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Clinical Case 037: finding fevers’ focus

Another case for Sepsis week.

67 yo. male traveller.  Recently been on vacation in Scotland, then spent a week in Singapore, flew into Perth (WA) then up to Broome to sit on the beach.  Spent all his time in metro areas, no farm / rural / jungle exposure.

Presents to the ED with a 2 day history of fevers, sweats and feeling generally miserable.  This case occurred in the midst of the Aussie swine flu pandemic – so he was fully loaded with Tamiflu as soon as he hit the front door!  However, this man had no respiratory symptoms at all – not even a sniffle.  Actually he had no good localizing symptoms at all. No cough, rash, diarrhea, no headaches, no abdo pain – nothing…

He had impressive fevers – t > 39, spiking every 3 – 4 hours.  But his other numbers remained relatively normal.  Examination was not really helpful – no ENT, chest, abdo or skin signs.  His urine was clean on dipstick.  A CXR was done in ED – normal, nothing to see.

FBP: WCC 17, neutrophilia, Hb 144, Platelets – 377

UECr = normal,

LFTs:  alb = 34, ALT and GGT just up, bilirubin = 16

CRP = 67

Cultures sent, rapid malaria kit / films Negative for malaria.  Serology sent for flu / respiratory panel

So – what to do?  Well the thinking was that he had likely early viral illness – and he was admitted for observation and not given any antibiotics.  “Reculture if febrile”  The next day his obs chart showed ongoing impressive fevers – spiking up to 40 every 4 hours.  Still no good signs.  He felt a bit nauseated and was dry from the sweats.

FBP = WCC now 26.2, neutrophilia, Hb 157, platelets = 577

UECr = slight bump in urea, Cr now 110 (up end of normal)

LFTs = albumin 29, ALT and GGT now about double normal ALP a bit up, bilirubin = 37

CRP now 189!

OK – what do you want to do next?

”Hi Doc, you looking after Mr McSmith? Well, not sure if these are just contaminants, but he seems to have both a gram positive and a GNB in his blood cultures. Seems unusual, maybe we should repeat them…..” Click you hang up and run for the antibiotic shelf….

Ok, all you fever hunters – what is your next move?

So my next move…. go back and take the history again.  I didn’t take the original history in ED, so I went back to the bedside and probed a bit more into what had been going on over the past few weeks, months etc.  All this whilst the nurses were making up a batch of broad-spectrum bug poison!

Whilst in the UK, this chap had been feeling unwell with lower abdo pain. He had consulted a GP, who thought he had mild diverticulitis and he had taken a 10 day course of Amoxil/clav acid with good effect.

He got better, and didn’t really think about it until asked…  Oh, actually, he had still been getting some mild lower abdo “aches”, “nothing he’d take a pill for though”.  And when pushed on history, the fevers, well, they had been intermittent for a few weeks, only became “troublesome” in the past few days!

So, I thought.  BINGO – he has a diverticular abscess, partly treated by the ABs, and still causing fevers.  Lets scan him.

At this point I was feeling pretty smart – I thought I had found a fever source and could carry on with the ABs, call a surgeon, and he would be OK.

Which showed a diverticular collection, but mainly showed this!

 

Source control in sepsis is crucial. You need to be certain you know where the fever is coming from and that it is treated – surgically if necessary.

History remains one of our best weapons.  It would be easy to order a batch of tests and cover with ABs until we get the results, but I am still constantly surprised in my practice how often the patient will tell you the answer if you probe with a careful history.  Sometimes you need to ask questions in differents ways to get the info you need.  and remember patients are human – they forget, overstate, get distracted and sometimes even lie!

So what happened – this man got tazobactam / pipperacillin on advice from a Micro guru and flown out for percutaneous CT guided drainage of his liver abscesses – these were polymicrobial, likely stemming from his diverticuitis the weeks before.

Comments

  1. Minh Le Cong says

    Hi casey
    nice work with the sepsis cases.
    this guy in this case needs more workup. He needs an echo, serial blood cultures. Q fever serology as well…although less likely given the recent positive BC results
    endocarditis till proven otherwise.

  2. …and fill him full of ABs on advice local microbiologist/sensitivities whilst awaiting results of Minh’s more detailed workup.

  3. So I get that he’d need serial BCs if you didn’t already have a positive but what will they change now that you have your bugs? I agree that a TEE/TOE is pretty important here though

    • Minh Le Cong says

      you should be careful diagnosing endocarditis on only one set of cultures. when I was doing internal medicine for my advanced skills year, we would hold off on IV ABs until we had three sets of serial BCs over 6-9hrs..if the patient was stable enough to do so!
      Sometimes the TOE is inconclusive. Its important to get a good diagnosis as endocarditis therapy is often for weeks if not months.

  4. Hepatic abscesses? Brilliant.

    You’re spot on with value of history vs a battery of tests – one of the strengths of rural docs is that we HAVE to rely on, as Sir Lancelot Spratt said “eyes, ears and hands foremost”

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