A Not So Simple UTI

A Not So Simple UTICase ConferenceNovember 20th, 2012 Jiten Patel & Alisha LacourHeadache X 1 weekChief Complaint49 year old woman with history of COPD and nephrolithiasis (first diagnosed 2011)4 Weeks ago:She presented to an outside hospital with urinary symptoms, nausea, vomiting and flank pain.

HPI4 Weeks ago:Urine cultures showed mixed flora Sent home on ciprofloxacin Follow-up with urology. She presented to the urology clinic 2-3 days laterClinically looked poor so she was admitted from the clinic for: IV antibiotics Placement of stents for hydronephrosis. She was sent home with ciprofloxacin and clindamycin Urine cultures drawn prior to discharge were negative. .

HPI2 Weeks ago:Followed up with urology Had successful laser ablation of the kidney stone5 days ago:She presented to the an outside hospital complaining of a headacheConstant and aching Fluctuated in intensity from 8/10 to 10/10No radiationDiffusely throughout the headNo alleviating factorsWorsened by light and soundsHPI Continued5 days ago (cont.):CT showed a possible subarachnoid hemorrhageShe was transferred to UH for neurosurgical evaluation. She was admitted by neurosurgery and observed in the ICU. A repeat head CT showed a stable subarachnoid hemorrhageShe was discharged home with follow-up.HPI Continued 3 days agoAfter being home for a few days she presented to UH with persistent headache. Also complained of:Mild dysuriaNo increase in frequency or incontinenceNo flank painLow grade fevers

HPI ContinuedKidney StonesESWL 2011COPDPast Medical HistoryCystolithotomy 2005

Past Surgical HistoryCiprofloxicin 500mg PO BIDOxycodone-Acetaminophin 5-325mg PO Q4-6 hoursTamsulosin 0.4mg PO QDayMedicationsPenicillin swelling of extremities AllergiesFather passed away from cardiac disease 70sMother passed away from lung cancer 60s Siblings healthySeveral family members with kidney stones

Family HistorySmokes 1-2 packs per day for 35 yearsQuit 3 weeks agoDenies any current alcohol useDenies any illictsLives with her fianc

Social HistoryUp to date on influenza immunizationUp to date on pneumococcal immunizationUp to date on Tetanus immunizationUp to date on PAPUp to date on MammogramNo colonoscopy

Health Maintenance Gen: No weight changesHEENT: no visual changes, sore throat, rhinorrheaCV: Per HPIRESP: Per HPIGI: no N/V/D/C/melena/BRBPRNeuro: No dizziness, numbness, seizureSkin: no new rashesGU: Per HPIROSVitalsTriageBP 110/60 P 68 RR 18 T 99.2 O2 100% on RA56 77kg BMI 27ExamBP 125/79 P 61 RR 16 T 98.8 O2 98% on RA

Physical ExamGENERAL: Awake, alert, and oriented. No acute distress.HEENT: The patient does have a hyperpigmentation over her left eyebrow. Normocephalic, atraumatic. Mucous membranes are slightly dry. No papilledema.CARDIOVASCULAR: Regular rate and rhythm. No murmursRESPIRATORY: Mild expiratory wheezing bilaterally.ABDOMEN: Bowel sounds present. Soft. Nontender. Nondistended.EXTREMITIES: No clubbing, cyanosis, or edema.Physical ExamNEUROLOGIC: Mental: Awake, alert, and oriented x4. Sensation intact to light touch. Reflexes are 2+ in biceps, triceps, patellar, ankleStrength is 5/5 bilaterally in the upper and lower extremities. Cerebellar function intact to finger to nose and heel to shinCN II-XII: EOMI intact, PERRLA, sensation intact to light touch, raises eyebrows, closes eyes tight, symmetric smile, tongue midline, good palate elevation, phonation/cough intact, shoulder shrug appropriatePhysical ExamLabs OSH (Day prior)134 98 133.8 29 0.93 (24-32)131Ca 8.2 (8.4-10.3) Mg 1.6 P 2.1 TP Alb TB AST ALT ALP7.2 2.7 1.6 20 20 61 (3.5-5.0)(100Sq20-100BactManyCasts3-5 Hyaline (4.5-11.0) 18.0 224 13.3

40.0N 92 L 4 M 39313.3Labs Admit134 102 134.0 26 0.9150Ca 8.5 Mg 1.6 P 2.1

Blood Cultures drawn UA:SgpHProtGluKetBiliBloodNitriteUrobilLE1.0117.025NegNegNeg25Neg8.0500RBC0-2 WBC3-5Sq1-2BactnegativeCasts0(4.5-11.0) 13.9 224 12.6

36.2N 96 L 3 M 19313.3CT Head 2/18

CT Head 2/18

CT Head 2/18

CTA Brain (2/19)

CTA Brain (2/19)

CT Brain (2/24)

CT Brain (2/24)

LPCSF ClearGlucose 12Total Protein 100.4WBC 198SEGS 67% LYMPHOCYTES 33%RBC 0Gram Stain:Many WBCsFew Gram negative rods

Labs

Gram StainGram Stain

Gram Stain

She was admitted:Placed in respiratory isolation Treated with:DexamethasoneVancomycin Imipenem due to her penicillin allergy.Her headache improved.Hospital CourseDay 2:Urine Cx from OSH: E. Coli >100,000Resistant to CiprofloxacinSusceptible to ticarcillin/clavulinate, ampicillin, gentamicin, nitrofurantoin, piperacillin/tazobactam, ampicillin/sublactam, tetracycline, cefazolinIntermediate to cephalothinBlood Cxs and CSF Cxs with Gram negative rods

Hospital CoarseMRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRA Brain

MRA Brain

Day 3 of hospital courseShe had a seizure sending her to the ICUCause due to the carbapenem or meningitisNeurology was consultedEEG doneMild to moderate abnormalityDiffuse slowingExcessive beta activityImipenem stopped and treated with gentamicin

Hospital CourseRepeat LPClearGlu 37Pro 64WBC 130N 9% L 89% M 2%RBC 0Gram Stain:No Organisms

Hospital CoarseHospital Day 4Initial Blood and CSF cultures :E. Coli CSF sensitive to aztreonam, ampicillin, piperacillin/tazobactam, imipenemBlood sensitive with above and gentamicin, bactrim, cefazolinBlood resistant to ciprofloxicin, moxifloxicinAntibiotics changed to aztreonamSomnolent from seizureHospital Day 6Clinically improvedReported feeling the best she had in weeksStepped down to the floor

Hospital CourseHospital Day 7Became more lethargicOn call intern notifiedEvaluated patient, noted papilledemaSTAT CT head OrderedHospital CourseCT Brain

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

Transferred back to ICUNeurosurgery ConsultedSubdural Hematoma with midline shiftTaken to the OR for emergent hemicraniotomyMental status did not improveFamily elected for palliative carePassed awayHospital CourseThank You