Name:
A 52-Year-Old Man with Fever and Chills
Description:
A 52-Year-Old Man with Fever and Chills
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Duration:
T00H08M31S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to episode 62, a 52-year-old man with fever and chills.
DR. WIENER: Okay, Cathy, today's patient is a 52-year-old man with a past medical history of alcoholic cirrhosis who presents with one day of fever and chills. He says over the last day, in addition to the fever and chills, he's feeling light-headed, his heart is racing, and he's developed a rash on his legs.
DR. HANDY: Okay, well, lots more to know here, but tell me more about his general state of health, particularly the cirrhosis. That'll have a lot of impact on what we're thinking because of the many complications of cirrhosis, and you also mentioned a rash. So we'll also need to hear more about that.
DR. WIENER: Okay, so he has documented cirrhosis due to past hepatitis C infection. He takes spironolactone since an admission over a year ago for poorly controlled ascites. He's had no documented esophageal varices, and since that admission last year, he's been doing pretty well. His baseline INR is about 1.8.
DR. HANDY: Coagulopathy is almost universal in patients with cirrhosis. There is decreased synthesis of clotting factors and impaired clearance of anticoagulants, so I'm not surprised to hear that he has the elevated INR. Cirrhotic patients are also at increased risk of infection. In patients with cirrhosis and ascites severe enough for hospitalization, like this patient did, spontaneous bacterial peritonitis can occur in up to 30% of individuals and can have a 25% in-hospital mortality rate.
DR. HANDY: But tell me more about his recent history and any potential exposure to regular pathogens.
DR. WIENER: Well, so it turns out this case is occurring in the fall and this patient lives in Washington DC, he works in an office. He did have a recent flu vaccination and is at no known risk of COVID-19 infection. However, he does note the two days ago he went with some friends to a house on the Eastern shore where they physically distanced but had dinner. They ate locally harvested crabs and oysters. The next day he started feeling queasy and that has progressed.
DR. WIENER: None of his other colleagues have felt unwell after the meal.
DR. HANDY: Well, while I love going to the Eastern shore for crabs I'm not much of an oyster person, the timeline and the history does suggest a foodborne illness. Tell me about his physical examination, especially the rash and at least some basic labs.
DR. WIENER: On exam, he appears acutely ill. He has a temperature of 39 degrees Celsius, a blood pressure of 78 over 59, a heart rate of 110 and an oxygen saturation of 95%. He has multiple areas that are abnormal on his lower legs. He has a few erythematous patches but some of these patches look like they've extended into ecchymoses. And some of the ecchymoses even have rare vesicles developing.
DR. WIENER: These are present on both lower extremities. His upper extremities have no rash. His labs are notable for a low white cell count of 1,700, normal electrolytes, except for an elevated creatinine to 2.3. His platelet count is 30,000 and his INR is now 2.0.
DR. HANDY: Well, based on what you said it definitely sounds like he has sepsis. And I'm also worried about ongoing bacteremia with the rash. He should definitely be admitted to the ICU with careful fluid resuscitation given his cirrhosis.
DR. WIENER: Okay, well, the question now asks, which of the following organisms is the most likely cause of his sepsis? And the options are A. Campylobacter jejuni; B. E. coli O157:H7; B. E. coli O157:H7; C. salmonella enteritidis; D. Shigella flexneri; or E. Vibrio vulnificus.
DR. HANDY: Well, all of the options listed can cause foodborne illnesses. But because this patient has cirrhosis and is presenting with sepsis, along with the rash on the lower extremities that you described, I would pick the answer E. Vibrio vulnificus.
DR. WIENER: Why did you go right there?
DR. HANDY: Well, it's important to recognize the clinical scenario of sepsis due to Vibrio. And I think everybody remembers the first time that they see a patient with this disease. While infection with Vibrio is rare, this organism is the most common cause of severe Vibrio infections within the United States. Like most Vibrios, Vibrio vulnificus proliferates in warm summer months and requires a saline environment for growth.
DR. HANDY: In the United States, infections in humans typically occur in the coastal states between May and October and most commonly affect men over the age of 40. Vibrio vulnificus has been linked to two distinct syndromes. One, a primary sepsis syndrome which usually occurs in patients with underlying liver disease, as in this patient. And then the second distinct syndrome a primary wound infection which generally affects people without underlying disease.
DR. WIENER: Tell me more about the Vibrio sepsis syndrome since that's apparently what's going on here.
DR. HANDY: Patients presenting with primary sepsis have a median incubation period of about 16 hours after which they develop malaise, chills, fever and then will be feeling overall week. About one third of patients develop hypotension, which is often apparent at admission. Cutaneous manifestations develop in most cases, usually within 36 hours of onset and characteristically involve the extremities with the legs more often than the arms or the trunk.
DR. HANDY: And a common sequence, like you pointed out initially, erythematous patches are followed by ecchymoses and vesicles and bullae. In fact, sepsis and hemorrhagic bullous skin lesions suggest the diagnosis in the appropriate settings, and necrosis and sloughing may also be evident on these lesions.
DR. WIENER: So the timing and the rash in this patient seem typical, what about his labs?
DR. HANDY: Laboratory studies typically reveal leukopenia more often than leukocytosis, and then also will show thrombocytopenia or elevated levels of fiber and split products.
DR. WIENER: Again, our patient is typical in that he had a low white cell count and low platelet count. But remember, it is typical for patients with cirrhosis to have thrombocytopenia. Cathy, are blood cultures helpful in this syndrome? Are they usually positive? And what's the overall prognosis of this sepsis?
DR. HANDY: Yeah, so I agree really with all of the above with regards to thrombocytopenia and also that blood cultures would be helpful. Vibrio vulnificus can be cultured from blood or even the cutaneous lesions. So I would definitely do that. Mortality rate approaches 50% with most deaths due to uncontrolled sepsis. So prompt treatment is critical and should include empiric antibiotic administration, aggressive debridement of any necrotic wounds and general supportive care.
DR. WIENER: What antibiotics would you suggest?
DR. HANDY: It's sensitive in vitro to a number of antibiotics, including tetracyclines, fluoroquinolones and third generation cephalosporins. Data from animal models suggest that either a fluoroquinolone or the combination of a tetracycline and a third generation cephalosporin should be used in the treatment of Vibrio vulnificus septicemia.
DR. WIENER: What about the other causes? You mentioned they all could cause a foodborne illness also.
DR. HANDY: So Campylobacter jejuni is a common cause of foodborne gastroenteritis typically from poultry. It can cause significant debility but not usually sepsis. The most dreaded complication which is uncommon is Guillain-Barré syndrome. E. coli is associated with ingestion of contaminated undercooked meat, raw milk and green vegetables. It may cause hemorrhagic diarrhea due to production of the Shiga-like toxin.
DR. HANDY: And in some cases it may cause renal failure or the hemolytic uremic syndrome.
DR. WIENER: And what about Shigella and salmonella?
DR. HANDY: Yeah, so again, both causes of foodborne GI illnesses. Shigella is a common cause of dysentery worldwide. Salmonella is a common cause of food poisoning including in the U.S., and often associated in this country with contaminated poultry and eggs. It may also cause typhoidal sepsis, but this case did not have the appropriate exposure or time course to suggest that.
DR. WIENER: Okay, great. So the teaching point in this case is that Vibrio vulnificus is a particular pathogen to keep in mind in patients with liver disease or cirrhosis. It's typically acquired through consumption of coastal seafood and may cause life-threatening sepsis.
DR. HANDY: And you can read more in Harrison's chapter on cholera and other Vibrio species. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.