Case No 2
22-aged female patient with Ewing sarcoma of ilium on neoadjuvant chemotherapy, admitted to hospital for fever and abdominal pain
Medical History
Present Illness: Nowadays after 4th cycle of NACHT (neoadjuvant chemotherapy). 4 days before the fever up to 38.5 °C, examined on orthopedic department, blood taken for blood count and basic biochemical tests, that reveal pancytopenia and high CRP, presently she complained pain in right lower abdomen, transported to department of infectious diseases
FHx: Nothing of note
EHx: Denies the contact with infection. She underwent outpatient chemotherapy, antibiotics given as a prophylaxis a month ago
WSHx: Secretary, on sick leave, single
PM/SHx: common child diseases, appendectomy, arthroscopy of right knee 2 years ago, surgery of collateral cruciate ligament,
half a year ago noted pain in right costal margin, a quarter of year ago – palpable lump,
MRI, PET examinations and biopsy helped to establish diagnosis of Ewing sarcoma, port implantation,
therapy with protocol NACHT (EURO-E.W.I.N.G.), doses were reduced because aplastic anemia after 3rd cycle of chemotherapy,
clinically good response with reduced tumour mass was noted
Allergies: Pollen, dust, drugs well tolerated
Medications: NACHT - now after 4th cycle
Abuse: Patient does not use tobacco, alcohol, illicit drugs
Physical Examination
Vital Signs (Vitals): T: 38.6 °C; HR: 89; RR: 20; BP: 85/69; satO2 97 % on 2L O2
Height/ Weight: h 163 cm, m 68 kg.
General: Patient lying weakened in bed
Psychiatry: Alert and oriented to person, place, and time
Skin: No rash or lesions. Turgor reduced.
Head: NCAT.
Eyes: PERRL, EOMI. No scleral icterus.
ENT: No nasal d/c. MMM. Oropharynx clear with no lesions/erythema. Tonsils normotrophic. Tongue with geographical coating.
Neck: No masses. No thyromegaly. No bruits.
Lymph Nodes: No cervical, axillar or inguinal LAD.
Chest: Symmetric.
Lungs: Breath sounds are bilaterally alveolar, bibasilar decreased.
No wheezing or rhonchi appreciated. Good air movement.
Cardiovascular: Rhythm irregular. Heart sounds without murmur. Pulses 2+ equal on both sides.
Abdomen:
slightly over niveau, tympanitic (drum-like) sounds on percussion,
soft, slightly tender, distended. No masses. No rebound/guarding. No hepatosplenomegaly. Tapottement negative. Bowel sounds barely audible.
Rectal: Not performed.
Extremities: Capillary refill slower. Venous cannula in right forearm.
Musculo-skeletal: Joints flexible without erythema.
Neurological: Cranial nerves II-XII grossly intact. No decrease in strength.
Normal sensation throughout.
Laboratory tests
Hematologic tests:
- Blood count: WBC: ! 0.9 10^9/l, RBC: *3.48 10^12/l, Hb: *104.0 g/l, Hct: *0.289 1/1, MCV: 83.0 fl, MCH: 29.9 pg, MCHC: 0.360 g/ml, RDW: *15.9 %, PLT: !! 19.0 10^9/l, Pct: *0.021 %, MPV: * 11.5 fl, PDW: 16.4 %
Leucocyte differential: Se: 0.49, Band: 0.28, Lymf: 0.09, Mono: 0.10, Eo: 0.00, Mmy: 0.01, Myelo: 0.03, PolyN: 13.00 /100 BazoN: 3.00 /100
Microscopically: Ne-seg: 0.72 1/1 Ne-band: 0.18 1/1 Ly: 0.06 1/1 Mo: 0.04 1/1 - Hemocoagulation: Qt s: *16.3 s, Qt-R: *1.23 1/1, INR: 1.32 1/1, QtN: 13.2 s, aptt-p: *45.8 s, aptt-R: *1.39 1/1, aptt-n: 33.0 s TT: *9.5 s, ET test: positive, D-Di: highly positive, >2000 ng DD/ml, AT III: *62 %
- Blood group: A1 Rh+
Biochemical tests:
- Urine chem.: U-pH: 6.0 U-SG: * 1.034 kg/l U-Glu: * 3 arb.j. U-Keto: 0 arb.j. U-Prot: * 1 arb.j. U-Bil: 0 arb.j. U-Uro: 0 arb.j. U-Krev: * 1 arb.j. U-Nit: 0 arb.j. U-Ask: 0 arb.j. U-Ery: 5 /ul U-Leu: 11 /ul U-EpDl: 8 /ul U-Kvas: * 1 arb.j. U-Na: * <10 mmol/l determined 2x U-K: * 19 mmol/l U-Cl: * 29 mmol/l; U-AMS: 4.3 ukat/l
- Plasma and serum chemistry: Glucose: *16.8 mmol/l, Na: *127 mmol/l, K: 4.56 mmol/l, Cl: *95 mmol/l, Ca: 2.11 mmol/l, P: 0.82 mmol/l, Mg: *1.19 mmol/l, Urea: 7.25 mmol/l, Crea: 84 umol/l, Bil: 9 umol/l, AST: *0.57 ukat/l, ALT: 0.39 ukat/l, ALP: 0.89 ukat/l, GMT: 0.34 ukat/l, AMS: 0.70 ukat/l, CB: *56.0 g/l, Alb: *27.0 g/l, PreA: not detected g/l, LDLC: 2.40 mmol/l, TAG: *5.40 mmol/l CRP: ! 414.4 mg/l PCT: >10 ng/ml
- Astrup: pH: *7.344 pCO2: 5.85 kPa pO2: !4.5 kPa BE: -1.2 mmol/l AKTB: 24.1 mmol/l SO2: *0.609
Microbiological examination:
- Urine culture: - urinated urine mid-stream sample: aerobe culture non-selective - primary culture sterile, further cultivation Staphylococcus epidermidis, selective culture for yeasts and moulds negative
- Blood culture BACTEC: from venipuncture: AE blood culture bottle BD BACTEC PLUS+Aerobic/F / negative, BACTEC / ANA blood culture bottle BD BACTEC Lytic 10 Anaerobic /F /:
primary culture Escherichia coli
antibiogram: antibacterial activity (disc diffuse method): C - sensitive, R - resistant, I - intermediate: amoxicillin/clav. R, amikacin C, ampicillin R, aztreonam C, cefepim C, ciprofloxacin R, cephalotin R, chloramphenicol C, colistin C, trimetoprim/Sulf. R, cefotaxime C, ceftazidime C, cefuroxime C, cefoxitin C, gentamicin C, imipenem C, ofloxacin R, pefloxacin R, cefoperazon/sulbac. C, tetracycline C, ticarc./clavul. I, piperac./tazobac. C, ampicillin/sulbac. R
MIC not yet available. - Stool - rectal swab, smear culture for enteropathogens: Escherichia coli, Citrobacter sp.
- Stool - sample for Clostridioides difficile antigen and toxin detection:: antigen: positive, toxin A+B (Imunochrom.): positive, toxin A+B (ELFA): positive
- Nose swab culture: Staphylococcus epidermidis sparsely
- Tonsils swab culture: primary culture, further culture Enterobacter cloacae
- Syphilis serology: RPR test negative; TPPA test: negative
Imaging and other paraclinical examinations
Imaging:
- Chest XR: Central venous line is inserted deeply into right atrium via right jugular vein, no leakage, no pneumothorax. Intravenous port is implanted subcutaneously on the right side. Suspicion of right-sided fluidothorax - opacification of the right lower lung zone, leak effusion to the interlobium
- Native X-ray of the abdomen: Bowel loops dilated: small intestine to 40-45 mm, wall infiltration of colon ascendens, of width up to 90 mm, other parts of the colon are of width 60 mm. Multiple air-fluid levels.
- Abdominal U/S: Marked inflammatory changes in the whole colon - colitis, the wall is thickened to 10 mm, lumen dilated to 45 mm. Free fluid nearby the liver of width 10 mm, also in the lesser pelvis and between intestinal loops.
- Abdominal CT scan: Describe yourself.
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Fig 1 Topogram |
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Fig 2 Native X-ray of the abdomen |
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Fig 3 Abdominal CT scan |
Other Paraclinical and Consultation Examinations
Electrophysiologic examinations:
- ECG: sinus tachycardia 155/min, PR 0,11, QRS 0,08, QT 0,30, semihorizontal axis, flatter T in leads II, III, aVF, V5-6
Endoscopic examinations:
- Colonoscopy: You will find conclusion a little later.
Diagnostic Conclusion
Make a diagnosis yourself.
Treatment
Select correct antimicrobial drugs.
Questions
- What is the intestinal complication?
- How can you treat this disease after cessation of intestinal passage?