Richard C. Walls
Patient Case Presentation
PC: 51 yo black F; admitted 6/27/13
87.1 kg, 66”
CC: Abdominal pain, ostomy leakage, hyperkalemia
HPI:
Hx ESRD(iHD), DM2, HTN, fungal/MDR-bacterial peritonitis requiring multiple operations
leading to enterocutaneous fistula and TPN-dependence.
Peritoneal dialysis -> Peritonitis (MDR citrobacter, bacteroides, enterococcus, candida) -> iHD
Following resolution, developed surgical complications (bowel perforation) -> G-tube & wound
vac. TPN-dependent due to frozen bowel. Plan for surgical takedown of EC fistula 09/2013.
2 wk PTA: clear liquid diet po -> full liquid -> 1 wk PTA leakage from ostomy bag, irritating
abdomen (green/yellow drainage larger in volume than usual), only local pain, no N/V
Reports pain at proline site, no redness/swelling/drainage (treated 2m PTA w/vanco, line not
removed due to limited access). Afebrile, no chills/nightsweats.
ED for management of ab pain/leakage, K+ found to be 6.7 w/peaked T-waves, leading to
admission. Received calc gluconate, insulin, D50, 30g Kayexelate, and dialysis.
PMH:
ESRD iHD
MDR peritonitis -> EC fistulas, bowel perf, frozen bowl; TPN
DM2 w/neuropathy/nephropathy/foot ulcers
Proline-associated cellulitis
Chronic pancytopenia due to ESRD & infection
HTN
GERD
PVOD (Pulmonary venoocclusive disease)
F/SH:
Father—HTN, brain cancer, DM2; Mother—Diverticulitis, arthritis; Sister—Deceased SLE
20 py smoker, no EtOH/illicits; lives with sons in flint, SNF in Saginaw recently
Home Meds:
Darbepoetin alfa 60 µsq weekly
Insulin - Lantus: 10 Uam, 20 Uhs
Insulin – Lispro: 2-12 UQID w/meal
Gabapentin 300 po qd
Fentanyl 75 µ/h q72 h
Hydromorphone 2 po q4h prn pain
Amlodipine 10 po qd
Hydralazine 50 po TID
Omeprazole/NaHCO3 20 po qd
Folic Acid 1 po qd
Allergies:
Ciprofloxacin (reaction unsure)
Protamine (reaction unsure)
Morphine (itching)
Clinical Course:
6/27
ED: K+ 6.6; proline site pain -> blood cultures; sysP(80s-90s) overnight
6/28
K+ 5.5 TPN resumed with reduced K+; Increasing proline site pain
6/29
K+ 4.6. Cultures grow GPCs; 1g vanco (11.4 mg/kg) cultures redrawn; pain
worsening, refused TPN
6/30
Much improved symptoms, cultures -> coag negative staph; plan for 2 wks of vanco
from first negative culture
7/1
Continued symptom resolution, post HD vanco – 9.0; redosed 1g; proline removed
7/2
Fevers overnight w/Stachy, recultured, Zosyn added
7/3
Isolated fever, Zosyn d/ced due to lack of culture growth/gram- suspicion, proline
replaced, preHD level 25.5, post HD level 17.7, redosed 1g
7/4
Afebrile overnight, occasional tachycardia
7/5
Fever overnight w/tachycardia, preHD level 30.4, post HD level 22.5, patient cried
because she had to stay another day due to large number of iatrogenic complications
7/6
Discharged to complete course of vancomycin
Problem List:
1. Hyperkalemia
6.6 in ED w/peaked T-waves
Managed with 1 g calcium gluconate, 10 U regular insulin, 25 g D50, & dialysis
5.5 -> 4.6 over 48 h
Stable for rest of admission in high 3s, low 4s
2. Proline Associated Bacteremia
Presented initially as pain and not treated, although cultures collected.
2 days into stay, patient exhibiting signs of sepsis (hypotension, tachycardia,
thrombocytopenia), and blood cultures grow coag negative staph, 1g vanco 6/29.
Symptoms improve, 7/1 vanco post HD 9.0, 1 g redose, proline removed.
Pt becomes febrile, Zosyn (3.375 q12) added, d/ced next day due to no culture growth.
HD levels 25.5/17.7 pre/postHD 7/3, redosed 1g
Fevers begin again, patient shows preHD level 30.4, post HD 22.5, dose held
Patient discharged to complete dialysis dosed vanco regimen until 7/13.
3. Fevers
First present on 7/1 after vanco re-dose, resolve 7/2 afternoon.
Isolated fever on 7/4, through 7/5 evening
No culture growth apart from initial S. epi. despite sampling HD cath, proline.
Leading suspicion is that vanco caused fevers, may want to consider linezolid/daptomycin
based on situation for patient in future.
4. ESRD
Hgb 10.2 on admit, fairly steady decline throughout admission down to 8.0 on 7/6
Some dilutional effect due to fluids (WBC 7.5 on admit, down to 2.9 on 7/6)
MCV 86-92, RDW 16.4-18.0, 4/21—FRTN 972, TSAT 67.5, B12 401, Folate 2.7
Continue darbepoetin 60 qweek, f/u outpatient
Phos 6.5-3.4, Ca++ ca 9.0, Alb ca 3.5
Continue paricalcitol 1 MWFw/HD, obtain iPTH outpatient & assess dose