INFECTIOUS DISEASE

WEEK
Foundations of Clinical Practice 2015

Case 1

History
-A 65-year-old man presents to the emergency room with
a 3-day history of severe, constant, worsening left lowerquadrant pain, with associated diarrhea, anorexia, and a
fever of 39c.
-His medical history is significantly for hypertension, mild
angina pectoris, and hypothyroidism.
-Medications
levothyroxine.

include

hydralazine,

aspirin,

-He lives alone but is independent and active.

and

Physical Examination
-He is febrile (39c) and tachycardic, at 110 beats per
minute, with a BP of 90/50 mm Hg, respiratory rate is
17/min.
-On clinical examination, the abdomen is distended and
rigid with direct & rebound tenderness at the left lower
quadrant, bowel sounds are hypoactive.
-His mucus membranes are dry and he is diaphoretic.

Considerations:
Patient presents with evidence of sepsis and possible early septic shock.
Initial goal (after taking history and PE) is resuscitation.
Adequate intravenous access is obtained and aggressive fluid resuscitation
(30ml/kg) is pursued.
A bladder catheter is inserted to monitor urinary output.
Supplemental oxygen (hi flow) may be required and intravenous opioid analgesia
is administered as necessary.

Given the clinical picture and suspicion of intra-abdominal infection,

intravenous broad-spectrum antibiotics (for gram negative rods and
anaerobes) are given to the patient.
Once resuscitation is underway, the next step is to proceed with
investigations.

Investigations
FBC reveals leukocytosis of 24
BUN of 30 mg/dL, and creatinine of 1.2 mg/dL.
Blood culture (to be taken possible before starting antibiotics) and
lactate levels
Amylase and lipase were within normal range.
Abdominal radiograph: no evidence of free air under the diaphragm
Abdominal CT
Shows sigmoid diverticulosis and an inflammatory phlegmon and associated
mesenteric fat stranding in the region of the sigmoid colon, with
extravasation of the rectally administered contrast, and free intraperitoneal
gas.

Diagnosis
Perforated sigmoid diverticulitis

Management
Emergency surgery is required for this patient with
perforated diverticulitis.
The basic tenet of management is control of intraabdominal sepsis with excision of the septic focus (e.g.,
source control), where possible.
Firstly, appropriate resuscitation is required for this
patient with septic shock and acute renal injury.
Once resuscitation is underway, proceed to surgery.

Management
Most patients with perforated sigmoid diverticulitis will
benefit from an initial stay in the Surgical Intensive Care
Unit (SICU).
Intravenous broad-spectrum antibiotics (especially for
gram negative and anaerobes) should be continued.
Duration of antibiotic therapy is determined by the
patients clinical course.
Both mechanical and pharmacologic venous
thromboembolism prophylaxes are beneficial.

Complications
Postoperative complications in the setting of intraabdominal sepsis include intra-abdominal or pelvic
abscess.
Suspicion for abscess formation should be aroused by
the occurrence of a prolonged ileus, nonfunctioning
stoma, persistent fever, or leukocytosis.
CT-guided drainage of intra-abdominal abscesses is
typically successful in managing sepsis.
Wound infections are common after a Hartmanns
procedure and are managed by opening the wound and
drainage of the abscess.

Case Conclusion
The patient undergoes a successful Hartmanns
procedure and is extubated in SICU the following day.
His stoma functions on day 2 and he recommences diet
on the fourth postoperative day.
He spends 7 days in the hospital and is discharged well
and improved.
He has his proximal colon assessed endoscopically prior
to successful reversal of Hartmanns procedure 6
months later.

Case 2

History
A 68-year-old man with a history of hypertension,
obesity, and tobacco use presents to the emergency
department.
His primary complaint is epigastric and right upperquadrant abdominal pain of 24-hour duration. He notes
that he has had similar pain on occasion before but
always had complete resolution of pain within a couple
of hours.
He reports his urine has been very dark for the last 12
hours.

Physical Examination
He is febrile on arrival with a temperature of 39c, a
blood pressure of 95/65, and a heart rate of 96.
On examination, the sclerae are mildly icteric. No
jaundice is present.
The abdomen is soft with direct tenderness at the right
upper quadrant area, (-) rebound tenderness; bowel
sounds are normoactive.

Considerations
Consider the following as differentials:

Cholecystitis
Choledocholithiasis
Cholangitis
Hepatitis
Pancreatitis
Peptic ulcer disease
Acute gastritis
Colonic carcinoma

Presence of fever indicates a possible infectious cause

Presentation Continued
Patient was admitted for further evaluation.
IV fluids started.
FBC, serum electrolytes, BUN/crea, amylase, lipase,
coagulation profile, hepatitis serology and liver function
test ordered.
Results showed leukocytosis of 14,300/mL with a
predominance of neutrophils, both bilirubin and alkaline
phosphatase were elevated.
Both the AST and the ALT are elevated at 210 and 334
IU/L, respectively.
Empirical antibiotics initiated.

Investigations
Ultrasound of the liver, gallbladder, hepatobiliary tree
and pancreas was ordered
The liver is normal in size with no abnormal masses noted.
The gallbladder is not distended with thickened walls; there
are several stones noted inside with sizes ranging from 0.751cm.
The common bile duct is dilated with a diameter of 1.4 cms
with note of single stone at the distal portion.
The pancreas cannot be visualized because of overlying bowel
gas.

Diagnosis
Obstructive jaundice secondary to choledocholithiasis

Presentation Continued
On the first hospital day patient still febrile and with
abdominal pain now developed hypotension (80/50mmHg)
and became disoriented.
A diagnosis of ascending cholangitis was made.
After initial resuscitation patient was scheduled for
emergent decompression via endoscopic retrograde
cholangiopancreatography (ERCP).

Case Conclusion
Patient underwent successful ERCP with stone basket
extraction and a sphincterotomy.
He was afebrile on day 2 post ERCP
Repeat FBC and liver function test both showed
decreasing levels of WBC and bilirubin.
IV antibiotics shifted to oral and IV fluids discontinued
on day 4.
Discharged improved on 5 with a schedule to do
elective laparoscopic cholecystectomy.

Case 3

History
The patient is a 78-year-old gentleman with a past history of
hypertension, peripheral vascular disease, and diabetes.
Two weeks ago, he underwent carotid endarterectomy and was
recently treated as an outpatient with ciprofloxacin for a UTI.
He presents back to the hospital with abdominal pain and
profuse watery diarrhea. He describes this as 10 bowel
movements a day and states that the stool is foul smelling.
He denies nausea/vomiting, melena, or hematochezia. He
denies any unusual food intake or recent travel, and he drinks
only city tap water. No one else in his household is sick.

Physical Examination
Upon exam, he is febrile (38.5c), mildly tachycardic,
but normotensive.
He appears dehydrated with dry mucous membranes
and dry skin.
His abdomen is soft, mildly distended, and diffusely
tender without peritoneal signs.
He has no abdominal scar.

Considerations
Acute onset of profuse diarrhea is most commonly from an infectious
cause (causes include viral infections such as norovirus, rotavirus,
and adenovirus).
Bacterial infections usually cause more severe diarrhea and in adults
are usually due to Vibrio, Escherichia coli, Salmonella,
Campylobacter or Shigella.
In patients with recent antibiotic use, Clostridium difficile infection
should be considered.
Parasitic infections are also possible and can be due to Giardia
lamblia, Cryptosporidium, and Entamoeba histolytica.
Noninfectious causes can include osmotic antibiotic-associated
diarrhea.

Initial Management
Resuscitate
Investigations
Blood investigations
Stool culture/sensitivity, identify any ova or parasites
Immunoassay for C. difficile toxin

Empiric PO metronidazole is started due to high clinical

suspicion for C. difficile colitis.
This test comes back positive on hospital day 2.

Definitive Management
Discontinue the offending antibiotic if they are still
taking it
Caution about using broad spectrum antibiotics in future
Prevent dehydration (IV hydration)
Medication:
Metronidazole, Vancomycin, Fidaxomicin

Probiotics
Surgery if complications develop