1. NYU Medical Grand Rounds Clinical Vignette Shella Saint Fleur-Lominy, PGY2 12/06/2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 86 year-old woman presents with decreased urine output and somnolence for two days. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Four months prior to this presentation, the patient who had chronic bilateral lower extremity edema worsening over two months with skin breakdown was admitted for cellulitis and treated with vancomycin and piperacilin-tazobactam. Hospital course was complicated by septic shock from hospital-acquired pneumonia requiring meropenem and discharge to a nursing home facility. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Two months later, the patient was readmitted from the NH for septic shock from multilobar pneumonia treated with vancomycin/meropenem/azithromycin and foley catheter- associated cystitis from multi-drug resistant Klebsiella pneumoniae treated with polymixin b (MIC = 1.5). Hospital course was complicated by vancomycin-resistant enterococcal central line bacteremia treated with linezolid, and acute tubular necrosis secondary to sepsis and requiring hemodialysis for two weeks. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Three days after discharge, the patient was brought back to the hospital with family complaining of the patient making very little urine and observed to be increasingly somnolent since the day before. no other urinary symptoms or fever noted History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Past Medical History: Coronary heart disease Congestive heart failure Insulin dependent Diabetes Mellitus Hypertension Hypercholesterolemia Paroxysmal atrial fibrillation Lower extremity venous stasis Past Surgical History: Triple-vessel coronary artery bypass surgery in 2000 Cholecystectomy Cataract surgery U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Additional History Social History: Immigrated from Syria Lives in nursing home facility No recent travel history No history of tobacco, alcohol or illicit drugs Family History: Non-contributory U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Additional History Allergies: Codeine Medications: Amlodipine 5 mg daily Metoprolol tartrate 12.5 mg twice daily Simvastatin 5 mg at bedtime Pantoprazole 40 mg daily Quetiapine 25 mg at bedtime Docusate 100 mg three times daily Bisacodyl 10 mg daily as needed for constipation Tramadol 25 mg twice a day as needed for pain Acetaminophen 650 mg 4 times a day as needed for pain Sliding scale of insulin aspart 3 times daily with meal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Physical Examination General: elderly woman, lying in bed sleeping and in no apparent distress. Vital Signs: T:97.2 BP:112/56 HR:64 RR:16 and O2 sat:96% on room air. Mental status: lethargic but arousable, oriented only to self and place, falls right back to sleep during interview. Exam significant for irregularly irregular heart rate, bilateral crackles at the lung bases, trace bilateral lower extremity edema, dry diaper on. Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Laboratory Findings CBC: hemoglobin 9.0 g/dL; hematocrit 30 % Basic Metabolic panel: urea nitrogen 67 mg/dL, creatinine 2.8 mg/dL, glucose 128 mg/dL Hepatic panel: aspartate aminotransferase 136 U/L, alanine aminotransferase 72 U/L, albumin 3.1 g/dL Erythrocyte sedimentation rate 61 mm/hr (0-20) B-type natriuretic Peptide 18000 pg/ml (<300) Remainder of the laboratory findings were within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Laboratory Findings Urinalysis: - yellow and turbid - moderate blood - 3+ protein - positive nitrite - large leukocyte esterase - 26 red blood cells - >100 white blood cells - 3 squamous epithelial cells - moderate bacteria U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Other Studies ECG: atrial fibrillation at the rate of 63 Chest X-Ray: bilateral hazy opacities consistent with edema, small bilateral pleural effusion U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Urinary tract infection Congestive heart failure Working Diagnoses U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Days 1-4: –The patient is started on intravenous vancomycin and tigecycline. She also received one dose of cefazolin and one dose of tobramycin. –Urine culture grows E. coli (sensitive only to cephalosporins, carbapenems and aminoglycosides) and K. pneumoniae (sensitive only to tigecycline; polymixin B MIC= 8) –Blood cultures remain no growth and vancomycin discontinued –The patient is successfully diuresed Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Days 5-10: –Mental status returns to baseline. –10-day course of Tigecycline is completed. –Urine output returns to normal and remains stable. The patient is discharged to nursing home on hospital day 11 Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Cystitis from multidrug resistant Klebsiella pneumoniae and E. coli Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS