Morbidity and Mortality Conference Jay V. Dy M.D. Medical Resident.

Morbidity and Mortality Morbidity and Mortality ConferenceConference

Jay V. Dy M.D.Jay V. Dy M.D.

Medical ResidentMedical Resident

– Good Morning!Good Morning!

Learning ObjectiveLearning Objective

To present a case of Severe Leptospirosis To present a case of Severe Leptospirosis and discuss its diagnosis, pathogenesis, and discuss its diagnosis, pathogenesis, complications and mode of treatment.complications and mode of treatment.

Identifying DataIdentifying Data

D.D. D.D.

25 year old female 25 year old female

FilipinoFilipino

single single

Chief Complaint: FeverChief Complaint: Fever

History of Present IllnessHistory of Present Illness

4 days PTA- undocumented intermittent fever 4 days PTA- undocumented intermittent fever (+) body malaise, (+) body malaise, (+) dry cough(+) dry cough(+) sorethroat, (+) sorethroat, (-) colds, rashes(-) colds, rashes

self-medicated with paracetamol self-medicated with paracetamol affording temporary relief.affording temporary relief.

History of Present IllnessHistory of Present Illness

Few hrs PTA - persistence of symptomsFew hrs PTA - persistence of symptoms(+) diarrhea, 2x(+) diarrhea, 2x(+) crampy epigastric pain. (+) crampy epigastric pain. (+) nausea(+) nausea

(-) vomiting(-) vomiting

AdmissionAdmission

Review of systemsReview of systems

(-) headache(-) headache

(-) dizziness(-) dizziness

(-) difficulty of (-) difficulty of breathingbreathing

(-) orthopnea(-) orthopnea

(-) paroxysmal(-) paroxysmalnocturnal nocturnal

dyspneadyspnea

(-) palpitations(-) palpitations

(-) dysuria(-) dysuria

(-) urinary frequency(-) urinary frequency

(-) joint pains(-) joint pains

Past Medical HistoryPast Medical History

Diagnosed w/ Leptospirosis 7 yrs agoDiagnosed w/ Leptospirosis 7 yrs ago– Unrecalled work upUnrecalled work up– Admitted St Paul’s Hospital for several daysAdmitted St Paul’s Hospital for several days– Given unrecalled IV antiboticsGiven unrecalled IV antibotics

Non hypertensiveNon hypertensive

Non diabeticNon diabetic

Non asthmaticNon asthmatic

No known allergiesNo known allergies

No previous operationNo previous operation

Family HistoryFamily History

(+) Hypertension- father(+) Hypertension- father

(+) DM- mother(+) DM- mother

(-) Bronchial asthma(-) Bronchial asthma

(-) PTB(-) PTB

(-) Cancer(-) Cancer

Personal/ Social HistoryPersonal/ Social History

Non smokerNon smoker

Non alcoholic beverage drinkerNon alcoholic beverage drinker

Works in the office Works in the office

Physical ExaminationPhysical Examination

General surveyGeneral survey: conscious, coherent not in : conscious, coherent not in respiratory distressrespiratory distress

Vital signs:Vital signs: BP 110/70, HR: 98 RR: 20, BP 110/70, HR: 98 RR: 20, T: 38cT: 38c

Skin: Skin: No rashes, no jaundiceNo rashes, no jaundice

HEENT:HEENT: pinkish palpebral conjunctivae, anicteric pinkish palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, sclerae, no nasoaural discharge,

no no tonsillopharyngeal congestion, tonsillopharyngeal congestion, dry lipsdry lips and tongueand tongue, no cervical , no cervical

lymphadenopathy, lymphadenopathy, flat neck veinsflat neck veins

Physical ExaminationPhysical Examination

Chest/LungsChest/Lungs: equal chest expansion, no retraction, : equal chest expansion, no retraction, clear breath soundsclear breath sounds

Heart: Heart: Adynamic precordium, normal rate,Adynamic precordium, normal rate, regularregular rhythym, S1 louder than S2 at the apex, rhythym, S1 louder than S2 at the apex,S2 louder than S1 at the base, PMI at 5thS2 louder than S1 at the base, PMI at 5thICS, LMCL, no murmurICS, LMCL, no murmur

Abdomen:Abdomen: flabby, normoactive bowel sounds, soft, flabby, normoactive bowel sounds, soft, no tenderness, no palpable mass, no tenderness, no palpable mass, no hepatosplenomegalyno hepatosplenomegaly

Extremities:Extremities: no gross deformities, no edema, no gross deformities, no edema,no cyanosis, full and equal pulsesno cyanosis, full and equal pulses

Salient featuresSalient features

25 y.o, F, single25 y.o, F, single

cc: fever x 5 dayscc: fever x 5 days

body malaise, dry cough, sore throatbody malaise, dry cough, sore throat

(+) 2 episodes of diarrhea(+) 2 episodes of diarrhea

(+) crampy epigastric pain(+) crampy epigastric pain

(+) nausea(+) nausea

P.E. Temp= 38cP.E. Temp= 38c

Flat neck veinsFlat neck veins

Dry lips and tongueDry lips and tongue

At the E.R.At the E.R.

Stool exam: brown, watery, rare mucus and Blastocystis hominis were seen

CBC: Hgb 12.1, Hct 35.5, wbc 13,470, seg 91, lym 6, platelet count 109,000

PLR 1L X 120cc/hr Paracetamol tablet for fever >37.8 c, Ciprofloxacin 500mg 1 tablet BID Omeprazole 20 mg 1 cap OD Difflam lozenges 1 losenge TID prn

Day of AdmissionDay of Admission

Initial ImpressionInitial Impression

Acute gastroenteritis with some signs of Acute gastroenteritis with some signs of dehydrationdehydration

T/C Dengue feverT/C Dengue fever

Course in the WardsCourse in the Wards 11stst hospital day (8/3) hospital day (8/3)

–intermittent intermittent feverfever (D6) (Tmax - 39.5 c)(D6) (Tmax - 39.5 c)–bloatednessbloatedness–crampy epigastric paincrampy epigastric pain–diarrhea, 8xdiarrhea, 8x–vomiting, 1xvomiting, 1xSecnidazole 500mg/tab. 4 tabs as single doseSecnidazole 500mg/tab. 4 tabs as single doseMetoclopramide 10 mg Iv push q8 Metoclopramide 10 mg Iv push q8 Loperamide 2 tabs x 1 doseLoperamide 2 tabs x 1 doseIVF rate: increased to 166 cc/hr.IVF rate: increased to 166 cc/hr.

Course in the WardsCourse in the Wards 11stst hospital day (8/3) hospital day (8/3)

PTT - 49.6PTT - 49.6 (n.v. 25.1-33.9 secs) (n.v. 25.1-33.9 secs)

PT was normalPT was normal

plt ct 69,000plt ct 69,000 fromfrom 109,000109,000

> Monitoring of platelet ct q 12 hrs.> Monitoring of platelet ct q 12 hrs.

>Stand by 4 units of FFP >Stand by 4 units of FFP

2nd hospital day (8/4)2nd hospital day (8/4)

– on and off on and off feverfever (D7) (37.0- 39.5 c) (D7) (37.0- 39.5 c)– bloatednessbloatedness– crampy epigastric paincrampy epigastric pain– 77 episodes of episodes of LBMLBM– 33 episodes of episodes of vomitingvomiting– direct epigastric tendernessdirect epigastric tenderness

Plain film of the abdomen: no localizing signsPlain film of the abdomen: no localizing signs

hydration/meds were continuedhydration/meds were continued

additional dose of Loperamide and Eldicetadditional dose of Loperamide and Eldicet

started Vamin glucosestarted Vamin glucose

22NDND Hosp day Hosp day

Course in the WardsCourse in the Wards 2nd hospital day (8/4)2nd hospital day (8/4)

Lab testLab test– K - 2.3K - 2.3– BUN - 23BUN - 23– creatinine - 3.1creatinine - 3.1


Problem: Problem: (+) Difficulty of breathing(+) Difficulty of breathing– Respiratory rate: 26Respiratory rate: 26– Flat neck veinsFlat neck veins– Clear breath soundsClear breath sounds

ABG: uncompensated metabolic acidosis. ABG: uncompensated metabolic acidosis. pO2=96.9, pO2=96.9, pHpH==7.287.28, , Pco2Pco2==20.120.1, , HCO3HCO3==9.39.3, , O2 sat=96.8, B.E.-14.9, Total CO2=9.9, O2 sat=96.8, B.E.-14.9, Total CO2=9.9, RR=26, Rm airRR=26, Rm air

– given NaHCO3 IVgiven NaHCO3 IV

2nd hosp day (aug4)2nd hosp day (aug4)


– CBCCBC: : Hgb 8.2Hgb 8.2, hct 23.6, seg 8,320, , hct 23.6, seg 8,320, seg 77, lym 17 and seg 77, lym 17 and

plt ct 71,000plt ct 71,000

>Reserved 2 u prbc>Reserved 2 u prbc>repeat CBC w/ plt ct in am >repeat CBC w/ plt ct in am >Blood culture done>Blood culture done>Referred to Nephrology & Infectious disease >Referred to Nephrology & Infectious disease

serviceservice

3rd hospital day (8/5)3rd hospital day (8/5)

– (+) (+) fever (D8fever (D8) (Tmax39.6 c)) (Tmax39.6 c)– (+) Epigastric tenderness(+) Epigastric tenderness– (+) decreased BM (semi-formed to soft)(+) decreased BM (semi-formed to soft)– (-) vomiting(-) vomiting

Rpt CBC: Rpt CBC: Hgb 8.4Hgb 8.4, , hct 24.4hct 24.4, , plt ct 84,000plt ct 84,000 from71,000 from71,000

Transfused 1 of 2 unit PrbcTransfused 1 of 2 unit Prbc

Increased omeprazole to 1 cap BIDIncreased omeprazole to 1 cap BID

Course in the WardsCourse in the Wards 3rd hospital day (8/5)3rd hospital day (8/5)

– PTT- 49.6 PTT- 49.6

– PT: Activity 66.4%PT: Activity 66.4% INR 1.2 INR 1.2 Vitamin K givenVitamin K given

– Urinalysis showed Urinalysis showed proteinuria +2, Bloodproteinuria +2, Blood +3+3, elev , elev RBC 572.2RBC 572.2, elev , elev WBC 14.4 WBC 14.4

Urine CS requestedUrine CS requested

3rd hospital day 3rd hospital day

–Problem: (+) dyspneaProblem: (+) dyspnea

–(+) distended neck veins(+) distended neck veins

–(+) bibasal crackles(+) bibasal crackles

–(+) bipedal edema(+) bipedal edema

Lasix 40mg IV givenLasix 40mg IV given

IVF rate was decreased to 40cc/hrIVF rate was decreased to 40cc/hr

Central line inserted (Central line inserted (13-1413-14 cmH2O) cmH2O)

22ndnd hosp day 3 hosp day 3rdrd hosp day hosp day

3rd hospital day (8/5)3rd hospital day (8/5)

– Stat ABG: Stat ABG: Po2 52.3, Ph 7.27Po2 52.3, Ph 7.27, , Pco2Pco2 32.3, HCO3 14.7, O2 sat 32.3, HCO3 14.7, O2 sat

83,83,B.E.B.E.

-10.9, -10.9, TCO2 15.7, RR 28 TCO2 15.7, RR 28 (O2 (O2 2LPM via 2LPM via Nasal cannula).Nasal cannula).

> Nasal cannula was shifted to MVM> Nasal cannula was shifted to MVM

> stand by intubation> stand by intubation

> scheduled for stat Hemodialysis> scheduled for stat Hemodialysis


Spec (pre HD) Spec (pre HD) – K 2.7, Ca 1.5, total protein 4.6K 2.7, Ca 1.5, total protein 4.6 and and Albumin Albumin

1.61.6– bun 23, bun 23, crea 3.1crea 3.1, SGOT 336, SGPT 78 , SGOT 336, SGPT 78

and T. Bili 1.4. and T. Bili 1.4.

Given K, Ca, and albumin correctionGiven K, Ca, and albumin correction


During dialysis: During dialysis: transfused w/ 4 units FFP transfused w/ 4 units FFP (150cc/unit/bag)=600cc(150cc/unit/bag)=600cc– 1 unit Prbc (250cc)1 unit Prbc (250cc)– 550cc flushing/ meds550cc flushing/ meds– Na HCO3 drip @ 40 cc/hr x 4 hrs= 160ccNa HCO3 drip @ 40 cc/hr x 4 hrs= 160cc– Ca Gluconate drip @ 80 cc/hr x 4 hrs= 320ccCa Gluconate drip @ 80 cc/hr x 4 hrs= 320cc– Kcl drip 10% 40meqs x 4 hrs = 100ccKcl drip 10% 40meqs x 4 hrs = 100cc

UF VolumeUF Volume (output)= (output)=4,000 cc4,000 cc HD total InputHD total Input= = 1,980 cc1,980 cc

33RDRD hosp day (Aug 5) hosp day (Aug 5)


> > scheduled for another hemodialysis.scheduled for another hemodialysis.

> Total Input=3,910 cc vs > Total Input=3,910 cc vs

Total output=4,340 cc (urine 340 + HD 4,000cc)Total output=4,340 cc (urine 340 + HD 4,000cc)

– Leptospira antigen test:(+) IgMLeptospira antigen test:(+) IgM

> > Penicillin GPenicillin G 2 million units IV q 4 given. 2 million units IV q 4 given.

44thth hospital day (8/6) hospital day (8/6)

– Problem: dyspneaProblem: dyspnea– BP: 110/60; CR 120s; RR40sBP: 110/60; CR 120s; RR40s– decreased urine output (7-8 cc/hr)decreased urine output (7-8 cc/hr)– (+) bloody secretions/sputum.(+) bloody secretions/sputum.– CVP 15 cmH2OCVP 15 cmH2O

– ABG: Po2 39ABG: Po2 39, ph 7.41, , ph 7.41, Pco2 32.9, HCO3Pco2 32.9, HCO3 20.6, O2 sat 75.120.6, O2 sat 75.1, B.E. -3.0, TCO2 21.6, , B.E. -3.0, TCO2 21.6, RR RR 6060 MVM 0.4 MVM 0.4

– reffered to a pulmonologist reffered to a pulmonologist

Course in the WardsCourse in the Wards 44thth hospital day (8/6) hospital day (8/6)

– immediately immediately intubated intubated

– hooked to a mechanical ventilator hooked to a mechanical ventilator (settings: AC mode, FiO2 100%, RR 20, (settings: AC mode, FiO2 100%, RR 20, TV 300, PEEP 5). TV 300, PEEP 5).

post intubationpost intubation

– ABG 1 hr post intubation still showed ABG 1 hr post intubation still showed hypoxemia (pO2 58, O2 sat 91.7 5%)hypoxemia (pO2 58, O2 sat 91.7 5%)

– Atrovent neb givenAtrovent neb given– PEEP was increased to 7.5 PEEP was increased to 7.5 – Patient immediately underwent Patient immediately underwent

(2nd)hemodialysis(2nd)hemodialysis


Pre HD LabsPre HD Labs– decreased decreased serum K (2.4 from 2.7), Ca 1.9, serum K (2.4 from 2.7), Ca 1.9,

Phosphorus 2.3Phosphorus 2.3 and and Mg 1.6Mg 1.6 (2.5-4.9). (2.5-4.9). – Serum Serum creatininecreatinine further increased (further increased (4.6 4.6 from from

3.1)3.1)

– Patient was given K, Ca, Mg and phosphorus Patient was given K, Ca, Mg and phosphorus correctioncorrection


During dialysis: During dialysis: – 100cc flushing/ meds100cc flushing/ meds– PNSS 40 cc/hr x 4 hrs= 160ccPNSS 40 cc/hr x 4 hrs= 160cc– Vamin glucose 40 cc/hr x 4 hrs= 160ccVamin glucose 40 cc/hr x 4 hrs= 160cc– Albumin 50ccAlbumin 50cc – HD total Input= 470 ccHD total Input= 470 cc– UF Volume (output)=3,000 ccUF Volume (output)=3,000 cc


afebrileafebrile

(+) tachycardia (100-118)(+) tachycardia (100-118)

(+) decreased urine output (4-5cc/hr) (+) decreased urine output (4-5cc/hr)

JVP 13cmH2OJVP 13cmH2O

Lasix was continuedLasix was continued

Post Intubation 5Post Intubation 5thth Hosp day Hosp day


Patient underwent 3rd hemodialysis. Patient underwent 3rd hemodialysis. During dialysis: During dialysis: – 50cc flushing/ meds50cc flushing/ meds– K Phos 40mmol in PNSS 100ccx 4hrs= 100ccK Phos 40mmol in PNSS 100ccx 4hrs= 100cc– Ca Gluc 5 g in 450cc pnss x 20cc/hr x 4=80ccCa Gluc 5 g in 450cc pnss x 20cc/hr x 4=80cc– MgSO4 5 g in 500cc PNSS X 20cc/hr x MgSO4 5 g in 500cc PNSS X 20cc/hr x

4=80cc4=80cc– total Input= 470 cctotal Input= 470 cc– UF Volume (output)=2,000 ccUF Volume (output)=2,000 cc


Pulmonary service was able to bring down Pulmonary service was able to bring down FiO2 to 0.6 but had desaturationFiO2 to 0.6 but had desaturation

eventually placed back to 100% FiO2eventually placed back to 100% FiO2

More bloody secretionsMore bloody secretions coming out/ coming out/ suctioned from ETsuctioned from ET

Frequent/ prn suctioning of secretions. Frequent/ prn suctioning of secretions.

PEEP was increased to 10. PEEP was increased to 10.


– CBC: Hgb 12.1, hct 35.1, CBC: Hgb 12.1, hct 35.1, wbc (wbc (15, 76015, 760 from 6,850), seg 74, plt ct 135,000 fro from 6,850), seg 74, plt ct 135,000 fro 128,000).128,000).

Pen G was discontinuedPen G was discontinuedPiperacillin TazobactamPiperacillin Tazobactam 2.25 IV q8 was 2.25 IV q8 was started.started.Total Input: 2,298ccTotal Input: 2,298ccTotal Output: 2,107cc Total Output: 2,107cc

(Urine 107 cc+ HD 2,000cc)(Urine 107 cc+ HD 2,000cc)


– afebrile (D2)afebrile (D2)

– lesser bloody secretionslesser bloody secretions from ET. from ET.

– Persistent oliguria (4-5 cc/hr)Persistent oliguria (4-5 cc/hr)

Lasix was continuedLasix was continued

patient had another dialysis (4th) patient had another dialysis (4th)


During dialysis: During dialysis: – 50cc flushing50cc flushing– 100cc OF100cc OF– Ca Gluc 5 g in 450cc pnss x 20cc/hr x 4=80ccCa Gluc 5 g in 450cc pnss x 20cc/hr x 4=80cc– Dialysis terminated due to BP 94/63 (3rd hr)Dialysis terminated due to BP 94/63 (3rd hr)– Bp went up 110/70 afterBp went up 110/70 after– total Input= 230 cctotal Input= 230 cc– UF Volume (output)=1,700 ccUF Volume (output)=1,700 cc


chest xray post HD: clearing of bilateral lung infiltrates.

FiO2 was titrated down to 30%.

S/P 4S/P 4thth dialysis dialysis


Problem: desaturation (02 sat 50%).

Fi0 was increased to 100%

suctioning of secretions

ambubagging

BP noted to be 0, HR 0.

hooked to a cardiac monitor: flat line.

CPR done

Given epinephrine 1 dose


revived after 3 minutes

Dopamine drip was started.

Bp went up to 110/70 from 50 pallpatory

ABG: mixed (slight) metabolic and respiratory acidosis with PO2 496 at FiO2 1.

Patient became fully awake and responsive


30 mins after referred again (O2 desaturation 80%)

suctioned secretions

BP=0, HR=0, flat line on cardiac monitor

CPR was done but after 15 minutes, relatives ordered to discontinue CPR

Patient was then declared expired.

Problem #1 Fever/DiarrheaProblem #1 Fever/Diarrhea

S> DOA: (+) Fever, (+) diarrheaS> DOA: (+) Fever, (+) diarrhea(+) myalgia(+) myalgia(+) nausea/ vomiting/ epigastric pain(+) nausea/ vomiting/ epigastric pain(+) dec platelet ct. 69,000 from (+) dec platelet ct. 69,000 from

109,000109,000

O> Temp= 38cO> Temp= 38cflat neck veinsflat neck veinsDry lips and tongueDry lips and tongue

Problem #1 Fever/DiarrheaProblem #1 Fever/DiarrheaA> T/C Dengue fever; A> T/C Dengue fever; > > Acute gastroenteritis with some signs of Acute gastroenteritis with some signs of dehydrationdehydration > R/O > R/O Typhoid feverTyphoid fever

P> Plasil 10 mg IV q 8 for vomitingP> Plasil 10 mg IV q 8 for vomitingLoperamide tabLoperamide tabCiprofloxacin 500mg tab bidCiprofloxacin 500mg tab bidSecnidazole tab 4 tabs x 1 dosSecnidazole tab 4 tabs x 1 dosHydration IVFHydration IVF platelet ct monitoring q12platelet ct monitoring q12

Blood CSBlood CS

Problem #1 Persistent feverProblem #1 Persistent fever

S> 3rd hospital day:S> 3rd hospital day:– (+) fever (D8)(+) fever (D8) (+) wading in floodwater 3wks (+) wading in floodwater 3wks– (+) Myalgia(+) Myalgia before onset of fever before onset of fever – (+) nausea(+) nausea– (+) decreased urine output/ elevated crea 3.1(+) decreased urine output/ elevated crea 3.1– (+) elevated SGOT 336(+) elevated SGOT 336

O> temp 38.5cO> temp 38.5c

A> A> T/C LeptospirosisT/C Leptospirosis

P> P> Leptospira Igm (+)Leptospira Igm (+)

Penicillin G 2 million units IV q4 Penicillin G 2 million units IV q4

Fever patternFever pattern

35

36

37

38

39

40

41

Oral/Oral/

OFOF

ParentParenteraleral

TotalTotal

InputInput

UrineUrine CreaCrea BBMM

DialyDialysissis

TotalTotal

outputoutput

DOADOA 1,6601,660 1,6401,640 3,3003,300 9x9x 9x9x

11stst HD HD 3,3253,325 3,3003,300 6,6256,625 13x13x 8x8x

22ndndHDHD 2,2602,260 4,6204,620 6,8806,880 9x9x 3.13.1 7x7x

33rdrdHDHD 1,0901,090 2,8202,820 3,9103,910 340340 3.13.1 2x2x 4,0004,000 4,3404,340

44ththHDHD 810810 10081008 2,9332,933 7878 4.64.6 1x1x 3,0003,000 3,0783,078

55ththHDHD 673673 16251625 2,2982,298 107107 3.83.8 1x1x 2,0002,000 2,1072,107

66ththHDHD 460460 568568 1,0281,028 3333 2x2x 1,7001,700 1,7331,733

Problem # 2 Decreased urine outputProblem # 2 Decreased urine output

Problem # 2 Problem # 2 Decreased urine Decreased urine outputoutput

O> JVP 6-7cm H2O ------> JVP 12-13 cm H2OO> JVP 6-7cm H2O ------> JVP 12-13 cm H2OClear breath sounds---->Bibasal cracklesClear breath sounds---->Bibasal crackles

(-) edema-------->grade 2 bipedal (-) edema-------->grade 2 bipedal edemaedema

A> A> Acute renal failure probably pre renal 2 to Acute renal failure probably pre renal 2 to dehydration (GI fluid loss) and/or Intrinsic renal dehydration (GI fluid loss) and/or Intrinsic renal failure secondary to leptospirosisfailure secondary to leptospirosis P> P> accurate I & O monitoringaccurate I & O monitoring

monitor bun, crea, electrolytesmonitor bun, crea, electrolyteshydration<-------->hemodialysishydration<-------->hemodialysis

22ndnd HD HD 33RDRD HD HD 44THTH HD HD 55THTH HD HD

NaNa 135-145 135-145 mmol/Lmmol/L

135135 140140 132132 135135

KK 3.5-5.5 3.5-5.5 mmol/Lmmol/L

2.32.3 2.72.7 2.42.4 2.92.9

BUNBUN 2.5-6.52.5-6.5

mmol/Lmmol/L

23 23 (8.3)(8.3)

23 23 (8.3) (8.3)

37 37 (13.2)(13.2)

31 31

(11)(11)

CreaCrea 53-8853-88

Umol/LUmol/L

3.13.1

(274)(274)

3.13.1

(274)(274)

4.64.6

(406.6)(406.6)

3.83.8

(335)(335)

Problem # 3 Problem # 3 Difficulty of BreathingDifficulty of Breathing

S> S> (+) Difficulty of breathing(+) Difficulty of breathing(+)bloody secretions(+)bloody secretions

– urine urine output: output: 340cc/24340cc/24 hrs(14cc/hr) hrs(14cc/hr) – total total input:input:4,490cc/244,490cc/24 hrs(187cc/hr hrs(187cc/hr

O> RR=40sO> RR=40s(+) distended neck veins(+) distended neck veins(+) bibasal crackles(+) bibasal crackles(+) bipedal edema(+) bipedal edema


A> Acute Respiratory failure 2 A> Acute Respiratory failure 2 to Pulmonary to Pulmonary congestion probably secondary to Acute renal congestion probably secondary to Acute renal failurefailure

2nd hosp day2nd hosp dayDay of Day of AdmAdm

33rdrd hosp day hosp day 3rd hosp day3rd hosp day

4th Hosp day4th Hosp day 5th Hosp day5th Hosp day

5th Hosp day5th Hosp day 6th Hosp day 6th Hosp day Post dialysisPost dialysis

pO2 pH Pc02 HCO3 O2 sat

FiO2 VT RR PEEP Cond

8/04 2nd HD

96.9 7.28 20.1 9.3 96.8 26 Rm air

8/05 3rd HD

111.3 7.33 23.1 12 98.2 28 O2 2lpm

8/05

52.3 7.27 32.3 14.7 83 28 O2 2lpm

8/06 4TH HD

39 7.41 32.9 20.6 75.1 60 MVM

8/06

37.1 7.41 32.1 20.2 72.5 52 MVM

8/06

58 7.45 29.5 20 91.7 100 300 24 5 AC

8/07 5TH HD

116.2 7.39 34.6 20.8 98.3 100 300 30 10 AC

8/08 6TH HD

496 7.28 46.9 21.9 99.9 100 300 15 10 AC


P> P> Nasal cannula was shifted to MVMNasal cannula was shifted to MVM

> stand by intubation--> stand by intubation--IntubatedIntubated

> Hemodialysis> Hemodialysis

> NaHCO3 IV> NaHCO3 IV

> CVP monitoring> CVP monitoring

> Accurate I & O> Accurate I & O

Problem# 4 HypokalemiaProblem# 4 Hypokalemia

S> (+) diarrhea x several episodesS> (+) diarrhea x several episodes

(+) vomiting x several episodes(+) vomiting x several episodes

A> Hypokalemia probably 2 to GI loss A> Hypokalemia probably 2 to GI loss (diarrhea)(diarrhea)

P> Na, k, crea monitoringP> Na, k, crea monitoring

KCL dripKCL drip

Problem #5 ANEMIAProblem #5 ANEMIA

S> (+) bloody/frothy secretions suctioned per ETS> (+) bloody/frothy secretions suctioned per ET

(-) black stools/ bloody stools(-) black stools/ bloody stools

O> pale palpebral conjunctivaeO> pale palpebral conjunctivae

(-) Petechiae(-) Petechiae

(-) bruises(-) bruises

DOADOA 11stst HD HD 22ndndHDHD 33rdrdHDHD

AMAM

33RDRDHDHD

PMPM

55THTHHDHD 66THTHHDHD

HgbHgb 12.112.1 10.510.5 8.28.2 8.48.4 14.814.8 12.112.1 10.410.4

HctHct 35.535.5 30.830.8 23.623.6 24.424.4 42.342.3 35.135.1 30.230.2

RBCRBC 4.34.3 3.83.8 2.92.9 33 5.35.3 4.44.4 3.83.8

WBCWBC 13,47013,470 7,9607,960 8,3208,320 6,8506,850 15,65015,650 15,76015,760 16,58016,580

SegSeg 9191 8080 7777 7979 7676 7474 7575

LymLym 66 1818 1818 1717 1717 1515 1414

MonMon 33 22 44 44 66 99 1010

Plt ctPlt ct 109,000109,000 69,00069,000 71,00071,000 84,00084,000 128,000128,000 135,000135,000 180,000180,000

Problem #5 ANEMIAProblem #5 ANEMIA

A> Anemia probably secondary to acute blood lossA> Anemia probably secondary to acute blood loss (T/C Alveolar /Interstitial hemmorhage)(T/C Alveolar /Interstitial hemmorhage)

T/C Anemia secondary to renal failureT/C Anemia secondary to renal failureT/C Anemia secondary to SepsisT/C Anemia secondary to Sepsis

P> CBC monitoringP> CBC monitoringBlood transfusion(2 u prbc)Blood transfusion(2 u prbc)PT/PTT- prolonged PTT (49.6)PT/PTT- prolonged PTT (49.6)Peripheral smear: Peripheral smear:

rbc: normocytic, normochromic, rbc: normocytic, normochromic, pletelets: decreasedpletelets: decreased

DIAGNOSISDIAGNOSIS

#1 Severe Sepsis (Leptosprosis)#1 Severe Sepsis (Leptosprosis)#2 Acute renal failure probably Intrinsic #2 Acute renal failure probably Intrinsic and pre renal secondary to leptospirosis and pre renal secondary to leptospirosis and dehydration (GI fluid loss)and dehydration (GI fluid loss)#3 Acute respiratory failure 2 to #2#3 Acute respiratory failure 2 to #2#4 Anemia probably secondary to alveolar #4 Anemia probably secondary to alveolar hemorrhage, renal failure and Sepsishemorrhage, renal failure and Sepsis#5 Hypokalemia secondary to GI loss #5 Hypokalemia secondary to GI loss (diarrhea)(diarrhea)

Cause of Death ?Cause of Death ?

Mucus PlugMucus Plug

Septic ShockSeptic Shock

ArrhythmiaArrhythmia

HypokalemiaHypokalemia

Pulmonary EmbolismPulmonary Embolism

Cause of Death ?Cause of Death ?Points ForPoints For Points AgainstPoints Against

Mucus plugMucus plug Sudden dyspneaSudden dyspnea

Sudden O2 desaturationSudden O2 desaturation

(+) mucus plugs/ big (+) mucus plugs/ big blood clotsblood clots on the tip on the tip and inside the lumen of and inside the lumen of the Endotracheal tube the Endotracheal tube upon removalupon removal

Septic ShockSeptic Shock Elevated Elevated WBC countWBC count

16,58016,580 from as low as from as low as 6,8506,850

TachycardiaTachycardia

(+) Leptospira IgM(+) Leptospira IgM

Had O2 desaturation Had O2 desaturation first before BP went first before BP went downdown

Cause of Death ?Cause of Death ?Points ForPoints For Points AgainstPoints Against

Arryhthmia/Arryhthmia/

HypokalemiHypokalemiaa

K 2.9K 2.9 Cardiac monitor: Cardiac monitor: showed no arrythmiashowed no arrythmia

Improving K level (2.9 Improving K level (2.9 from 2.4) w/ ongoing from 2.4) w/ ongoing correctioncorrection

Pulmonary Pulmonary EmbolismEmbolism

Sudden onset Sudden onset dyspnea, O2 dyspnea, O2 desaturation, desaturation, tachycardia,tachycardia,

Patient is relatively Patient is relatively immobile (intubated)immobile (intubated)

pO2 400pO2 400

CASE DISCUSSION CASE DISCUSSION LeptospirosisLeptospirosis

LeptospirosisLeptospirosis

zoonosis with protean manifestations zoonosis with protean manifestations

caused by the spirochete, Leptospira caused by the spirochete, Leptospira interrogansinterrogans

Infection in small rodents (carrier animals) Infection in small rodents (carrier animals) usually occurs during infancyusually occurs during infancyanimals shed the organism in their urine animals shed the organism in their urine intermittently or continuously throughout intermittently or continuously throughout life resulting in life resulting in contamination of the contamination of the environment, particularly waterenvironment, particularly water.. Organisms may remain viable for days to Organisms may remain viable for days to months in soil and water with a neutral pH.months in soil and water with a neutral pH.

Portals of entry include cuts or abraded Portals of entry include cuts or abraded skin, mucous membranes or conjunctiva. skin, mucous membranes or conjunctiva. The infection is rarely acquired by The infection is rarely acquired by ingestion of food contaminated with urine ingestion of food contaminated with urine or via aerosols. or via aerosols.

Controversy exists as to whether Controversy exists as to whether Leptospira can penetrate the intact skin.Leptospira can penetrate the intact skin.

Risk factors for infection Risk factors for infection

Occupational exposure — farmers, Occupational exposure — farmers, ranchers, abattoir workers, trappers, ranchers, abattoir workers, trappers, veterinarians, loggers, sewer workers, rice veterinarians, loggers, sewer workers, rice field workers, military personnel, field workers, military personnel, laboratory workerslaboratory workers

Recreational activities — fresh water Recreational activities — fresh water swimming, canoeing, kayaking, trail bikingswimming, canoeing, kayaking, trail biking

Household exposure — pet dogs, Household exposure — pet dogs, domesticated livestock, rainwater domesticated livestock, rainwater catchment systems, and infestation by catchment systems, and infestation by infected rodents.infected rodents.

Other — Skin lesions, contact with wild Other — Skin lesions, contact with wild rodentsrodents

The spirochetes enter the host through abraded skin or intact mucous membranes and travel to the liver where they reproduce.

After an incubation period of 2 to 30 days (usually 5 to 14 days), leptospiremia occurs, spreading organisms to all parts of the body including the meninges

LEPTOSPIROSISLEPTOSPIROSIS

2 general patterns occur:

1 anicteric leptospirosis (90%)

2 icteric leptospirosis or Weil disease (10%)

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

– fever (fever (75 to 100)75 to 100)

– MyalgiasMyalgias (50-80%) (50-80%)

– headache (15-30%)headache (15-30%)

– nonproductive coughnonproductive cough (25 to 35%) (25 to 35%)

– nausea, vomitingnausea, vomiting and and diarrheadiarrhea (50%) (50%)

less common symptoms:less common symptoms:–arthralgias arthralgias

–bone pain bone pain

–sore throatsore throat

–abdominal painabdominal pain

Physical examinationPhysical examination– conjunctival suffusion- (40-70%) conjunctival suffusion- (40-70%) – muscle tendernessmuscle tenderness (30-40%) (30-40%)– Jaundice (50-80% in severe form)Jaundice (50-80% in severe form)– Splenomegaly Splenomegaly – LymphadenopathyLymphadenopathy– PharyngitisPharyngitis– HepatomegalyHepatomegaly– skin rashskin rash

Liver failure is generally reversible and not Liver failure is generally reversible and not a cause of death in leptospirosis.a cause of death in leptospirosis.

Dyspnea, oliguria, WBC counts above Dyspnea, oliguria, WBC counts above 12,900/mm312,900/mm3

Alveolar infiltrates on chest radiography Alveolar infiltrates on chest radiography have been associated with adverse have been associated with adverse outcomes. outcomes.

Complications — While most cases of Complications — While most cases of leptospirosis are mild to moderate, the leptospirosis are mild to moderate, the course may be complicated by course may be complicated by renal renal failurefailure, uveitis, , uveitis, hemorrhagehemorrhage, acute , acute respiratory distress syndrome, myocarditis respiratory distress syndrome, myocarditis and rhabdomyolysisand rhabdomyolysis

The potential severity of leptospirosis was The potential severity of leptospirosis was illustrated in a retrospective study of 60 illustrated in a retrospective study of 60 patients with leptospirosis requiring ICU patients with leptospirosis requiring ICU admission in India .admission in India .– Multiorgan failure developed in 46 patients Multiorgan failure developed in 46 patients

(77 percent)(77 percent)– the mortality for patients with leptospirosis the mortality for patients with leptospirosis

requiring ICU admission was 52 percent.requiring ICU admission was 52 percent.

Severe pulmonary diseaseSevere pulmonary disease may be may be underdiagnosed in regions of high endemicity. underdiagnosed in regions of high endemicity.

Among 321 patients with serologic and clinical Among 321 patients with serologic and clinical evidence of leptospirosis in Peru, seven (3.7 evidence of leptospirosis in Peru, seven (3.7 percent) had percent) had severe pulmonary manifestationssevere pulmonary manifestations, , including including hemoptysis hemoptysis in sixin six

5 of the 7 patients died, 4 from 5 of the 7 patients died, 4 from pulmonary pulmonary hemorrhagehemorrhage and 1 from and 1 from acute respiratory acute respiratory distress syndrome and multiorgan failuredistress syndrome and multiorgan failure

LABORATORY FINDINGS — Leptospirosis is a LABORATORY FINDINGS — Leptospirosis is a nonspecific clinical illness, and routine laboratory tests nonspecific clinical illness, and routine laboratory tests are similarly nondiagnostic. are similarly nondiagnostic. White blood cell (WBC)White blood cell (WBC) counts are generally less than counts are generally less than 10,000/mm3 but may range 10,000/mm3 but may range between 3,000 and between 3,000 and 26,000/µL26,000/µLUrinalysis frequently shows proteinuria,Urinalysis frequently shows proteinuria, pyuria, granular pyuria, granular casts and occasionally casts and occasionally microscopic hematuriamicroscopic hematuria Elevated creatine kinase is found in approximately 50 Elevated creatine kinase is found in approximately 50 percent of patients and may be a useful clue for the percent of patients and may be a useful clue for the diagnosisdiagnosis

Approximately 40 percent of patients have Approximately 40 percent of patients have minimal to moderate elevations of hepatic minimal to moderate elevations of hepatic transaminases (usually <200 IU/L). transaminases (usually <200 IU/L). Hyponatremia is common in severe Hyponatremia is common in severe leptospirosis.leptospirosis.

Thrombocytopenia is uncommon, but a poorly Thrombocytopenia is uncommon, but a poorly understood hemorrhagic diathesis may occur in understood hemorrhagic diathesis may occur in the absence of demonstrable coagulation the absence of demonstrable coagulation defects or severe thrombocytopenia. defects or severe thrombocytopenia. Pancytopenia has been reported as the Pancytopenia has been reported as the presenting manifestation in case reports with presenting manifestation in case reports with complete resolution following treatment with complete resolution following treatment with penicillin [penicillin [2929]. The CSF may show a neutrophilic ]. The CSF may show a neutrophilic or lymphocytic pleocytosis with minimal to or lymphocytic pleocytosis with minimal to moderately elevated protein concentrations and moderately elevated protein concentrations and normal glucose. A low CSF glucose normal glucose. A low CSF glucose concentration is rarely seen [concentration is rarely seen [3030].].

Imaging — Chest radiographs may show Imaging — Chest radiographs may show small nodular densities, which can small nodular densities, which can progress to confluent consolidation or a progress to confluent consolidation or a ground glass appearance Pathologically, ground glass appearance Pathologically, these infiltrates may represent alveolar these infiltrates may represent alveolar hemorrhage, ARDS, or pulmonary edemahemorrhage, ARDS, or pulmonary edema

DIAGNOSIS — Because the clinical DIAGNOSIS — Because the clinical features and routine laboratory findings of features and routine laboratory findings of leptospirosis are not specific, a high index leptospirosis are not specific, a high index of suspicion must be maintained for the of suspicion must be maintained for the diagnosis. The organism can be cultured, diagnosis. The organism can be cultured, but the diagnosis is more frequently made but the diagnosis is more frequently made by serologic testing.by serologic testing.

Culture — As noted above, leptospirosis can be Culture — As noted above, leptospirosis can be confirmed by culture of the organism from confirmed by culture of the organism from clinical specimens in appropriate media. Bclinical specimens in appropriate media. BBlood and CSF specimens are positive during Blood and CSF specimens are positive during the first 10 days of the illness. Ithe first 10 days of the illness. IIsolation of the organism from the blood is Isolation of the organism from the blood is successful in approximately 50 percent of cases.successful in approximately 50 percent of cases. Urine cultures become positive during the Urine cultures become positive during the second week of the illness and remain so for up second week of the illness and remain so for up to 30 days after the resolution of symptomsto 30 days after the resolution of symptoms

Serology — Because some clinical microbiology Serology — Because some clinical microbiology laboratories do not offer culture for the diagnosis laboratories do not offer culture for the diagnosis of leptospirosis, serological tests are most often of leptospirosis, serological tests are most often used for confirmation. used for confirmation.

A number of serologic tests are employed or are A number of serologic tests are employed or are under development, including the microscopic under development, including the microscopic agglutination test (MAT), macroscopic agglutination test (MAT), macroscopic agglutination test, indirect hemagglutination, and agglutination test, indirect hemagglutination, and ELISA ELISA

While all of these assays are useful in While all of these assays are useful in establishing the diagnosis, the gold standard is establishing the diagnosis, the gold standard is considered to be the MAT Unfortunately, this considered to be the MAT Unfortunately, this test requires live organisms, considerable test requires live organisms, considerable expertise, and is performed only by reference expertise, and is performed only by reference laboratories such as the CDC.laboratories such as the CDC. Like other serologic tests, the MAT is most Like other serologic tests, the MAT is most specific when a fourfold or greater rise in titer is specific when a fourfold or greater rise in titer is detected between acute and convalescent detected between acute and convalescent serum specimens. However, a single titer of serum specimens. However, a single titer of >1:800 is strong evidence of current or recent >1:800 is strong evidence of current or recent infection with leptospira. infection with leptospira.

Cross reactive antibodies have been Cross reactive antibodies have been associated with syphilis, relapsing fever, associated with syphilis, relapsing fever, Lyme disease, and legionellosis [Lyme disease, and legionellosis [11]. The ]. The level of the antibody titers as found in the level of the antibody titers as found in the MAT cannot be used to predict the serovar MAT cannot be used to predict the serovar that infects the individual patient that infects the individual patient

Since the MAT is not readily available, another Since the MAT is not readily available, another assay typically is performed first in suspected assay typically is performed first in suspected cases of leptospirosis. cases of leptospirosis. Two commercially available rapid tests, the Two commercially available rapid tests, the microplate IgM ELISA and an IgM dot-ELISA microplate IgM ELISA and an IgM dot-ELISA dipstick test, performed well in studies dipstick test, performed well in studies conducted in the United States and Thailand that conducted in the United States and Thailand that used MAT as the comparator used MAT as the comparator If one of these assays is positive, sera for MAT If one of these assays is positive, sera for MAT can then be sent to the CDC can then be sent to the CDC

LEPTOCHECK (Rapid test for antibodies LEPTOCHECK (Rapid test for antibodies to Leptospira)to Leptospira)

Sensitivity 100% (only 90% in a study Sensitivity 100% (only 90% in a study made in India by Maskey et at)made in India by Maskey et at)

Specificity 92% (Maskey et at)Specificity 92% (Maskey et at)

TREATMENT — The vast majority of infections TREATMENT — The vast majority of infections with leptospira are self-limiting. with leptospira are self-limiting.

Although penicillins, tetracyclines, Although penicillins, tetracyclines, chloramphenicolchloramphenicol, and , and erythromycinerythromycin have anti have anti leptospiral activity in vitro and in animal models, leptospiral activity in vitro and in animal models, it remains controversial whether antimicrobials it remains controversial whether antimicrobials produce a beneficial effect in mild human produce a beneficial effect in mild human leptospirosis since the illness has a variable leptospirosis since the illness has a variable natural history. natural history.

Nevertheless, if the illness is severe Nevertheless, if the illness is severe enough to result in a physician visit and enough to result in a physician visit and the diagnosis is recognized, antibiotic the diagnosis is recognized, antibiotic therapy should be given.therapy should be given.

Efficacy — Two small, randomized, Efficacy — Two small, randomized, placebo-controlled trials have shown a placebo-controlled trials have shown a benefit from antimicrobial therapy. In one benefit from antimicrobial therapy. In one in which in which doxycyclinedoxycycline (100 mg PO twice (100 mg PO twice daily) was compared to placebo, daily) was compared to placebo, doxycycline shortened the illness by an doxycycline shortened the illness by an average of two days and prevented average of two days and prevented shedding of the organism in the urine [shedding of the organism in the urine [11]. ].

In the second trial, patients with severe In the second trial, patients with severe leptospirosis who were treated with leptospirosis who were treated with penicillin (6 million units daily) had fewer penicillin (6 million units daily) had fewer days of fever, more rapid resolution of days of fever, more rapid resolution of serum creatinine elevations, and a shorter serum creatinine elevations, and a shorter hospital stay; penicillin therapy also hospital stay; penicillin therapy also prevented urinary sheddingprevented urinary shedding

Supportive care with dialysis, ventilatory support, Supportive care with dialysis, ventilatory support, and blood products may be necessary in severe and blood products may be necessary in severe cases of leptospirosis.cases of leptospirosis.Antimicrobial treatment — Human leptospirosis Antimicrobial treatment — Human leptospirosis is often self-limited and requires no antibiotic is often self-limited and requires no antibiotic treatment. treatment. Symptomatic patients presenting for medical Symptomatic patients presenting for medical care should be treated to shorten the illness and care should be treated to shorten the illness and decrease shedding of the organism in the urine. decrease shedding of the organism in the urine. We suggest the following approach that varies We suggest the following approach that varies with the clinical presentation with the clinical presentation

We suggest treatment with oral We suggest treatment with oral doxycyclinedoxycycline for outpatients because it is for outpatients because it is also effective for rickettsial disease, which also effective for rickettsial disease, which can be confused with leptospirosis (100 can be confused with leptospirosis (100 mg orally twice daily in adults; 2 mg/kg per mg orally twice daily in adults; 2 mg/kg per day in two equally divided doses in day in two equally divided doses in children 8 years of age to a maximum children 8 years of age to a maximum dose of 200 mg daily). dose of 200 mg daily).

The exceptions are children 8 years or The exceptions are children 8 years or pregnant women, in whom we suggest pregnant women, in whom we suggest treatment with treatment with amoxicillinamoxicillin (25 to 50 mg/kg (25 to 50 mg/kg in three equally divided doses).in three equally divided doses).

For hospitalized adults with severe For hospitalized adults with severe disease, we suggest intravenous therapy disease, we suggest intravenous therapy with with penicillin (6 million units dailypenicillin (6 million units daily), ), doxycycline (100 mg twice daily), doxycycline (100 mg twice daily), ceftriaxoneceftriaxone (1 g every 24 hours), or (1 g every 24 hours), or cefotaximecefotaxime (1 g every six hours). (1 g every six hours).

PROGNOSIS — Mortality rates in PROGNOSIS — Mortality rates in hospitalized patients with leptospirosis hospitalized patients with leptospirosis have ranged from have ranged from 4 to 50 percent. 4 to 50 percent.

Pulmonary hemorrhage (30-70%) Pulmonary hemorrhage (30-70%) A A retrospective review of 282 cases of retrospective review of 282 cases of leptospirosis during a 2002 outbreak in leptospirosis during a 2002 outbreak in India identified risk factors for mortality India identified risk factors for mortality

Most authorities agree that if antibiotics Most authorities agree that if antibiotics are not started early in the disease (are not started early in the disease (up to up to the fourth daythe fourth day), they do not change the ), they do not change the course of the illness (50-80%motality)course of the illness (50-80%motality)

PREVENTION — Vaccination of domestic PREVENTION — Vaccination of domestic animals against leptospirosis provides animals against leptospirosis provides substantial protection, but is not effective substantial protection, but is not effective in 100 percent of animals. Some in 100 percent of animals. Some immunized animals become infected and immunized animals become infected and excrete leptospires in their urine.excrete leptospires in their urine.

The major control measure available for The major control measure available for humans is to avoid potential sources of humans is to avoid potential sources of infection such as stagnant water, water infection such as stagnant water, water derived from run off from animal farms, derived from run off from animal farms, rodent control, and protection of food from rodent control, and protection of food from animal contamination. animal contamination.

Thank youThank you

Morbidity and Mortality Conference Jay V. Dy M.D. Medical Resident.

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Transcript of Morbidity and Mortality Conference Jay V. Dy M.D. Medical Resident.