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, lesions
ABDOMEN
EXTREMITIES
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT  No excessive lacrimation,
CHEST AND LUNGS
HEART nasoaural discharge, throat
ABDOMEN itchiness/sore throat
EXTREMITIES  Noted feeling of dry mouth
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS  No chest pain, orthopnea,
HEART
PND, cough episodes,
ABDOMEN
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, melena,
ABDOMEN
EXTREMITIES tenesmus
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS
HEART  No complaints of edema on
ABDOMEN upper and lower extremities
EXTREMITIES
GENITO-URINARY
HEMATOLOGIC
ENDOCRINOLOGIC
NEUROLOGIC
GENERAL APPEARANCE
SKIN
HEENT
CHEST AND LUNGS  No dysuria, hematuria,
HEART
sand-like sensation when
ABDOMEN
EXTREMITIES voiding, penile 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
HEART
cardiorespiratory distress,
ABDOMEN weak-looking, ectomorph
GENITO-
EXTREMITIES
URINARY/RECTAL
NEUROLOGIC
  BP: 110/60 mmHg
GENERAL APPEARANCE  HR: 113 bpm
VITAL SIGNS
SKIN  RR: 24 cpm
HEENT
CHEST AND LUNGS  T: 37.1o Celcius
HEART  O2 sat: 99%
ABDOMEN
GENITO-
EXTREMITIES  Wt.: 55.8 kg
URINARY/RECTAL  Ht.: 178 cm
NEUROLOGIC
 BMI: 17 kg/m2
GENERAL APPEARANCE
VITAL SIGNS  (+) pallor
SKIN
HEENT  No rashes, lesions, open
CHEST AND LUNGS wounds, jaundice
HEART
ABDOMEN  Dry skin
GENITO-
EXTREMITIES  Fair complexion
URINARY/RECTAL
NEUROLOGIC
  Anicteric sclera
GENERAL APPEARANCE  Slightly pale palpebral
VITAL SIGNS
SKIN conjunctiva
HEENT  Non-sunken eyeball
CHEST AND LUNGS
HEART  No nasoaural discharge,
ABDOMEN tonsillopharyngeal
GENITO-
EXTREMITIES congestion
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
GENITO-
EXTREMITIES
URINARY/RECTAL
NEUROLOGIC
GENERAL APPEARANCE  Symmetrical chest
VITAL SIGNS
SKIN expansion
HEENT  No retractions
CHEST AND LUNGS
HEART
 Both lung fields were
ABDOMEN resonant
GENITO-
EXTREMITIES  No tactile and vocal
URINARY/RECTAL
NEUROLOGIC fremitus
GENERAL APPEARANCE
VITAL SIGNS
SKIN  Clear breath sounds on all
HEENT lung fields
CHEST AND LUNGS
HEART
 No bronchophony,
ABDOMEN egophony, and whisper
GENITO-
EXTREMITIES pectoriloquey
URINARY/RECTAL
NEUROLOGIC
GENERAL APPEARANCE  Adynamic precordium
VITAL SIGNS
SKIN  No lifts, heaves and thrills
HEENT  PMI heard best at 5th ICS
CHEST AND LUNGS
HEART
LMCL
ABDOMEN  S1>S2 at apex, S2>S1 at
GENITO-
EXTREMITIES base
URINARY/RECTAL
NEUROLOGIC  No S3, S4, murmurs
GENERAL APPEARANCE
VITAL SIGNS
SKIN  Flat
HEENT  16 bowel sounds per minute
CHEST AND LUNGS
HEART
heard on all quadrants
ABDOMEN  (+) tenderness on epigastric
GENITO-
EXTREMITIES area
URINARY/RECTAL
NEUROLOGIC
GENERAL APPEARANCE
VITAL SIGNS  Grossly normal extremities
SKIN  Full and equal peripheral
HEENT
CHEST AND LUNGS pulses
HEART  No cyanosis
ABDOMEN
GENITO-
 CRT: 1-2 seconds
EXTREMITIES
URINARY/RECTAL  (+) Homan’s sign, bilateral
NEUROLOGIC
GENERAL APPEARANCE
VITAL SIGNS
SKIN  No CVA tenderness
HEENT
CHEST AND LUNGS  No penile discharge
HEART  Pendulous, non-edematous
ABDOMEN
GENITO-
EXTREMITIES scrotum
URINARY/RECTAL
NEUROLOGIC
 GENERAL APPEARANCE  No external hemorrhoids
VITAL SIGNS
SKIN  Good sphincteric tone
HEENT  Non-collapsed rectal vault
CHEST AND LUNGS
HEART  No mass appreciated
ABDOMEN  (+) brownish fecal material
EXTREMITIES
GENITO-URINARY/RECTAL on examining finger, no
NEUROLOGIC blood
 GENERAL APPEARANCE
VITAL SIGNS
SKIN
HEENT
CHEST AND LUNGS  Oriented to person, place
HEART 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 asymmetry,
VITAL SIGNS
SKIN (+) bicorneal reflex
HEENT  VIII – Intact gross hearing
CHEST AND LUNGS
HEART  IX, X – Intact gag reflex,
ABDOMEN uvula midline
EXTREMITIES  XI – Good shoulder shrug
GENITO-URINARY/RECTAL
NEUROLOGIC 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 dysdiadochokinesia,
VITAL SIGNS
SKIN dysmetria
HEENT  No agraphesthesia,
CHEST AND LUNGS astereognosis
HEART
ABDOMEN  No Babinski, ankle clonus,
EXTREMITIES asterixis
GENITO-URINARY/RECTAL
NEUROLOGIC
 No meningeal signs
Salient Features
HISTORY
21/M, Roman Catholic, lives in Pasay City, admitted for the 1 st 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 1 st 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 onset of  Claims to have no open wound on the
fever
lower extremity during exposure to flood
 Fever water
 Chills
 Mineral drinking water
 Nausea and vomiting
 Diarrhea
 No dysuria
 Abdominal Pain  No jaundice
 Myalgia  Anicteric sclera
 Body weakness
 Decrease in urine ouput
 (+) Homan’s sign

DECISION: CANNOT BE RULED OUT

 Amoebiasi Gastroente
s ritis Dengue

Leptospiro Urinary Tract

sis Infection

FEVER

DIARRHEA

NAUSEA AND VOMITING

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

 Amoebiasi Gastroente
s ritis Dengue

Leptospiro Urinary Tract

sis Infection

FEVER

DIARRHEA

NAUSEA AND VOMITING

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, Crea, • Solufundin iso 1L • NPO to LSLF diet
100/60 BUN, Fecalysis, fast drip 500 cc then
• HR: 113 Urinalysis regulate at 250 cc/hr • Monitor v/s q1 to
• RR: 24 • KUB UTZ q4
• Followed by PLR at
• Wt.: 53 kg • Repeat BUN, crea, 160 cc/hr
• O2 sat: 99% Na, K tom AM • Advised admission
• Total calcium, • Pantoprazole 40mg
albumin, IV
phosphorus, • Metoclopramide
magnesium 10mg IV
• CXR PA • Ciprofloxacin 500
mg/tab OD
• 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 mg • Monitor I and O
done • ABG IV now accurately
• (+) wading in • Paraccetaml 500
mg/tab now then
flood
PRN for T>/= 37.8
• (+) Homan’s sign • Paracetamool 300
• (+) pinkish mg IV PRN T>/=
conjunctiva 38.4

• (+) febrile episode • Increase IV rate to

(T – 37.9) 200 cc/hr
8/13/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• Noted repeat crea • LeptoPCR • Continued IV rate to • Monitor I and O
of 11.2 from 9.54 • HBsAg, Anti-HBs, 200 cc/hr accurately
• UO – 210 Anti-HBc Igm,
• Explained the need Anti-HCV • Refer to surgery
for stat HD; • PT, PTT service re:
consent given for insertion of CVC
the procedure and
CVC insertion
• Noted yellowish-
discoloration of
skin
8/13/18

 eGFR - 6.2 ml/min/1.73m2

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

HEPATITIS MARKER RESUL ABG PARAMETER RESULTS

TS pH 7.34
HBsAg NR PaCO2 37.1
Anti-HBs NR PaO2 99
Anti-HBc IgM NR HCO3 19.7
Anti-HCV NR Base Excess -4.9
O2 97.3%
8/13/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) muscle pain • Ciprofloxacin shifted • Monitor I and O
• (+) scleral to Ceftriaxone 2g IV accurately
injection OD
• Increased IV rate to • Insert IFC
• (+) pallor
250 cc/hr
• 100/70, 94, 20, • For stat HD
37.2 - Duration: 3 hrs
• CBS, dry lips and - BFR 150-180
oral mucosa, no - DFR 300
edema - UF 500 ml +
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 to • Monitor I and O
250 cc/hr accurately
• CXR findings:
- (-) pneumothorax • For 2nd HD
- Tip of CVC at SVC - Duration: 4 hrs
- CVC patent - BFR 180
- DFR 300
• S/P HD (8/13/18) - UF 1L + flushing
• Febrile episode - Reuse dialyzer
(38.1) - Flushing 50cc q15
min
• I – 5315
• O – 55
8/13/18
8/14/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) post prandial • Continue IV rate to
vomiting 250 cc/hr
• No diarrhea
• No febrile episodes • D/C Racecadotril
• (+) pallor • Give
• 120/70,, 86, 20, 36.9 Metoclopramide 1
• SCE, CBS amp now
• 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, crea, • Continue PNSS IV • For HD tom
diarrhea, vomiting, pre HD rate to 150 cc/hr • HD settings:
abdl pain - Duration 4 hours
• (+) pallor - BFR 180
• CBS - DFR 300
• No edema - UF 1L + flushing
- Reuse dialyzer
- Flushing 50cc q15
min
8/15/18
NOTES DIAGNOSTICS THERAPEUTICS REMARKS
• (+) cough episodes, • Decrease PNSS IV • Empty urine bag
non-productive rate to 100 cc/hr prior to giving of
• No dyspnea Furosemide, then
• Decreased breath • Give Furosemide 40 quantify UO after
sound, R mg IV
• 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 episodes • Continue PNSS IV • WOF for signs of
• No dyspnea rate to 100 cc/hr congestion
• 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 episodes • For pre-HD Na, K, • Decrease PNSS IV • Increase UF to 3L +
• No dyspnea BUN, crea rate to 60 cc/hr flushing
• No febrile episodes
• (+) edema on • Give Furosemide 40
facial/neck area mg IV now
• 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, Na, • Shift to PNSS 1L +
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 1L Remove IFC
• No febrile episode x 60 cc/hr
• No desaturation Facilitate repeat Crea,
• Decrase in edema on Na, K
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.