1. Problem case
경희의료원 감염내과
R2 이동영

2. 증례1

3. 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

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

5. 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 (-)

6. Physical Examination V/S 60/30 mmHg-108 회/min-20 회/min-36.9 °C
Height: 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

7. 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 aPTT 60.5
Chemistry :
TB/DB /0.85 mg/dL
ALP/rGT /14 mg/dL
BUN/Cr /2.0 mg/dL
Na/K/Cl /3.9/103 mmol/L
LDH/Uric acid 599/ mg/dL
U/A :
RBC 5-9/HPF WBC /HPF Protein(++)
PH Specific gravity Occult blood (++)
many bacteria(+)
ABGA: %(RA)  VBGA 가능성!
Prot/alb /2.0 g/dL
AST/ALT 82/28 U/L
Ca/P/Mg /3.3/1.5 mg/dL
CRP/Glu /108 mg/dL
CK/Myoglobin 992/ ng/dL

8. EKG

9. Chest AP

10. 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

11. 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

12. 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

13. 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

14. 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

15. Both leg (입원 11시간후)

16. 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

17. 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

18. 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

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

20. 증례2

21. 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

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

23. 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(-)

24. Physical Examination V/S 70/50 mmHg-92 회/min-20 회/min-36.0 °C
Height: 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

25. Lt lower leg skin lesion: 내원 당시

26. 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 aPTT 54.7
Chemistry:
TB/DB /1.55 mg/dL
ALP/rGT /346 mg/dL
BUN/Cr /1.8 mg/dL
Na/K/Cl /3.4/102 mmol/L
LDH/Uric acid 594/ mg/dL
U/A :
RBC 5-9/HPF WBC 5-9/HPF Protein(++)
PH Specific gravity Occult blood (+++)
ABGA: – % (RA)
Prot/alb /2.4 g/dL
AST/ALT /224 U/L
Ca/P/Mg /3.3/1.5 mg/dL
CRP/Glu /162 mg/dL
CK/Myoglobin 493/853.3 ng/dL

27. EKG

28. Chest AP

29. 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

30. 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

31. 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

32. 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

33. Leg lesion
내원 1일 후
내원 3일 후