Case No 1
53-years old female morbidly obese patient with transversal spinal cord lesion and after amputation of both lower extremities was sent to the hospital for fever with infected decubitus in gluteal region
Medical History
Present Illness: Huge pelvic decubital ulcer troubled her for a very long time, it is treated by her friend. About a week ago worsened her local finding on the left hip. Second day is febrile, maximally 38.3 °C, pain not recorded, yesterday once vomited, other problems are denied. Today examined by GP, his record describes an extensive necrotic infected focus on the decubitus edge. That is why the patient was sent to traumatologic out-patient clinic. Blood sample was taken for blood count and basic biochemical tests. Lab test revealed leukocytosis with raised neutrophil count and highly elevated CRP. On agreement with the duty doctor she was sent to the ID Dept at the Bulovka Hospital.
FHx: Not relevant to the present status.
EHx: Denies contact with infection.
W/SHx: disability pension, disability pension, her financial situation is tight, not self-sufficient,
she is completely dependent on care of her friend.
PMHx: common child diseases, arterial hypertension on therapy,
chronic CAD, s/p NSTEMI front and lower wall, diabetes mellitus II type on PAD, probably badly controlled, mild dyslipidemia on therapy,
morbid obesity, metabolic syndrome, COPD (chronic obstructive pulmonary disease), serious polyneuropathy combined etiology,
s/p viral hepatitis A, chronic VHB and VHC by parere
PSHx: polytrauma 10 years ago, spinal cord injury with paraplegia,
above-knee amputation of LLE, later after a fall from inavlid wheelchair she underwent below-knee amputation of RLE
because fractures of the distal femur and lower leg were complicated by gangrene and phlebothrombosis,
other complications: huge inoperable abdominal hernia, mixed post-traumatic incontinence, s/p appendectomy
GHx: Postmenopause
Allergies: pollen, NKDA
Medications: Baclofen 25 mg 1-0-1 tbl po, Berodual N inh as necessary, Cymbalta 60 mg 0-0-1 tbl po, Euphyllin CRN 300 1-1-1 tbl po,
Helicid 20 mg 1-0-0 cps po, Kalium chloratum 500 mg 1-0-0 tbl po, Lyrica 150 mg 2-0-2 tbl po, Moduretic 1-0-0 tbl po, Motilium 1-0-1 tbl po, Pentomer Retard 400 mg 1-0-1 tbl po,
Siofor 1000 mg 1-1-1 tbl po, Amaryl 3 mg 1-0-0 tbl po, Rilmenidin 1-0-0 tbl po, Telmisartan 80 mg 1-0-0 tbl po, Vasocardin 100 mg 1-0-1 tbl po, Warfarin 3 mg 1-0-0 tbl po,
Doreta in pain as necessary (obtained from med list that patient brought in)
Abuse: The patient started smoking when she was 16 years and now smokes roughly 10 cigarettes daily, alcohol intake occasionally, she rejects illicit drugs.
Physical Examination
VS: T 36,3 °C, HR 87/min., BP 117/73, RR 14/min., SpO2 NA.
General: Morbidly obese woman lying in bed.
Psychiatry: Alert and oriented to person, place, and time, co-operating, psychomotor speed reduced.
Skin: Skin without icterus, cyanosis, exanthem, normal turgor.
extensive pressure ulcer IIIrd-IVth stage localized on dorsal side of amputation stump.
Defect of extensive range affecting also ilium.
In gluteal region there is necrotic skin, no fluctuation. Intensive odour.
Head: NAD.
Eyes: PERRL, EOMI.
ENT: Nares without any discharge. Mucous membranes moist. Oropharynx without erythema or exudate.
Tongue a little drier, with whitish coating.
Neck: Jugular vein filling not increased. Neck is supple, no masses, no thyroid enlargement.
Lymph Nodes: Not palpable.
Cardiovascular: RRR. Heart sounds, S1 and S2 normal, no m/g/r. Pulses 2+ equal on both sides.
Lungs: Breathing alveolar with numerous moist rales/crackles bilaterally. Good air movement.
Abdomen: Obese, scar after laparatomy, extreme abdominal hernia. Abdomen soft, difficult to palpate due to obesity.
No rebound or guarding. Normoactive bowel sounds.
Rectal: Deferred.
Extremeties, MSK: LLE: above-knee amputation, RLE: below-knee amputation.
Neurological: Cranial nerves intact, motor skills of upper extremities are normal,
paraplegia, DTR cannot be investigated because s/p amputation, complete loss of sensitivity of the lower body.
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Fig 1 S/p high femoral amputation of LLE, s/p operation of extensive pressure ulcer localized on dorsal side of amputation stub, after reamputation and necrectomia, defect of extensive range affecting also ilium |
Laboratory Tests
Hematologic examination:
- Blood count: WBC:! 27.0 10^9/l RBC: 4.61 10^12/l Hb:*100.0 g/l Hct:*0.323 1/1 MCV:*70.1 fl MCH:!21.7 pg MCHC:*0.310 kg/l RDW:*20.6% PLT: 319.0 10^9/l
Leukocyte differential (microscopically): Se: 0.79 1/1 Band: 0.13 1/1 Ly: 0.03 1/1 Mo: 0.05 1/1 rougher granulation of neutrophiles, - Hemocoagulation: PT-time: 15.9 s PT-R:*1.21 1/1 INR:1.29 1/1 PT-N: 13.1 s aptt-p: 39.5 s aptt-R: 1.15 1/1 aptt-n: 34.3 s
Biochemical tests:
- Urine chem.: cannot be collected
- Bioch. of plasma and serum: Gluc: *2.3 mmol/l, Na: 134 mmol/l, K: 4.70 mmol/l, Cl: 100 mmol/l, Urea:*8.10 mmol/l, Cr: 76 umol/l, Bil: 10 umol/l, AST: 0.33 ukat/l, ALT: 0.21 ukat/l, ALP: *2.39 ukat/l, GGT: *1.10 ukat/l, CRP: ! 303.9 mg/l
Microbiologic examination:
- Bioptic material
Microscopy: sparse leukocytes, erythrocytes, fibrin, without microbes
Aerobic culture non-selective: primary culture- [1] Proteus mirabilis ++
- [2] Acinetobacter baumannii ++
- [3] Enterococcus faecium +
- [4] Staphylococcus epidermidis +
- [5] Candida albicans +
Selective culture: fungal positive, MRSA negative
Antibiogram - antibacterial activity (disc diffuse method): C - sensitive, R - resistant, I - intermediate
| Antibiotic | [1] | [2] | [3] | [4] | [5] |
| oxacillin | R | ||||
| ampicillin | C | R | R | ||
| amoxicillin/clavulanic acid | C | R | R | ||
| ampicillin /sulbactam | C | R | |||
| piperacillin /tazobactam | C | R | |||
| cephalotin | C | R | R | ||
| cefuroxime | C | R | |||
| cefotaxime | C | R | |||
| ceftazidime | C | R | |||
| cefepime | C | R | |||
| cefoperazone /sulbactam | C | R | |||
| imipenem | C | R | |||
| meropenem | C | R | |||
| co-trimoxazole | C | R | R | ||
| tetracycline | R | R | C | ||
| tigecycline | R | C | C | ||
| erythromycin | R | R | |||
| clindamycin | R | ||||
| vancomycin | C | ||||
| teicoplanin | C | C | |||
| gentamicin | C | R | R | ||
| amikacin | C | R | R | ||
| ciprofloxacin | C | R | R | ||
| chloramphenicol | C | R | R | ||
| colistin | R | C | |||
| linezolid | C | ||||
| mupirocin | C | ||||
| rifampicin | C | ||||
| fluconazole | C | ||||
| itraconazole | C | ||||
| amphotericin B | C | ||||
| nystatin | C | ||||
| pimafucin | C |
- Tracheal aspirate - screening in intensive care
Microscopy: leukocytes ++, epithelia +, mucin, Gram negative cocci ++
Aerobe culture non-selective: primo-culture: Acinetobacter baumannii +++, Candida albicans +
Selective culture: fungal positive, MRSA negative
Antibiogram: see [2] and [5].
Imaging and Other Paraclinical Examinations
Imaging studies:
- Chest XR: Cardiac silhouette and mediastinal contours are normal. Inflammatory infiltrate in the upper and partially middle lung field on the right. The visualized osseous structures and soft tissues are grossly unchanged. Central venous line via v. subclavia, end of catheter is projected to the confluence of brachiocephalic veins, without paravasation, no pneumothorax.
- CT scan of the abdomen and pelvis: Ionnic contrast administered i.v.: Iomeron 400 120 ml iv and orally diluted, without reaction: Limitations of the examination: a patient obese with a huge abdominal hernia, the left lateral part of the abdominal cavity out of the gantry. Discrete bilateral fluidothorax with adjacent compressive atelectasis. Pericardial effusion. Diffuse, possible tumorous infiltration of urine bladder wall, eventual neoplasmatic changes of vagina are not certainly differentiable. A suspect fistula is visible dorsally on the left side in the subcutaneous tissue, an end is visible in the iliac bone, where is apparent cortical defect with soft tissue infiltration (17 × 14 mm), medially leads to the sacroiliac joint without cortical defect and without propagation bone. In the level of the fistula, there is solid spherical formation (20 × 15 mm), probably enlarged lymph node. Marked emphysema in the soft tissues of the left thighs. Cholecystolithiasis (solitary concrementum of size 16 mm). Hepatosplenomegaly (KK 22 mm), hepatic parenchyma homogenous without focal changes of slightly reduced density, Gallbladder and bile ducts not dilated. Splenomegaly (140 × 70 mm). Condition after breaking the upper cover plate L3 and after dorsal stabilization of vertebrae Th11-L2 Infiltation to free fluid in both hip joints.
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Fig 2 CT scan: Topogram |
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Fig 3 CT scan: axial view of the pelvis |
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Fig 4 CT scan of the abdomen and pelvis: coronal image |
Electrophysiologic examinations:
- ECG: sinus rhythm 74/min., 1 SVES, PQ 120 ms, QRS 107 ms, ST iso, T posit.
Consultations:
- Surgical consultation:
The patient with suspicion of neoplasma growing out of urinary bladder or genital organs.
The catheter cannot be set. Consultation of urologist is required.
Concerning of surgery of huge pressure ulcer in the area of the whole gluteus to sacrum, in dorsal and ventral
part of stub after amputation in femur.
Swollen vulva, not painful, however because sensory loss after transverse spinal cord lesion.
Morbid obesity, polymorbidity, diabetes mellitus. No active co-operation.
The ulcer is bordered and covered with eschar, no fluctuation, no discharge, no retention in subcutaneous layer.
Recommendation: At present not indicated for débridement. It should be waited until demarcation, whether it will be suitable for surgery, that will be done in the general anaesthesia (GA). Urologist's opinion is indispensable. Nephrostomy should be suitable solution for avoiding incontinence and and unability to indwelling of long-term urinary catheter. - Urologic consultation: According to patient's history data, the urinary catheter has been inserted in the past,
but despite a fully inflated balloon (40-50 ml) it fell out from the urinary bladder.
Last indwelling of the catheter is not known.
The last time she was followed-up at the outpatient clinic of the urology department a year ago, the Foley catheter has been replaced.
Physical examination: It is impossible to differentiate individual parts of the vulva. There is a voluminous reddish papillary mass at the site of the expected external urethral orifice. The structure is free for finger entry. Entrance to the vagina is localized normally.
Conclusion: Completely atypical finding, the changes in urethra cannot be excluded. Long-term urinary catheter was inserted with the balloon filled to volume 20 ml.
Recommendation: After improvement of the health condition, it is recommended to make biopsy and to check the urethral orifice. Epicystostomy (suprapubic cystostomy) cannot be placed in an empty urinary bladder. - Urologic consultation:
(later) S/p exarticulation in left hip joint.
Urine flows through something like cloaca and causes skin maceration.
The wound is without retention, remnants of necrotic skin on the edges, and necrosis of muscle in the bottom of the ulcer bed.
Surgical débridement and subsequent adaptation suture were performed,
then the VAC (Vacuum-Assisted Closure) system was put into operation.
A gauze bandage was applied to the wound and the VAC system was connected to continuous suction.
Recommendation: Further re-bandage after 4 days.
Diagnostic Conclusion
Describe all diagnoses what can be seen from patient history, physical examination and further examinations.
Therapy
Suggest the combination of antibiotics and their dosing according to sensitivity of isolates.
Task
- Decide diagnoses and propose antibiotic therapy. Nevertheless, you do not send your solution by e-mail.
- Actual development, diagnostic conclusions and therapy will be published next week.