Case Study
A. A. 23 year old male from Balintawak,Q.C. was admitted to PGH on Aug. 25, 1981 for behavioral changes.
His illness started 2 years prior to admission when he had recurrent left flank pains, tolerable in intensity occurring about once a month, without dysuria and usually associated with fever and resolving spontaneously. He did not seek consultation until about 2 months PTA, when he developed difficulty of urination associated with urgency, fever, chills and hypogastric pains. He was treated with Urobactrim at Jose Reyes Memorial Hospital and followed on OPD basis with improvement.
2 weeks PTA, the patient again became oliguric and later anuric. He was readmitted in the same hospital where he underwent 2nd peritoneal dialysis for 16 exchanges. He was discharged improved with home medicines consisting of Lasix, Apresoline, Maalox. About this time, he noted a tender left inguinal mass which spontaneously ruptured and had been continuously draining purulent material.
7 days PTA, he was noted to be again oliguric but he did not seek consultation for financial reasons.
4 days PTA, his oliguric persisted this time associated with vomiting, anorexia, and generalized body weakness. 12 hours PTA, he was noted to be restless, talkative, disoriented later becoming assaultive and combative. He was brought to PGH and was subsequently admitted.
Past medical history revealed traumatic cataract (L) eye at 7 years of age. Family history is positive for asthma and PTB. He works as a messenger in a printing shop, drinks and smokes occasionally.
Physical examination on admission revealed a conscious, incoherent, disoriented, restless man in respiratory distress with temperature of 38.0 C. Other vital signs were unremarkable. He was tachypneic with harsh breath sounds and ronchi on both lung fields. There were no rales. There were no abnormal heart findings. There was a firm LUQ mass about 5-6cm,., below tje left subcostal margin, with exquisite tenderness on the left hemiabdomen and left CVA. Likewise, there was a draining sinus on the (L) inguinal area discharging yellowish, mucoid, non-foul smelling purulent material. There was no pedal edema, but there was faint peripheral pulses and cyanotic nailbeds. Neurological exam was normal. Laboratory examinations revealed neutropenic of 2,000-3,000 WBC with slight toxic granulation. Urinalysis showed brownish and turbid urine, albumin, and innumerable pus cells.
Blood chemistries before dialysis revealed the following: BUN - 120 mg%, creatinine - 16.6 mg%, Na - 125 mEq/L, K - 4.5 mEq/L , Cl - 79 mEq/L, uric acid - 14.3 mg%, Ca - 6.0 mEq/L and PO4 - 9.0 mEq/L. Post dialysis chemistries after 45th exchanges showed the BUN - 62, creatinine - 8.8, Na - 125, K - 5.0, Cl - 90. Gram’s stain of the sinus exudate in the (L) inguinal area revealed gram positive cocci, mostly in clusters some in pairs and few in chains. Urine culture was positive 50,000 colonies of S. aureus. Blood sinus exudate, and dialysate cultures were positive for S. aureus. ABG result for 3 consecutive days were PO2 - 90 - 61 - 112 and for 3 consecutive days. Chest x-rays was normal. Plain film of the abdomen noted a density on the (L) hemiabdomen ‘’ displacing the inferior aspect of the transverse colon superiorly and the descending colon inferiorly’’. No abnormal calcification was noted. Osseous structures were intact.
In the ward, he was noted to be hypotensive despite normal CVP, tachycardic with cold clammy skin as well as progressive peripheral cyanosis. He was given Solucortef 1 gm. stat dose, Prostaphlin, Chloromycetin and Tobramycin was administered per IV. He was also maintained on Intropin drip. The patient stabilized over the next 24 hours but remained highly febrile. Peritoneal dialysis was continued. He was referred to Urology Service who declined surgical intervention and advised continuance of dialysis and medical support. On the 3rd H.D., patient went into C-P arrest and was successfully resuscitated. However, he remained stuporous, with fixed dilated pupils and negative caloric test. He was hooked to a Bird’s respirator for ventilatory support. The patient however, deteriorated and succumbed on the 4th hospital day.
ROJ@17nov6