Watery diarrhoea cryptosporidium

Peter is a 47 y.o man who presents with a 4 week history of watery diarrhoea on a b/g of renal transplantation for PCKD.

HOPC:
4 weeks ago, Mr P developed a sudden episode of watery diarrhoea that has not resolved over. He has 4 diarrhoeas 8-12 times a day. No blood, mucous seen in the stool. Volume of the fecal material is high. His normal bowel motion is 1/day. He also developed fevers, chills and rigors &abdominal cramps during day 1 and 2 but has not have any of this symptoms since then.

Other relevant negatives (considering he is immunocompromised)

• No LOW, night sweats, lack of appetite.
• No cough, sputum, SOB.
• No chest pain, palpitations.
• No symptoms of UTI but has noticed a low volume of urine output (10-15mL). Claims to be dehydrated.
• No fainting, dizziness, blackouts.
• No Neurological signs.

He presented to the GP on day 2 and was subsequently admitted to hospital last week and treated.

• I- flu vaccination is up to date
• Contact - works with children (prone to norovirus, adenovirus, rotovirus diarrhoea). Last worked? No other sick contacts.
• Travel - No travel. Any dubious food? Any stream water or tank water?
• O - irrelevant
• A- lives with a cat
• D- imunnosuppressive drugs + cardiac drugs.
• Sex - never ask.

Med Hx.

1. PCKD diagnosed during the 80's. Currently on 3rd transplant. First transplant lasted 4 days. His last transplant was in 94'. On immunosupressive drugs for it. Has 1 URT infection/ 2mths. and also occasional diarrhoea. Attributed to him working with children. Hospital admissions for complications?
2. Cardiac disease with triple bypass done? any symptoms? PND, orthopnea, pillows used, exercise tol?

Medication?

Family history?

Social history?

• Live with? Family, children?
• DALYs?
• Support?
• Finanacially stable?
• depressed?
• Smokes, drink?
• exercise
• diet

Osteomyelitis

Most common bug is SA treat with flucoxicllin.
Randomly, in radical prostectomy, most commonly by pseudomonas (10-20% ciprofluxacillin resistant).

Septic arthritis

Septic arthritis - acutely inflammed joint and may destroy within 24hrs. Treat empirically with antibiotics.

Signs/symptoms

• Swollen, red joint
• associated fevers, chills and rigors, consider localised symptoms.

DDX - OA, gout, haemarthrosis, less likely psoriatic arthritis, reactive arthritis.

Ix-

1. Imaging - x-rays may be normal, consider CT, U/S, MRI.
2. FBE, ESR, CRP - raised WCC, inflammation.
3. U&E and LFT for baseline.
4. Joint aspiriate - appearance: turbid,yellow, low viscosity, microscopy: raised WCC, neutrophils. Culture& sensitivty: for the organism + sensitivity. also for polarized light microscopy: crystals (negatively bifringement crystals for gout)

Mx-

1. Analgesia
2. Empirical antibiotics until culture is known. Flucloxacillin (as most common organism is SA. consider benzylpenicillin + gentamicin)
3. Consult microbiologist
4. Consider joint wash-out especially in prosthetic knee.
5. Seek/ treat underlying cause - immunosupression? focus of infection?

Other medication to consider

1. MSSA - 1st/2nd gen cephalosporin - cephazolin/cephalexin.
2. Gp D streptococci - (like GP A but affects immunocompromised patients). Ideal medication would be penicillin as you would prefer a narrow spectrum medication to avoid antibiotic resistance (unnecessay killing of gram negative) but ceftriazone for convinience - as it is once a day dose and lower risk of PICC line occlusion.
3. infected prosthetics - combination therapy with flucoxicillin + ciprofluoxacin or rifampicin. better chance of killing organism due to presence of biofilm. options: surgery to remove joint then IV antibiotics until aseptic then joint replacement takes 9 months or lifelong prophalaxis.
4. ???Culture negative - cipro, rifampicin(treat myco), fusedic acid.

PUO: investigations

PUO is defined as a temperature of >38.3 degrees for more than 3 weeks.

DDX think broadly from top to down.

1. Infection - abscesses
2. CTD/autoimmune
3. Malignancy
4. Drugs
5. Others; hypothalamic lesion, factitious fevers.

Ix:

1. FBC - raised WCC
2. U&E - ARF, pyelonephritis, baseline for antibiotic treatment
3. LFT - liver damage especially abscess
4. Haemolytic anemia - anemia, raised weiyong is smelly bilurubin, raised urobilinogen, raised LDH, reticulocytosis, direct antiglobulin test. Considering drug reaction?
5. Myeloma screen - serum plasma electrophoresis (paraprotein & monoclonal band), urine plasma electrophoresis (Bence Jones protein). beta2 microglobulin, Ig G, M, A levels
   
6. autoimmune - Rf, ANA, dsDNA, ENA, complement activity (C3, C4), ESR, CRP, GBM, ANCA(C & P), liver/kidney microsomal antibodies.
7. peripheral blood flow cytology
8. copper, ceruloplasmin.
9. ACE
10. septic workup. consider TB.
    
11. viral serology - HIV, HAV, Hbs Ag, HCV, others:flavivirs, mycoplasma, CMV, EBV, Q fever. CD4.
12. Imaging: CT brain, body, sinuses.
    

Febrile neutropenia

Definition: neutrophil count less than 0.5x 10^9/L or >38 degrees fever associated with neutrophils less than 1x 10^9/L with predicted to further drop.

DDX:

1. Drugs- post chemo(typically 10-14 days after chemotherapy), cytotoxic agents, carbimazole,sulfonamides.
2. Infection- viral or severe sepsis
3. Autoimmine- neutrophil antibodies (SLE, haemolytic anemia.)
4. hypersplenism - leukemias, felty's syndrome
5. bone marrow failure - Myeloproliferative, mylelofibrosis, malignant infiltration(myeloma), aplastic anemia, leukemia, infection(TB), drugs.
   

Examination: Paying attention to respiratory, abdominal (neutropenia colitis [typhlitits]), cardiac, pelvic(urinary). Look at mouth for mucositis and skin for rashes.

Treatment:

1. Initiated even if patient is afebrile but appears toxic. Assume septicemia.
2. Choice depends on local susceptibility. Cover for pseudomonas due to high morbidity and mortality.
3. Treat with broad spectrum Antibiotics - ceftazidime/cefepine( 4th generation - good pseudomonas cover + gram -ve), + timentin(ticarcillin+calvulanate acid)[ for gram +ve plus pseudomonas cover]. Austin protocol is ceftapine + gentamycin for more sick people and ceftriaxone + stat gentamycin for not so sick people. Note this this does not provide cover for staph aures, enterococci, TB, PCP, anaerobes.
4. Consider vancomycin for hospital acquired MRSA (rising due to increase presence of venous lines), serious shock, intravascular devices(PICC LINES ESPICALLY IN ONCOLOGY PATIENTS). This could result in the death of gut commensals and overpopulation of gut VRE which could lead to sepsis.
5. Treat routinely with anti-fungals(nilstat drop) and mouth washes to control ulcers and fungal mouth infections. Anti-virals if reactivation of VZV or HSV.
6. Consider barrier nursing and postive pressure room.
7. septic work up - blood (3 sets), sputum, urine, stool cultures. Swab also from any peripheral or central line. CXR
8. FBC, U&E, LFT, ABG ( decide if person is in hypoxic drive or not)
9. Continue until afebrile or neutrophil count recovers.
10. Failure to respond after 96 hrs consider fungal infections - candida or aspergillosus.(tx- amphotericin B or fluconazole)
11. Consider PCP, TB.
12. Granolocyte CSF- seek expert advice.
13. Education- food prep, hand washing, trauma to skin, oral hygiene, no live vaccines. If temp > 38 degrees go to ED.

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Always be aware of shock. Circulatory failure resulting in inadequete organ pefusion. bp <90.>

1. Call for arrest team
2. ABC ( high flow oxygen, consider bagging)
3. Initial work up - sats, glucose level, ECG, CXR, U&E (ARF?), LFT, FBE, CRP, ESR.
4. Septic workup and commence antibiotics (above) if suspected septic shock.
5. Need to correct for hypotension to maintain adequete organ perfusion.
6. IV access with 2 large bore for cystalloid infusion.
7. Consider inotropes(dobutamine) or vasopressors (dopamine, noreadrenalin) via central venous line to maintain a bp of >90mmHg, CVP 8-12mmHg, MAP>65.
8. Achieve a urine output of >0.5mL/kg/hr.