1. Case of the Week `R1 유태경

2. CASE 1 발열을 주소로 내원한 49 세 여자

3. 11229333 이 O 임 (F/49) Admission: 06-08-27 Chief complaint Fever o/s) 내원 2 일전 Chief complaint Fever o/s) 내원 2 일전 Present illness Present illness - 그동안 특별한 병력 없던 환자로, 06 년 2 월 Essential tremor& CKD ( stage 5 ) 진단 받고, 본원 내과 & 신경과 OPD F/U - 그동안 특별한 병력 없던 환자로, 06 년 2 월 Essential tremor& CKD ( stage 5 ) 진단 받고, 본원 내과 & 신경과 OPD F/U - Uremic symptom 이 점점 aggrevation 되는 양상 보이고, serum Cr 9.7 까지 상승하여, 06 년 8 월 14 일 Dual lumen catheter insertion 하고 혈액투석 시작 - Uremic symptom 이 점점 aggrevation 되는 양상 보이고, serum Cr 9.7 까지 상승하여, 06 년 8 월 14 일 Dual lumen catheter insertion 하고 혈액투석 시작 - 06 년 8 월 21 일 AVF( Lt radio-cephalic ) op 시행하고 본원 AKU 에서 - 06 년 8 월 21 일 AVF( Lt radio-cephalic ) op 시행하고 본원 AKU 에서 혈액 투석 지속 혈액 투석 지속 - 내원 2 일전부터 Fever, Chill 발생하고, 상기 증상이 혈액투석 후 악화되 는 양상보여 admission - 내원 2 일전부터 Fever, Chill 발생하고, 상기 증상이 혈액투석 후 악화되 는 양상보여 admission

4. Past medical history Past medical history DM / HTN / Hepatitis / TB ( - / - / - / - ) DM / HTN / Hepatitis / TB ( - / - / - / - ) ESRD on HD ESRD on HD Essential tremor Essential tremor Osteoporosis Osteoporosis Op Hx ( + ) : AVF, Lt 06 년 8 월 21 일 at 본원 GS Op Hx ( + ) : AVF, Lt 06 년 8 월 21 일 at 본원 GS Personal history Personal history Alcohol ( - ) Smoking ( - ) Alcohol ( - ) Smoking ( - ) Allopurinol, Diavita, Ferrous sulfate, Kalimate Domperidone, Pergolide, Clonazepam, Propranolol

5. General Fatigue(+) Fever(+) Chills(+) Wt loss(-) H & Neck Headache(+) Sore throat(-) Dual lumen catheter insertion site pain(-) Respiratory Cough(-) Sputum(-) Dyspnea(-) GI A/N/V/D/C(+/-/-/-/-) Abd pain(-) Renal Dysuria(-) Hematuria(-) Frequency(-) Review of System

6. Physical Examination Vital sign 90/50mmHg – 108 회 /min – 35 회 /min – 39.6°C 90/50mmHg – 108 회 /min – 35 회 /min – 39.6°C General appearance - Alert mentality - Acutely ill-looking appearance H&Neck - Dual lumen catheter insertion site inflammation(+) - Dual lumen catheter insertion site inflammation(+) Chest - Clear breath sounds without crackle - Rapid & regular heart beats without murmur Redness(+) Swelling(-) Warmth(-) Tenderness(+) Exudate(+)

7. Abdomen - Soft and flat abdomen - Normoactive bowel sound - Abdominal tenderness/rebound tenderness(-/-) - Abdominal tenderness/rebound tenderness(-/-) Back & Extremity - CVA Td(-/-) - CVA Td(-/-) - pretibial pitting edema(-/-) - pretibial pitting edema(-/-) - good thrill at the AVF, Lt - good thrill at the AVF, Lt Physical Examination

8. Lab Finding CBC/DC 19,980 /mm 3 – 10.6 g/dl – 31.4 % - 198K MCV 87.3 fL MCH 29.3 pg seg: 89.3% ESR 55mm/hr Chemistry AST / ALT 25 / 13 U/L Prot / Alb 6.7 / 2.6 g/dL BUN / Cr 44 / 8.5 mg/dL Na / K / Cl 133 / 5.5 / 102 mmol/L Ca / P / Uric acid 7.9 / 2.9 / 6.8 mg/dL CRP 13.5 mg/dL UA RBC many WBC 2-4 Anemia d/t chronic illness Serum iron 112 uq/dL TIBC 204 ug/dL VitB12 332 pg/mL Fol(S) 8.0 ng/mL Fer(S) 44 ng/mL

9. Chest X-ray(06.8.22)

10. Initial accessment 1. Catheter – related bloodstream infection with exit site infection with exit site infection 2. ESRD on HD 3. Essential tremor 4. Osteoporosis

11. #1. Catheter - related bloodstream infection 1. Blood Culture (CVC & peripheral) 2. Catheter removal and catheter tip culture 3. Antibiotics therapy ( Vancomycin 1g q 4days IV) 4. CBC/DC, CRP F/U Diagnostic & Therapeutic Plan

12. Clinical Course - HD2 #1. Catheter related bloodstream infection #1. Catheter related bloodstream infection S) fever(-) chills(-) S) fever(-) chills(-) O) V/S 120/80mmHg – 78 회 /min – 20 회 /min – 36.5°C O) V/S 120/80mmHg – 78 회 /min – 20 회 /min – 36.5°C A) Catheter related bloodstream infection A) Catheter related bloodstream infection P) Vancomycin 1g iv q3-4days P) Vancomycin 1g iv q3-4days F/U Blood culture F/U Blood culture CBC/DC 9,510 /mm3 – 10.6 g/dl – 32.0 % - 229K ( seg: 60.7 % ) ESR 81 mm/hr CRP 13.7 Blood Culture 모두 G(+) cocci

13. Clinical Course 8/31 VANCO 1g iv q3-4days 8/308/279/1 8/27 Blood Culture : 모두 A pure of S. epidermidis Tip Culture : Moderate of S. epidermidis CRP 13.5 13.7 2.3 WBC 19,980 9,510 11,670 8/28 Dual lumen Catheter remove 8/29 Dual lumen Catheter reinsertion 37°C 38°C 36°C 39°C

14. CASE 2 Fever 를 주소로 내원한 64 세 여자

15. 11400777 문 O 순 (F/64) Admission: 06-08-06 Chief complaint Fever o/s) 1 day ago Chief complaint Fever o/s) 1 day ago Present illness Present illness - 30 년 전 DM, 4 년전 DM nephropathy, HTN 진단받고 본원 내과 OPD F/U - 30 년 전 DM, 4 년전 DM nephropathy, HTN 진단받고 본원 내과 OPD F/U - 05 년 12 월 경 anorexia, nausea 등 uremic symptom 발생하여, - 05 년 12 월 경 anorexia, nausea 등 uremic symptom 발생하여, 투석 권유 하였으나 refuse 투석 권유 하였으나 refuse - 06 년 4 월 oliguria, pulmonary edema 로 내원하여 ( 당시 Cr 8.0) Dual lumen catheter insertion 하고 HD 시작 - 06 년 4 월 oliguria, pulmonary edema 로 내원하여 ( 당시 Cr 8.0) Dual lumen catheter insertion 하고 HD 시작 - 06 년 4 월 28 일 Lt AVF op (Lt brachio-basilic ) 시행하고 본원 - 06 년 4 월 28 일 Lt AVF op (Lt brachio-basilic ) 시행하고 본원 AKU 에서 혈액투석 지속 AKU 에서 혈액투석 지속 - 내원 1 일전 HD 후부터 Fever, chills 발생하여 admission - 내원 1 일전 HD 후부터 Fever, chills 발생하여 admission

16. Past medical history Past medical history DM : 30 년전 진단 ( IMXP37 20/10IU ) DM : 30 년전 진단 ( IMXP37 20/10IU ) HTN : 4 년전 진단 ( Irbesartan, Nifedipine ) HTN : 4 년전 진단 ( Irbesartan, Nifedipine ) TB : 10 년전 진단 ( medication 후 완치판정 ) TB : 10 년전 진단 ( medication 후 완치판정 ) Op Hx ( + ) : AVF, Lt 06 년 4 월 28 일 Op Hx ( + ) : AVF, Lt 06 년 4 월 28 일 Personal history Alcohol ( - ) Smoking ( - ) Personal history Alcohol ( - ) Smoking ( - )

17. General Fatigue(-) Fever(+) Chills(+) Wt loss(-) Head / Neck Headache(-) Sore throat(-) Dual lumen catheter insertion site pain(-) Respiratory Cough(-) Sputum(-) Dyspnea(-) GI A/N/V/D/C(-/-/-/-/-) Abd pain(-) Renal Dysuria(-) Hematuria(-) Frequency(-) Review of System

18. Physical examination Vital sign 130/90mmHg – 102 회 /min – 24 회 /min – 40°C 130/90mmHg – 102 회 /min – 24 회 /min – 40°C General appearance - Alert mentality - Acutely ill-looking appearance H&N - Dual lumen catheter insertion site inflammation(+) - Dual lumen catheter insertion site inflammation(+) Chest - Clear breath sounds without crackle - Regular heart beats without murmur Redness(+) Swelling(-) Warmth(+) Tenderness(+) Exudate(+)

19. Abdomen - Soft and flat abdomen - Normoactive bowel sound - Abdominal tenderness/rebound tenderness(-/-) - Abdominal tenderness/rebound tenderness(-/-) Back & Extremity - CVA Td(-/-) - CVA Td(-/-) - pretibial pitting edema(-/-) - pretibial pitting edema(-/-) - good thrill at the AVF, Lt - good thrill at the AVF, Lt Physical examination

20. Lab Finding CBC/DC 8,120/mm 3 – 11.0 g/dl – 34.2% - 94k ( seg: 89.6 % ) ESR 53 ( seg: 89.6 % ) ESR 53Chemistry BUN/Cr 41/5.6 mg/dL AST/ALT 37/14 U/L Prot/Alb 6.9/3.0 g/dL Na/K/Cl 123/4.9/90 mmol/L Ca/P/Uric acid 7.5/1.5/4.9 mg/dL CRP 25.9 UA RBC 2~4 WBC 5-9

21. Chest X-ray(06.8.6)

22. Initial acessment 1. Catheter – related bloodstream infection with exit site infection with exit site infection 2. ESRD on HD, S/P AVF, Lt 3. DM with multiple complication ( retinopathy, neuropathy,nephropathy ) 4. HTN

23. Diagnostic & Therapeutic Plan #1. Catheter related bloodstream infection 1. Blood Culture (CVC & peripheral) 2. Catheter removal and catheter tip culture 3. Antibiotics therapy (Vancomycin 1g q4days IV + Ceftriaxone 2g qd IV) (Vancomycin 1g q4days IV + Ceftriaxone 2g qd IV) 4. CBC/DC, CRP F/U

24. Clinical course 8/7 8/7 Blood & Tip culture : 모두 MRSA 8/14 F/U Blood 시행 CRP 25.9 27.7 23.4 WBC 8,120 12,300 15,320 Dual lumen Catheter remove AXON 2g iv qd 8/8 AVF,Lt 통해 HD 시행 39°C 38°C 37°C 36°C 40°C 8/14 8/7 Blood & Tip : 모두 G(+) cocci VANCO 1g iv q4days

25. HD 11 (06.8.17) #1. Catheter related bloodstream infection #1. Catheter related bloodstream infection S) Fever (+) S) Fever (+) O) O) A) Catheter related bloodstream infection r/o metastatic complication r/o metastatic complication P)1. Echocardiography, Bone scan, abdominal sono 2. Rifampin 300mg qd 추가, Vancomycin Level Check 2. Rifampin 300mg qd 추가, Vancomycin Level Check F/U Blood Culture F/U Blood Culture CBC/DC 11,630 /mm3 – 9.3 g/dl – 28.3 % - 385K ( seg: 77.4 % ) ESR 70 mm/hr CRP 18.3 8/14 Blood Culture : 모두 A pure of MRSA

26. Echocardiography (06.8.18)

27. Bone scan (06.8.21)

28. HD 16 (1) - 06.8.22 #1. Catheter related bloodstream infection S) Fever (+) O) CBC/DC 13,350 /mm3 – 8.5 g/dl – 24.9 % - 309K ( seg: 81.3 % ) ESR 49 mm/hr CRP 12.3 Vancomycin Level : 10.7 8/18 Blood Culture : 모두 A pure of MRSA Bone scan Old Comp Fx(T11&12, T1&2),Active joint lesion in Lt. ankle. Echocardiography No valve vegetation & valve requrgitation R/O infective endocarditis R/O osteomyelitis Abdominal sono Relatively small sized both kidneys R/O hepatic, renal abscess

29. HD 16 (2) - 06.8.22 A) Catheter related bloodstream infection r/o AVF infection r/o AVF infection P) Rifampin 300mg bid 증량, F/U Blood Culture Extremity arterial & venous sono Extremity arterial & venous sono

30. Extremity Arterial & Venous Doppler (06. 8.23)

31. HD 24 (06.8.30) #1. Catheter related bloodstream infection S) Fever (+) O) A) Catheter related bloodstream infection AVF site thrombophlebitis AVF site thrombophlebitis P) Antobiotics change (Linezolid 600mg bid) F/U Blood Culture F/U Blood Culture CBC/DC 8,090 /mm3 – 7.1 g/dl – 19.5 % - 271K ( seg: 68.7 % ) CRP 11.1 Vancomycin Level : 16.6 8/28 Blood Culture : 모두 A pure of MRSA Extremity arterial & venous doppler (06.8.23) focal extravasation with edema of the adjacent soft tissue

32. Clinical course 8/22 RFP 300mg po qd 8/78/30 8/7 Blood & Tip : 1,2 모두 MRSA 8/18 Blood :1,2,3 모두 MRSA 8/14 Blood : 1,2 모두 MRSA CRP 25.9 27.7 23.4 18.3 12.3 15.0 11.1 7.1 WBC 8,120 12,300 15,320 11,630 13,350 9,710 8,090 6,390 Dual lumen Catheter remove 8/22 Blood :1,2 모두 MRSA 8/17 RFP 300mg po bid VANCO 1g iv q4days AXON 2g iv qd 8/8 Linezolid 600mg bid AVF,Lt 통해 HD 시행 8/28 Blood :1,2 모두 MRSA 39°C 38°C 37°C 36°C 40°C 9/2