Problem case 경희의료원 감염내과 R2 이동영

증례1

History Chief complaint Present illness Fever Both leg pain (onset: 2 day ago) Present illness M/59, 평소 건강히 지내던 자로 내원 1주전 생선회덮밥 먹은 후 내원 3일전부터 general weakness, fatigue 있었고 2일전부터 both leg pain, 1일전부터 fever 생겨 ER 내원

Past medical history DM/ HTN/ Hepatitis/ Pulmonary Tb (-/-/±/-) Hepatitis-20대에 우연히 B형 간염보균자라 들음 Personal history Smoking (-) alcohol (-) Occupation history 운수업

Review of system General : fatigue (+) fever (+) chill (+) Malaise (+) H & N : headache (-) sore throat (-) visual opacity (-) Chest : chest pain (-) palpitation (-) cough (-) sputum (-) dyspnea (-) GI : Anorexia/N/V/D/C (+/-/-/-/-) abdominal pain (-) Urinary : dysuria (-) frequency (-) urgency (-) voiding difficulty (-) Musculoskeletal : both leg pain (+) LBP (-)

Physical Examination V/S 60/30 mmHg-108 회/min-20 회/min-36.9 °C Height: 175 cm BW: 70.5 Kg General : Drowsy mentality SKIN : purpura or patch on both lower leg and back H/N : no thyroid gland enlargement no cervical LN enlargement no neck vein engorgement E/ENT : isocoric pupil with PLR(++/++) pinkish conjunctiva with clear sclerae Chest : Coarse breath sound with BLL crackle Rapid heart beat without murmur Abdomen : soft and flat abdomen abdominal Td/RT(-/-) hypoactive B.S. Shifting dullness(-) B/Ext : CVA tenderness(-/-) pitting edema(-/-) Both leg swelling(++) purpura on lower leg

Initial Lab Finding CRP/Glu 2.2/108 mg/dL CBC/DC :1,210/mm3-10.7g/dL-33.3%-27K (seg 81.7%) INR 2.33 aPTT 60.5 Chemistry : TB/DB 2.81/0.85 mg/dL ALP/rGT 49/14 mg/dL BUN/Cr 5.6/2.0 mg/dL Na/K/Cl 130/3.9/103 mmol/L LDH/Uric acid 599/4.9 mg/dL U/A : RBC 5-9/HPF WBC 10-29/HPF Protein(++) PH 5.0 Specific gravity 1.015 Occult blood (++) many bacteria(+) ABGA: 7.313 - 39.4 - 33.0 - 19.5 - 53.2%(RA)  VBGA 가능성! Prot/alb 5.6/2.0 g/dL AST/ALT 82/28 U/L Ca/P/Mg 8.2/3.3/1.5 mg/dL CRP/Glu 2.2/108 mg/dL CK/Myoglobin 992/2678.9 ng/dL

EKG

Chest AP

Initial problem lists 1. hypotension with tachycardia, hypoxia, metabolic acidosis, pancytopenia  septic shock 2. both leg pain with increased muscle enzyme, azotemia 3. Previous Hx. Of HBV

Initial Assessment & Plan 1. Hypotension with tachycardia, hypoxia, metabolic acidosis, pancytopenia A) Septic shock 최근 sea food intake Hx., HBV carrier의 Hx., skin lesion  Vibrio septic shock 가능성 P) W/U Blood & urine culture Korean antibody 4종 Legionella, Mycoplasma antibody Adequate hydration, Vasopressor ABGA f/u, Bicarbonate Antibiotics: Vancomycin, ciprofloxacin, doxycyline

increased muscle enzyme, azotemia A) Rhabdomyolysis d/t infection 2. both leg pain with increased muscle enzyme, azotemia A) Rhabdomyolysis d/t infection ARF (Ccr=33mL/min) d/t septic shock, rhabdomyolysis P) W/U Spot urine Na Cr BUN for FENa FEUN (FENa=0.084, FEUN=10.68) Abd US Adequate hydration Urine alkalinization Diuretics

3. Previous Hx. Of HBV A) if LC  Child C (total 11~12) Septic shock에 의한 liver function악화 P)W/U Viral Marker Abd US or Abd CT

Abd US liver function deterioration d/t sepsis Coarse liver parenchyma  LC more likely HBsAg/HBcAb/HbsAb (+/+/-) Anti-HCV (-) #3. B viral LC, Child C (total 10 or 11) liver function deterioration d/t sepsis

Both leg (입원 11시간후)

Both leg pain 입원 17시간 후 LDH (U/L) CK (U/L) 4:00 599 992↑ 13:00 960 6890↑↑ leg swelling↑↑ Palpation: soft and tense Dorsalis pedis pulse(±)  # 2. Soft tissue infection with rhabdomyolysis Compartment syndrome possible  OS consult for fasciotomy

ABGA 내원 당시 Normal anion gap Metabolic acidosis (serum AG=10) 점차 High anion gap Bicarbonate 투여에도 반응 하지 않는 acidosis로 발전 pH pCO2 pO2 HCO3 SaO2 O2 5:00 7.30 29.8 98.3 14.4 96.8 4L 8:42 7.18 25.9 105.8 9.5 96.7 21:00 7.11 43.3 74.5 13.7 89.7 2L 23:01 7.03 21.38 101.9 5.6 94.5 2:43 6.84 34.3 95.9 5.7 90.1

Hospital course Septic shock으로 adm. Both leg hemorrhagic bullae: 내원 11시간 Uncontrolled metabolic acidosis: 내원 20시간 Both leg compartment syn.으로 fasciotomy계획 Expire: 내원 25시간

Isolated Bacteria #1. Vibrio alginolyticus septic shock Wound Culture 2 개 Blood Culture 3 쌍 #1. Vibrio alginolyticus septic shock

증례2

History Chief complaint Both leg pain (onset: 1 day ago) Present illness M/46, heavy alcoholics로서 1년 전 건강검진에서 DM 및 fatty liver 진단 내원 1주전 충남 당진에서 전어회, 새우회 먹었고 내원 1일전 부터 Lt. leg & Rt. foot edema, pain 생 겨 2차 병원 경유하여 본원 ER 내원

Past medical history DM/ HTN/ Hepatitis/ Pulmonary Tb (+/-/-/-) DM- No med Personal history Smoking (-) alcohol (+): 매일 소주 1병 Occupation history 건축업(담 쌓는 일)

Review of system General : fatigue (-) fever (-) chill (-) Malaise (+) H & N : headache (+) sore throat (-) visual opacity (-) Chest : chest pain (-) palpitation (-) cough (-) sputum (-) dyspnea (-) GI : A/N/V/D/C (-/-/-/-/-) abdominal pain (-) Urinary : dysuria (-) frequency (-) urgency(-) voiding difficulty (-) Musculoskeletal : both leg pain (+) LBP(-)

Physical Examination V/S 70/50 mmHg-92 회/min-20 회/min-36.0 °C Height: 175 cm BW: 70 kg General : Alert SKIN : patch, purpura on both lower leg (especially Lt. leg) H/N : no thyroid gland enlargement no cervical LN enlargement no neck vein engorgement E/ENT : isocoric pupil with PLR(++/++) pinkish conjunctiva with clear sclerae Chest : CBS without crackle Regular heart beat without murmur Abdomen : soft and flat abdomen abdominal Td/RT(-/-) hypoactive B.S. Shifting dullness(-) B/Ext : CVA tenderness(-/-) pitting edema(-/-) Both leg swelling(++) purpura on lower leg

Lt lower leg skin lesion: 내원 당시

Initial Lab Finding CRP/Glu 14.9/162 mg/dL CBC/DC :37,530/mm3-13.1g/dL-39.5%-226K (seg 92.9%) INR 1.18 aPTT 54.7 Chemistry: TB/DB 3.26/1.55 mg/dL ALP/rGT 105/346 mg/dL BUN/Cr 13/1.8 mg/dL Na/K/Cl 134/3.4/102 mmol/L LDH/Uric acid 594/3.4 mg/dL U/A : RBC 5-9/HPF WBC 5-9/HPF Protein(++) PH 5.0 Specific gravity 1.025 Occult blood (+++) ABGA: 7.479 - 20.3 – 105.6 - 14.7 - 98.2% (RA) Prot/alb 5.0/2.4 g/dL AST/ALT 241/224 U/L Ca/P/Mg 8.2/3.3/1.5 mg/dL CRP/Glu 14.9/162 mg/dL CK/Myoglobin 493/853.3 ng/dL

EKG

Chest AP

Initial problem lists 1. hypotension with CRP & leukocytosis↑  septic shock 2. both leg pain with increased muscle enzyme, azotemia both leg skin lesion 3. LFT elevation 4. DM

Initial Assessment & Plan 1. hypotension with CRP & leukocytosis↑ A) Septic shock 최근 sea food intake Hx, daily alcohol intake, skin lesion  Vibrio septic shock 가능성 P) W/U Blood & urine culture Legionella, Mycoplasma antibody Adequate hydration & Vasopressor Antibiotics: iv ciprofloxacin, doxycycline

increased muscle enzyme, azotemia & both leg skin lesion 2. both leg pain with increased muscle enzyme, azotemia & both leg skin lesion A) Rhabdomyolysis d/t infection ARF (Ccr=51mL/min) d/t septic shock, rhabdomyolysis P) W/U Spot urine Na Cr BUN for FENa FEUN (FENa=0.02, FEUN=7.33) Abd US Adequate hydration Urine alkalinization Diuretics skin lesion culture

3. LFT elevation 4. DM A) alcoholic hepatitis alcoholic LC, possible P) w/u abd US viral marker 4. DM A) DM P) W/U HbA1C  6.8% OGTT insulin injection

Leg lesion 내원 1일 후 내원 3일 후