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Clinical Case Presentation January 2024

Chee Sing Hui

Supervisor: Dr Alan Ch’ng Swee Hock

Current Posting: Hospital Seberang Jaya


Case Scenario

Mr T 78 years old gentleman

Underlying

1. Diabetes Mellitus

2.Hypertension

3. Dyslipidemia

4. History of right neck of femur frature, post right short PFN in 2018


Under KK Butterworth follow up


Previous medications

T. Atenolol 50mg OD

T. Gliclazide MR 60mg OD

T. Mecobalamin 500mcg OD

T. Perindopril 2mg OD

T. Metformin 1g BD

T. Simvastatin 40mg ON


Premorbid

  • Well, ambulating without aid, no history of fall after 2018

  • bADLand iADLindependent. Able to drive car around, able to watch TV

  • No cognitive issue, no depressed mood, no incontinence.

  • Has hearing impairment

  • Bilateral knee OA


Past admission

  • Admitted to Private hospital for 3 weeks before admitted here in Hospital Seberang Jaya

  • Treated there for Klebsiella pneumonia bacteremia

  • Done USG abdomen, Chest and spine x-ray, which showed multiple osteophyte over spines

  • Was discharged with

  • Upon discharge he lost his ability to walk, appetite was poor, back pain, enervated and debilitated requiring full support from his wife


Presenting illness

After 2 weeks at home, he started to have

  • Shortness of breath

  • Productive cough

  • Altered


Presented to ED HSJ on 25/10/23

  • BP 101/54, PR 84, Spo2 93% under room air, Temp 36.9c, Reflo(DXT) 5.1

  • Alert, responsive, but appeared lethargic, delirious

  • Lungs bilateral lower zones crepitation

  • CVS no murmur

  • Per abdomen soft, non tender no mass felt

  • Power Upper limbs: 4/5, lower limbs 3/5


Chest x-ray



Blood ix

TWC 78

Hb 10.4

Plt189

ABG under room air: pH , pO2 64.6, Lac 2.5, HCO3 25.9

CRP 196

Urea 8.6, Na 122, K 4.5, Create 123


Blood ix

Blood C&S on 26/10:

Klebsiella pneumonia

  • Sensitive: Amikacin, Augmentin, Unasyn, Ceftriaxone, Cefuroxime, Gentamicin

  • Resistance: Ampicillin


Diagnosis

  1. HAP with Klebsiella pneumonia bacteremia-Partially treated

  2. AKI and transaminitis(resolving)

  3. Hypoactive delirium

  4. NCNC anemia



Treatment

  • Patient was given IV Unasyn 3g TDS

  • Npo2 3L/min

  • For USG abdto look for collection

  • ECHO to look for vegetation

  • R9J8MH6t3BYCPXMFLa35R7aUJV9i4siPhX



Blood ix



Blood culture

  • Ultrasound was quickly done on 26/10/23 which showed no collection,

  • Seen by ophthalmology team on 30/10: No evidence of endophthalmitis,

  • ECHO was done on 1/11/23 which showed no vegetation.


So...

After 1 week of IV Unasyn

Patient still lethargic, not orientated to place. 4AT score 7. Body generalised swelling.

Patient remained afebrile

He managed to wean off oxygen

Inflammatory markers decreasing



Are you happy with the current treatment?

Most of the non-ESBL Klebsiella Pneumonia bacteremia would’ve been discharged after completed 1 week of antibiotics


Blood culture

Repeated blood culture on 4/11/2023:

Klebsiella pneumonia

  • Sensitive: Augmentin, Unasyn, Ceftriaxone, Tazocin, Cefoperazone, Cefepime, Gentamicin

  • Intermediate: Unasyn

  • Resistance: Ampicillin, cefuroxime, Co-trimoxazole



IDR on 1/11/2023

Input from physiotherapist: Patient showing bilateral hamstring tightness, more stiff over left lower limb, can sit but lower back pain limiting his posture, can sustain less than 5 mins only. The pain was radiating from back to leg

  • X-ray spine showed multiple osteophytes from L1-5

  • Modified Barthel Index: 54

Plan

  • Restart T.Pregabalin75mg BD

  • Add Ketoprofen patch 1/1 OD over lower back

  • Encourage bed mobility, sitting up and prop up patient


IDR on 1/11/2023


During the IDR, we suspected spinal pathology





CT Abdomen Pelvis was done on 9/11/2023

  1. L3/L4 infective spondylodiscitis associated with anterior paraverterbral collection, multiple multioloculated, multiseptated intramuscular collections are seen involving left psoas (5.2x3.2x13.3) and right psoas (5.2x2.6x13.6), right iliacus (4.6x5.2cm) muscles extending to right iliopsoas muscle at the upper thigh and right pectineus muscle (1.8x4.4cm) and right posterior subphrenic loculated collections (2.9x4x4.3cm)

  2. Cholelithiasis

  3. Bilateral pleural effusion


MRI lumbosacral spine (11/11/23)

  1. Spondylodiscitis involving L3/L4 and L4/L5 levels with evidence of extension to epidural region, extensive multiloculated abscessessinvolving pre-and paravertebral muscles, as well as bilateral psoas, iliopsoas and illacus muscles.

  2. L5/S1 disc bulge causes moderate bilateral subarticular recess narrowing, mild bilateral neuroforaminal narrowing and spinal canal stenosis


MRI Lumbosacral spine





Diagnosis

  1. Invasive klebsiella pneumonia

  2. Hypoactive delirium, deconditioning

  3. NCNC anemia


Treatment

  • Drainages were inserted bilaterally into the psoas muscles

  • IV Unasyn for 4-6 weeks

  • Repeat CT TAP later to look for resolution of abscesses

  • Spine –Conservative treatment

  • Rehabilitation

  • Nutrition

  • Bedsore prevention


Discussion

  1. How is this Klebsiella Pneumonia different from typical Klebsiella pneumonia infection.

  2. Is delirium expected in this patient?

  3. This case is typically an atypical presentation of illness in Geriatric patients we see everyday. What are the risk factors of atypical presentation in this case?




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