Morbidity Conference. Presented by 肝膽腸胃科張瀚文

Transcription

1 Morbidity Conference Presented by 肝膽腸胃科張瀚文

2 Chief Complaint General weakness for three days

3 Present Illness This 63-year-old female with diabetes and on oral hypoglycemic agents presented with 3-day history of general weakness. She also had thirsty, watery diarrhea, fever (?) but denied abdominal symptoms. She reported productive cough with yellowish sputum, short of breath, chest tightness for one day.

4 Physical Examination Clinically, she looked ill, had a temperature of 36.2 C, blood pressure of 103/55 mmhg. Tachycardia (110/min) and tachypnea (18/min) were noted also. Anicteric sclera and erythematous conjunctiva in the left eye was found on inspection. Chest auscultation revealled crackles at right lower lung without heart murmur

5 Physical Examination On abdominal examination, there were no tenderness, liver and spleen were impalpable. Slight flank knocking pain. There were no skin lesion.

6 Blood Investigations Sugar : 573 mg/dl Acetone : trace BUN: 38 mg/dl Cr: 1.5 mg/dl Na: 128 meq/l K: 3.5meq/L Hb: 12.9 gm/dl Ht: 37.0 % WBC: 10300/uL Band 9 % Neut 70% Lymph 8% Metamyelocyte 6%

7 Blood Investigations Blood gas PH: 7.36 pco2: 28.8 mmhg po2: 72.9 mmhg HCO3: 18 mmol/l B.E.: -8.0 mmol HbA1c: 12.8 % Albumin : 2.7 gm/dl Bilirubin (T): 0.5 mg/dl GOT: 91 U/L GPT: 102 U/L

8 Clinical Impression DM, poor control. Pneumonia with sepsis. Abnormal liver function.

9 Initial Management Fluid resuscitation. Control blood sugar by sliding scale. Empiric antibiotics. Abdominal echogram. Blood and sputum cultures.

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12 Clinical course Admission: 01/18 Ophthalmology consultation: 01/19 Abdominal echogram and abdominal CT scanning: 01/20. CT-guided abscess drainage: 01/24. Ophthalmology consultation: 01/28, 02/02. Remove drainage catheter:02/09.

13 Antibiotics agents Cefamezine: 01/18 01/20. Flumarin: 01/20 01/27. Mefoxin and GM: 01/27 01/30. Cirpoxin and Amikin: since 01/30.

14 Cultures Blood cultures(01/19): Klebsiella ozaenae Abscess culture(01/24): Klebsiella pneumonia Sputum culture(01/28): Pseudomonas aeruginosa Eye culture(02/04): no growth.

15 Causes of Liver abscess Portal pyremia Ascending infection Direct infection No obvious causes : often in diabetic patients

16 K. Pneumoniae liver abscess The leading pathogen in Taiwan. Associated with diabetes mellitus: %. Mostly cryptogenic. Clinical presentations: fever, chillness, abdominal pain, hepatomegaly. Susceptible to all cephalosporin and aminoglycosides, but resistant to ampicillin and ticarcillin/carbenicillin.

17 K. Pneumoniae liver abscess Diagnostic examinations include : Blood cultures CT- or untrasonographically-guided aspiration of the the abscess, with or without catheter drainage to obtain a specimen for gram staining and aerobic/ anaerobic cultures

18 K. Pneumoniae liver abscess Routine test should include: CT scanning of the whole abdomen HIV serology Blood chemistry and fasting blood sugars

19 K. Pneumoniae liver abscess Catheter drainage is the major treatment strategy unless multiple microabscesses are present. Combined with 3-week course of parenteral antimicrobial treatment. Catheter drainage is usually continued for 1-2 weeks. Maintain oral antimicrobial treatment for 1-2 months after discharge to prevent relapse.

20 K. Pneumoniae liver abscess The catheter drainage is removed when : Cultures of the liver abscess become sterile. The daily drainage output is less than 5 ml for several days. Afervescence occurs even after the drainage tube is clamped.

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22 K. Pneumoniae liver abscess Metastatic foci: endophthalmitis (5), menigitis (4), lung abscess(4), psoas muscle abscess (2), brain(1), lung and brain(1), splenic abscess(1),and necrotizing fasciitis of the right leg(1). Cauaes of death: fulminant sepsis(50%), metastatic infection to critical organs(11.1%),diabetic complications, COPD,nosocomial pneumonia.

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24 Endophthalmitis Endogenous (2-10%)vs exogenous. Most common sources of endogenous endophthalmitis: hepatobiliary system, the urinary tract, and the lung. Most cases of endogenous endophthalmitis arise in the patients with underlying diabetes mellitus with an Klebsiella bacteremia from the hepatic source.

25 K.P Endophthalmitis Responsible 90% of endogenous endophthalmitis. Destruction of optic receptors: endotoxin? Impaired phagocytic function in diabetic patients. Ocular symptoms may present early in the natural history or after drainage of liver abscess. Involvement of both eyes can occur.