1. Vital Signs are Vital: Tachycardia as a Sign of Something More Insidious Joseph Knapper, MD and Bhavin Adhyaru, MS, MD J Willis Hurst Internal Medicine Residency Program; Emory University; Atlanta, GA 30303 Learning ObjectivesHospital Course References Case Presentation Clinic Visit #1 History: 64 year old male with PMH of Diabetes Mellitus and BPH Presentation: Fever, dysuria, hematuria, increased urinary frequency x 3 days Exam: HR = 110 and mild scrotal swelling Workup: UA: 3+ LE Testicular ultrasound: bilateral hydroceles, no torsion Treatment Plan: 7 day course of ciprofloxacin Clinic Visit #2: 1 week after initial visit - symptoms and tachycardia persisted Prescribed additional 7 days ciprofloxacin for complicated UTI Clinic Visit #3: Symptoms 1 week after 2 nd Visit: No improvement. Now developed urinary retention requiring occasional self-catheterization Exam: Afebrile, HR in 130’s, scrotal swelling unchanged, no penile discharge Rectal Exam: No prostatic masses or tenderness Labs: WBC = 9.7. UA = Trace LE, 26-50 WBC’s, 11-25 RBC’s, + Bacteria ECG: Sinus tachycardia with HR 131 Plan: Admitted for further workup of sepsis and urinary retention Patient placed on IV Ceftriaxone due to concern for ciprofloxacin-resistant UTI No improvement after several days  broadened to IV piperacillin-tazobactam Blood and urine cultures came back negative but still no clinical improvement CT Abdomen/Pelvis ordered: Two large prostatic abscesses Abscesses drained in OR by urology and ceftriaxone injected into prostatic tissue Patient’s symptoms improved and tachycardia resolved Cultures from abscess fluid eventually grew out E. coli and E. faecalis Discharged to complete 4 week course of linezolid (E. faecalis resistant to cipro) Symptom free at 1 month follow up visit CT Abdomen/Pelvis with Contrast Hospital Course (Continued) 1.Recognize tachycardia as a manifestation of systemic illness and, in certain cases, underlying infection 2.Understand the presentation and diagnosis of a prostate abscess 3.Understand the management strategy for a prostate abscess Figure 1. CT of the Abdomen and Pelvis shows a diffusely enlarged heterogeneous prostate, with 2 large fluid collections. The fluid collection on the left measures 4.6 cm x 3 cm, and the collection on the right measures 2.1 x 1.3 cm. Patient’s tachycardia was overlooked on multiple consecutive clinic visits Persistent tachycardia despite antibiotic therapy should raise red flags: Inappropriate antibiotic choice More serious infectious etiology Maintain high-index of suspicion for prostate abscess in males with UTI or prostatitis who do not respond to standard therapy Signs and symptoms of prostate abscess are generally non-specific Fever, chills, and leukocytosis are frequently absent. 1 1 Patients often have a normal prostate exam. 1 1 Risk factors include diabetes, prostatic hyperplasia, and urinary catheterization. 1,2 12 Transrectal ultrasonography is preferred if prostate abscess is strongly suspected. 2 2 Drainage and broad-spectrum antibiotics are the standard of care. 2 2 Mortality rates are low with appropriate treatment and outcomes are generally good. 1 1 1.Weinberger M, Cytron S, Servadio C, Block C, Rosenfeld JB, Pitlik SD. Prostatic abscess in the antibiotic era. Rev Infect Dis. Mar-Apr 1988;10(2):239-249. 2.Brede CM, Shoskes DA. The etiology and management of acute prostatitis. Nat Rev Urol. Apr 2011;8(4):207-212. Discussion Nisha H. Fernandes, MD Bhavin B. Adhyaru, MS, MD Acknowledgements