October 2023 Critical Care Case of the Month: Multi-Drug Resistant K. pneumoniae

Robert A. Raschke MD

University of Arizona College of Medicine-Phoenix

Phoenix, AZ USA

History of Present Illness:

A 75-year-old man presented from a skilled nursing facility with altered mental status and hypotension. He had a seven-year-long history of steroid-dependent myasthenia gravis, but had previously declined Covid vaccination, and subsequently experienced a severe case of COVID-19 pneumonia five months prior to admission. This resulted in chronic respiratory failure and renal failure for which he subsequently underwent tracheostomy, tunneled subclavian vein dialysis catheter placement and percutaneous endoscopic gastrostomy (PEG). He had resided in a skilled nursing facility since then, requiring four subsequent hospital readmissions for complications. These sequentially included septic shock due to a catheter associated blood stream infection, an intra-abdominal abscess due to PEG migration into the peritoneum resulting in fungal blood stream infection, recurrent intra-abdominal infection with multiple organisms, and bacterial pneumonia. Treatment of these infectious complications included replacement of the tunneled dialysis catheter and exploratory laparotomy with debridement of multiple abscesses. The abdominal wound was left open to heal by secondary intention. The patient received multiple courses of broad-spectrum antibiotics over the preceding four months including (at various times) ampicillin/sulbactam, anidulafungin, piperacillin/tazobactam, cefepime, colistin, meropenem, micafungin, TMP/SMZ, and tobramycin. During his most recent admission three weeks previously, the patient experienced rectal hemorrhage due to ulceration caused by a rectal tube, and a sacral decubitus pressure ulcer was discovered.

Late on the day of admission, staff at the skilled nursing facility where the patient resided noted altered mental status and a BP of 55/38, but reported no other new symptoms. They administered 2L of normal saline, cefepime and vancomycin, and transferred the patient for admission to our ICU at l am. The patient was non-verbal due to delirium and ventilator dependence and could offer no further history. His full code status was described by skilled nursing staff as “adamantly full code.”

Physical examination:

• Vital Signs: Temperature: 96.5 F. Heart rate 114 bpm. Respiratory rate 19 bpm. Blood pressure BP 74/36 mmHg (on norepinephrine 50 mcg/min infusion). SpO2 100% (on 30% FiO2).
• The patient was chronically critically-ill appearing and severely deconditioned.
• An 8.0 cuffed tracheostomy, a PEG and a tunneled right subclavian hemodialysis catheter were present– none of which appeared obviously infected.
• HEENT was otherwise unremarkable (ophthalmological examination was not performed).
• The lungs were clear.
• Cardiac exam was tachycardic and hyperdynamic.
• The abdomen had a large midline wound lined with pink, non-odorous granulation tissue. The abdomen was otherwise soft and nontender.
• A 6X6cm sacral pressure wound extended into subcutaneous tissues and was not obviously infected.
• Stools removed from a rectal tube were maroon and heme positive.
• No skin lesions were noted.

Laboratory results:

• CBC: WBCC 24.4 x 10⁹/L, Hb 8.3 g/dL, platelets 193 x 10⁹/L
• Electrolytes: Na 142 mmol/L, K 3.7 mEq/L mEq/L, Cl 109, bicarb 11 mEq/L,
• Renal function: BUN 94 mg/dL, creatinine 3.5 mg/dL
• Liver Enzymes: AST 1790 U/L, ALT 1111 U/L, Alkaline phosphatase 270 IU/L, albumin 1.8 mg/dL, t-bilirubin 0.7 mg/dL
• Lactate 6.4 mmol/L
• Procalcitonin 12.7 ng/mL
• Random cortisol level was 8.2 mcg/dL.

A chest radiogram is depicted below (Figure 1).

Figure 1. Admission portable chest x-ray.

A presumptive diagnosis of septic shock and adrenal insufficiency were made, and piperacillin/ tazobactam, vancomycin and hydrocortisone were administered intravenously. The patient received an additional 3.5L of normal saline over the following 8 hours; but nevertheless, required increasing doses of intravenous norepinephrine, phenylephrine, vasopressin and epinephrine infusions to maintain MAP >60 mmHg. It is now morning.

Which of the following actions are most important to be immediately undertaken? (Click on the correct answer to be directed to the second of 4 pages)

1. The tunneled dialysis catheter should be removed.
2. Computerized tomography of the chest, abdomen and pelvis should be obtained.
3. Prior microbiology results and local antibiograms should be reviewed.
4. Antibiotic coverage should be broadened.
5. Point of Care echocardiography should be performed.

Cite as: Raschke RA. October 2023 Critical Care Case of the Month: Multi-Drug Resistant K. pneumoniae. 2023;27(4):40-44. doi: https://doi.org/10.13175/swjpccs040-23 PDF

December 2014 Critical Care Case of the Month: Weak for Weeks

Bhupinder Natt MD¹

Shadi Koleilat MD²

Janet Campion MD¹

¹Division of Pulmonary, Allergy, Critical care and Sleep Medicine

²Department of Neurology

University of Arizona Medical Center

Tucson, AZ

History of Present Illness

A 65 year old woman presents with weakness involving both upper and lower extremities that is intermittent over the last 3 months, but in the last 2 weeks she has also noticed increasing neck weakness, droopy eyelids and increased drooling. Prior to this she was able to walk without difficulty and ride a recumbent bike for 20 minutes, but now is having difficulty walking on her own. She denies fevers, weight loss, shortness of breath, chest pain, palpitations, LE edema, joint pain, rash, any recent or current GI/GU symptoms and no new medications.

Past Medical History, Social History, and Family History

The patient has a past history of hypertension, hyperlipidemia, diabetes mellitus Type II, GERD, obstructive sleep apnea (compliant with BiPAP), atrial fibrillation and hypothyroidism. She has a 40 pack-year history of tobacco use. Family history is noncontributory.

Medications

• Dabigatran 75mg BID
• Esomeprazole 20 mg BID
• Furosemide 30 mg BID
• Insulin glargine 50 Units BID and Lispro per sliding scale
• Levothyroxine 88 mcg per day
• Losartan 50 mg QD,
• Pregabalin 75 mg BID
• Rosuvastatin 40 mg per day

Physical Examination

Vital signs: Afebrile. Pulse 86, respiratory rate 20, PaO2 92% on room air

General: Awake, fully oriented, dysarthric speech.

HEENT: Non-icteric, ears, nares, oropharynx unremarkable; there is no neck LAD, elevated JVP or thyromegaly.

Respiratory: Normal breath sounds, no wheeze or rhonchi.

CVS: Irregularly irregular rhythm, no murmurs. Peripheral vascular exam normal.

Abdomen: Obese, soft, non-tender with normal bowel sounds. No organomegaly appreciable.

Extremities: Trace pedal edema, normal muscle bulk and tone.

CN: Ptosis bilaterally, no nystagmus, reactive pupils, extra-ocular muscles intact, sensation intact, weak cheek puff, symmetric palate excursion, normal tongue protrusion.

Motor: Neck flexion and extension 4-/5, bilateral pronator drift, no focal lower extremity weakness, no muscle atrophy, no tremors or fasciculations.

Sensation: Intact to light touch hands and feet.

Reflexes: 2+ and symmetric throughout.

Gait: Wide-based and slow, can only walk short distances before experiencing bilateral leg weakness.

Laboratory: Normal electrolytes, complete blood count, and liver function tests. Creatinine mildly elevated at 2.1 mg/dL.

EKG

Atrial Fibrillation.

What is the most likely diagnosis? (Click on the correct answer to proceed to the next panel)

1. Guillain-Barré syndrome (GBS)
2. Hypothyroidism
3. Lambert-Eaton myasthenic  syndrome (LEMS)
4. Motor neuron disease (ALS)
5. Myasthenia gravis crisis

Reference as: Natt B, Koleilat S, Campion J. December 2014 critical care case of the month: weak for weeks. Southwest J Pulm Crit Care. 2014;9(6):302-8. doi: http://dx.doi.org/10.13175/swjpcc141-14 PDF