
HEENT Sensory
CHEST AND LUNGS
100% 100%
HEART
ABDOMEN 100% 100%

EXTREMITIES
GENITO-URINARY/RECTAL DTR
NEUROLOGIC ++ ++

++ ++
 GENERAL APPEARANCE No
VITAL SIGNS dysdiadochokinesia,
SKIN dysmetria
HEENT
CHEST AND LUNGS No agraphesthesia,
HEART astereognosis
ABDOMEN
No Babinski, ankle
EXTREMITIES
GENITO-URINARY/RECTAL clonus, asterixis
NEUROLOGIC No meningeal signs
Salient Features
HISTORY
21/M, Roman Catholic, lives in Pasay City, admitted for the 1st time at our
institution
Chief Complaint: Loose-watery stool

 Fever, chills, excessive sweating  No rashes

 Body malaise  No joint pains
 Myalgia  No headache
 Epigastric pain  No dysuria
 5-6 episodes of diarrhea  No signs of bleeding
 Around 8 episodes of vomiting  Unremarkable PMH
 (+) Wading on flood water 1
week before onset of fever
 Ate home-cooked meal prior to
onset of vomiting/diarrhea
 Decrease in appetite and urine
output
HISTORY
21/M, Roman Catholic, lives in Pasay City, admitted for the 1st time at our
institution
Chief Complaint: Loose-watery stool

 Non-smoker, occasional alcoholic  No history of recent travel

beverage drinker, denies illicit
drug use
 Service crew at fastfood
restaurant
 Eats home-cooked meal, food at
work, street foods
 Mineral drinking water
PHYSICAL EXAMINATION
 110/60 mmHg, 113 bpm, 24 cpm,
37.1 C, 17.5 kg/m2
 (+) pallor, dry skin
 Slightly pale conjunctive, dry lips,
pinkish gums and oral mucosa
 (+) tenderness on epigastric area
of the abdomen
 (+) Homan’s sign
 No rashes, jaundice, open
wounds and lesion
 Anicteric sclera
 No nasoaural discharge
 No tonsillopharyngeal congestion
 No lympandenopathies
 Unremarkable chest, lungs, and
heart findings
 Normoactive bowel sounds
 No cyanosis and edema
 No CVA tenderness
 Unremarkable DRE, and
neurologic findings
Approach to Diagnosis
 Acute
FEVER

Chronic
 Infectious

FEVER Neoplastic

Iatrogenic
 Infectious

FEVER

DIARRHEA Neoplastic
NAUSEA AND VOMITING

Iatrogenic
 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
URINARY TRACT INFECTION (ACUTE
PYELONEPHRITIS)
RULE IN RULE OUT
 Fever  More common in women
 Chills  No history of recurrent UTI
 Nausea and vomiting  No dysuria, hematuria, sand-like
sensation while voiding
 No CVA tenderness

DECISION: RULED OUT

 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
DENGUE

RULE IN RULE OUT

 Fever  No complaints of nasal and gum
 Chills bleeding
 Nausea and vomiting  No incidence of dengue in their
 Diarrhea neighborhood
 Abdominal Pain  No recent travel to endemic area
 Myalgia
 No petechial rashes
 Anorexia
 No joint pains
 Body weakness
 Pallor
 (+) tenderness on epigastric area

DECISION: CANNOT TOTALLY RULE OUT

 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
LEPTOSPIROSIS

RULE IN RULE OUT

 (+) wading in flood water 1 week before  Claims to have no open wound
onset of fever
on the lower extremity during
 Fever
exposure to flood water
 Chills
 Nausea and vomiting  Mineral drinking water
 Diarrhea  No dysuria
 Abdominal Pain
 No jaundice
 Myalgia
 Anicteric sclera
 Body weakness
 Decrease in urine ouput
 (+) Homan’s sign

DECISION: CANNOT BE RULED OUT

 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
GASTROENTERITIS

RULE IN RULE OUT

 Fever  No recent travel
 Chills  Mineral drinking water
 Nausea and vomiting
 Diarrhea
 Non-mucoid, non-bloody stool
 Abdominal Pain
 Anorexia
 Eats street food

DECISION: CANNOT TOTALLY RULE OUT

 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
AMOEBIASIS

RULE IN RULE OUT

 Fever  No recent travel
 Chills  Mineral drinking water
 Nausea and vomiting  Non-mucoid, non-bloody stool
 Diarrhea
 Abdominal Pain
 Anorexia
 Eats street food

DECISION: CANNOT TOTALLY RULE OUT

 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
COURSE IN THE ER (8/12/18)
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• BP: 70/50 to • CBC, Na, K, • Solufundin iso 1L • NPO to LSLF
100/60 Crea, BUN, fast drip 500 cc diet
• HR: 113 Fecalysis, then regulate at
250 cc/hr
• RR: 24 Urinalysis • Monitor v/s q1
• Wt.: 53 kg • KUB UTZ • Followed by PLR to q4
• O2 sat: 99% • Repeat BUN, at 160 cc/hr
crea, Na, K tom • Advised
AM • Pantoprazole admission
• Total calcium, 40mg IV
albumin, • Metoclopramide
phosphorus, 10mg IV
• Ciprofloxacin 500
magnesium
mg/tab OD
• CXR PA • Racecadotril
10mg/tab TID or if
with 2 eps of
formed stool
DIAGNOSTICS (8/12/18)
 Urinalysis: Light yellow, pH of 6.0, turbid, SG of 1.025, sugar – trace, albumin -
++, blood - ++, pus cells – 8-10, RBC – 28-30, EC – moderate, bacteria – few,
leukocytes – trace

 Fecalysis: Yellowish brown, soft, RBC – rare, Pus cells – rare, no parasitic ova
seen, no stages of Amoeba seen
DIAGNOSTICS (8/12-13/18)
CBC PARAMETERS RESULTS
WBC 10.13 H
RBC 4.63
Hb 13.4 BLOOD CHEM/SEROLOGY RESULTS
Hct 40.1 BUN 61.00 H
Platelets 120 L Creatinine 9.54 H
Neutrophil 85.10 H Sodium 140.00
Lymphocytes 7.6 L Potassium 3.90
Monocyte 6.50 Calcium 7.40 L
Eosinophil 0.50 Phosphorus 3.30
Basophil 0.30 Magnesium 2.60 H
MCV 86.60 Albumin 2.00 L
MCH 28.90
MCHC 33.30
RDW 13.20
DIAGNOSTICS (8/12-13/18)
 eGFR – 7.4 ml/min/1.73m2
 Estimated baseline crea: 1.3
 Corrected Ca – 9.0
DIAGNOSTICS (8/12-13/18)
 KUB UTZ Findings:
• History of elevated crea, no UO
• Both kidneys normal in size
• Right kidney cortical thickness of 1.06 cm
• Left kidney cortical thickness of 1.16 cm
• Increased parenchymal echogenicity relative to the liver and spleen
• IMPRESSION: Bilateral renal parenchymal disease based on echogenicity.
Underfilled UB
DIAGNOSTICS (8/12-13/18)
 Gastroenteritis Amoebiasis

FEVER Dengue Leptospirosis

DIARRHEA

NAUSEA AND VOMITING

Urinary Tract
Infection
Admitting Impression
Acute Kidney Injury secondary
to dehydration probably
secondary to Acute
Gastroenteritis
To consider Leptospirosis
Course in the Ward
8/12/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• History and PE • LeptoMAT • Omeprazole 40 • Monitor I and O
done • ABG mg IV now accurately
• (+) wading in • Paraccetaml 500
mg/tab now then
flood
PRN for T>/= 37.8
• (+) Homan’s • Paracetamool
sign 300 mg IV PRN
• (+) pinkish T>/= 38.4
conjunctiva
• Increase IV rate
• (+) febrile to 200 cc/hr
episode (T –
37.9)
8/13/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• Noted repeat • LeptoPCR • Continued IV rate • Monitor I and O
crea of 11.2 • HBsAg, Anti- to 200 cc/hr accurately
from 9.54 HBs, Anti-HBc
• UO – 210 Igm, Anti-HCV • Refer to surgery
• Explained the • PT, PTT service re:
need for stat insertion of
HD; consent CVC
given for the
procedure and
CVC insertion
• Noted
yellowish-
discoloration of
skin
8/13/18

 eGFR - 6.2 ml/min/1.73m2

BLEEDING PARAMETERS RESULTS

PT Patient 14.80 BLOOD CHEM/SEROLOGY RESULTS
PT Control 13.20 BUN 78.00 H
PT INR 1.15 H Creatinine 11.22 H
PT Activity 80.00 Sodium 137.00
APTT Patient 37.30 H Potassium 4.00
APTT Control 31.20
 8/13/18

HEPATITIS MARKER RESULTS ABG PARAMETER RESULTS

HBsAg NR pH 7.34
Anti-HBs NR PaCO2 37.1
Anti-HBc IgM NR PaO2 99
Anti-HCV NR HCO3 19.7
Base Excess -4.9
O2 97.3%
8/13/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) muscle pain • Ciprofloxacin • Monitor I and O
• (+) scleral shifted to accurately
injection Ceftriaxone 2g IV
OD • Insert IFC
• (+) pallor
• Increased IV rate
• 100/70, 94, 20, to 250 cc/hr • For stat HD
37.2 - Duration: 3 hrs
• CBS, dry lips - BFR 150-180
and oral - DFR 300
mucosa, no - UF 500 ml +
edema flushing
- Dialyzer lops 18
- Flushing 50cc q15
min

• For stat CVC

insertion
8/13/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• S/P CVC insertion • Portable CXR • Continue IV rate • Monitor I and O
to 250 cc/hr accurately
• CXR findings:
- (-) pneumothorax • For 2nd HD
- Tip of CVC at - Duration: 4 hrs
SVC - BFR 180
- CVC patent - DFR 300
- UF 1L + flushing
• S/P HD (8/13/18) - Reuse dialyzer
• Febrile episode - Flushing 50cc q15
(38.1) min

• I – 5315
• O – 55
8/13/18
8/14/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) post prandial • Continue IV rate
vomiting to 250 cc/hr
• No diarrhea
• No febrile • D/C Racecadotril
episodes • Give
• (+) pallor Metoclopramide
• 120/70,, 86, 20, 1 amp now
36.9
• SCE, CBS
• No edema
8/14/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) bibasal rales • Decrease PNSS IV
• No edema rate to 150 cc/hr

• S/P HD (8/14/18)

• D1 Ceftriaxone
• I – 5830
• O - 225
8/15/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• No dyspnea, For repeat BUN, • Continue PNSS IV • For HD tom
diarrhea, crea, pre HD rate to 150 cc/hr • HD settings:
vomiting, abdl - Duration 4 hours
pain - BFR 180
• (+) pallor - DFR 300
• CBS - UF 1L + flushing
• No edema - Reuse dialyzer
- Flushing 50cc q15
min
8/15/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) cough • Decrease PNSS IV • Empty urine bag
episodes, non- rate to 100 cc/hr prior to giving of
productive Furosemide, then
• No dyspnea • Give Furosemide quantify UO after
• Decreased 40 mg IV
breath sound, R
• Noted edema on
facial and neck
area, and upper
extremities

• UO of 350 cc for 8
hours
8/15/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• No cough • Continue PNSS IV • WOF for signs of
episodes rate to 100 cc/hr congestion
• No dyspnea
• No febrile
episodes
• (+) edema on
facial/neck area
• Still with
decreased
breath sounds
• No bipedal
edema

• D2 Ceftriaxone
• Noted UO of 410
cc after
Furosemide

• I – 4050
• O – 1900
8/16/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• No cough • For pre-HD Na, • Decrease PNSS IV • Increase UF to 3L
episodes K, BUN, crea rate to 60 cc/hr + flushing
• No dyspnea
• No febrile • Give Furosemide
episodes 40 mg IV now
• (+) edema on
facial/neck area
• Still with
decreased
breath sounds
• Noted scrotal
edema
8/16/18

 eGFR: 10.6 ml/min/1.73m2

BLOOD CHEM/SEROLOGY RESULTS

BUN 55.00 H
Creatinine 7.02 H
Sodium 136.00
Potassium 2.90 L
8/17/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• S/P HD (8/16/18) • Repeat Crea, • Shift to PNSS 1L +
Na, K tom 40 mEqs KCl x 60
• No dyspnea cc/hr for 3 cycles
• No febrile
episode
• SCE, CBS

• Noted crea of
7.02 from 11.22, K
of 2.90
• Good UO

• No signs of
congestion

• D4 Ceftriaxone
• I – 4000
• O – 4300
8/18/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• No dyspnea • Continued PNSS Remove IFC
• No febrile 1L x 60 cc/hr
episode Facilitate repeat
• No desaturation Crea, Na, K
• Decrase in
edema on
facial/neck area
• SCE, CBS
• Decrease in size
of scrotal edema

• D5 Ceftriaxone
• I – 2660
• O – 5990
8/18/18

 eGFR: 30.7 ml/min/1.73m2

BLOOD CHEM/SEROLOGY RESULTS

Creatinine 2.79 H
Sodium 145.00
Potassium 3.90
Working Impression
Acute Kidney Injury probably
secondary to Infection
To consider Leptospirosis
Case Discussion
Overview

 Caused by the pathogenic species of Leptospira, a spirochete usually

microscopically seen by dark-field examination
 Mild form: fever, headache, myalgia
 Severe form (Weil’s disease): jaundice, renal dysfunction, and hemorrhagic
diathesis
 Occurs most common in the tropics and subtropics
 Happens during the rainy season in the tropics
 Transmission occurs through abraded skin, cuts or through mucosal
membranes, especially in the conjunctiva and oral mucosa

Harrison’s Principle of Internal Medicine 19th Ed.

Timeline of Leptospirosis infection

Harrison’s Principle of Internal Medicine 19th Ed.

Clinical Presentation

Leptospirosis CPG, 2010

Clinical Presentation

 The incubation period of leptospirosis may range from 2 to 28 days.

 Asymptomatic seroconversion is the most common result of infection.
 Mildest presentation fever, headache, and myalgia, accompanied by
other nonspecific findings such as nausea and vomiting, diarrhea,
nonproductive cough, and maculopapular rash
 Conjunctival suffusion (red eyes without exudate) and severe calf pain are
not specific.
 Mild leptospirosis may resolve spontaneously without requiring antimicrobial
therapy.

Leptospirosis CPG, 2010

Clinical Presentation

 Severe manifestations of leptospirosis include any combination of jaundice,

renal failure, hemorrhage (most commonly pulmonary), myocarditis, and
hypotension refractory to fluid resuscitation
 Other complications include aseptic meningitis and ocular involvement
including uveitis.
 Current usage of the term “Weil’s disease” refers to fever, jaundice, and
renal failure and is often considered synonymous with severe leptospirosis.

Leptospirosis CPG, 2010

Diagnosis

Leptospirosis CPG, 2010

Diagnosis

 The clinical assessment and epidemiologic history are more important.

 Early recognition and treatment is MORE important to prevent
complications of the severe disease and mortality.
 However, if definitive or confirmatory diagnosis is warranted in suspected
cases and for epidemiological and public health reasons, these are the
locally available diagnostic tests for leptospirosis.

Leptospirosis CPG, 2010

Specific Diagnostics

Leptospirosis CPG, 2010

Specific Diagnostics

 Microscopic demonstration Leptospires may be visualized in clinical

specimens by dark-field microscopy or by immunofluorescence or light
microscopy after appropriate staining
 Microscopy of blood is of value only during the first 7-10 days of the acute
illness during leptospiremia.
 Dark-field microscopic examination of body fluids is both insensitive and
lacks specificity.
 False positive and false negative results are easily made even in
experienced hands.

Leptospirosis CPG, 2010

Ancillary Diagnostics

Leptospirosis CPG, 2010

Management

Leptospirosis CPG, 2010

Management

 Antibiotic therapy should be started as soon as the diagnosis of leptospirosis

is suspected regardless of the phase of the disease or duration of
symptoms.

Leptospirosis CPG, 2010

Prevention

 The most effective preventive measure is avoidance of high-risk exposure

(i.e. wading in floods and contaminated water, contact with animal’s body
fluid).
 If high risk exposure is unavoidable, appropriate personal protective
measures include wearing boots, goggles, overalls, and rubber gloves.

Leptospirosis CPG, 2010

Pre exposure Prophylaxis

 NOT ROUTINELY RECOMMENDED

 In those individuals who intend to visit highly endemic areas AND are likely
to get exposed pre-exposure prophylaxis may be considered for short-term
exposures.
 For non-pregnant, non-lactating adults
 Doxycycline (hydrochloride and hyclate) 200 mg once weekly, to begin 1
to 2 days before exposure and continued throughout the period of
exposure
 NO recommended pre-exposure prophylaxis that is safe for pregnant and
lactating women

Leptospirosis CPG, 2010

Post exposure Prophylaxis

Leptospirosis CPG, 2010

Thank You.