MSGM Clinical Case Discussion October 2025
- Malaysian Society of Geriatric Medicine
- Oct 1
- 5 min read
Prepared by: Drs Rosdina Zamrud, Kejal Hasmukharay
Supervisor: PPUM
Title: Redefining norms in patient advocacy: Complex urosepsis case series
Case 1
Mr. PL is an 89-year-old gentleman who lives alone, is functionally independent with a Clinical Frailty Scale (CFS) score of 4. His medical history includes diabetes mellitus, hypertension, and dyslipidaemia. His old medications include; Metformin 850 mg once daily and Simvastatin 10 mg once daily; however, he was non-adherent and had been lost to follow-up.
He was admitted after a syncopal episode in the toilet. He reported squatting during a bowel movement and, upon attempting to stand, experienced sudden weakness in both legs, leaving him unable to rise. He remained seated for about two hours before trying to stand again. He also reported a six-month history of altered bowel habits, including intermittent loose stools and vomiting, especially when unable to pass stool.
Investigations revealed iron deficiency anaemia with an initial suspicion of gastrointestinal malignancy. His haemoglobin dropped from 7.2 g/dL to 6.3 g/dL pre-transfusion and improved to 8.0 g/dL post-transfusion. Red cell indices showed an MCV of 76 fL, MCH of 23.8 pg, and MCHC of 314 g/L. Serum iron was low at 1.7 µmol/L, with transferrin saturation at 5%. Abdominal X-ray showed a dilated bowel measuring 7.3 cm (Figure 1). Tumour markers revealed CA19-9 at 54 U/mL and CEA at 2.2 ng/mL. Faecal occult blood testing was positive. (Table 1)
A contrast-enhanced CT scan of the abdomen and pelvis on 12/6/25 showed an enlarged prostate measuring 4.5 x 5.6 x 4.3 cm (volume 56.3 mL) with multiple ill-defined hypodense lesions; the largest at the apex measured 1.0 x 1.0 x 0.9 cm (Figure 2). There was no significant lymphadenopathy or intestinal obstruction. Splenomegaly with possible infarcts was noted.
Figure 1: CT scan of the abdomen showed an enlarged prostate measuring 4.5 x 5.6 x 4.3 cm (volume 56.3 mL) with multiple ill-defined hypodense lesions; the largest at the apex measured 1.0 x 1.0 x 0.9 cm.
He underwent esophagogastroduodenoscopy (OGDS) on 13/6/25, revealing D1 duodenitis and a fundal polyp; two biopsies were taken. The rapid urease test was negative. Colonoscopy was limited by poor bowel preparation but reached the transverse colon with normal findings.
During admission, he was diagnosed with E. coli urosepsis complicated by a prostate abscess and possible splenic infarcts, suggesting septic emboli. Urine analysis was positive for nitrites, leukocytes (3+), and blood (3+), although the sample was likely from a catheter. His septic markers trend downward, and he remained clinically well. kidneys, ureters, and bladder (KUB) showed no stones. Blood cultures were negative. The infectious diseases team reviewed him, and intravenous Augmentin was restarted.
Discussion questions
1. What key factors should be considered when assessing syncope in elderly patients with multiple chronic illnesses?
2. Could his unusual presentation—including vague or absent urinary symptoms, syncope, and non-specific gastrointestinal complaints—indicate an atypical or blunted infectious response that is commonly observed in older adults?
3. How should iron deficiency anaemia and positive faecal occult blood be investigated in older adults, balancing diagnostic yield and patient tolerance?
4. In patients with E. coli urosepsis complicated by prostate abscess, should aggressive treatment continue if the patient is clinically well and septic markers are improving? What factors influence the decision between conservative and surgical management?
Case 2
Mdm M is a 76-year-old lady with a Clinical Frailty Scale (CFS) score of 4. She lives alone; her son resides in Australia, and her daughter lives in Kota Bharu. Her medical history includes diabetes mellitus, osteoporosis, non-alcoholic steatohepatitis (NASH), asthma, hypertension, and ischemic heart disease.
Her previous medications included Mixtard insulin 24/36 units and Metformin 1 gram twice daily. About one month prior to admission, during a visit to her son in Australia, she did not administer Mixtard regularly and was instead prescribed Metformin and Empagliflozin. Her most recent HbA1c was 7.6%.
She was admitted after a two-day history of fever. When her children could not reach her, a neighbour arranged for a locksmith to enter her home. She was found confused and soiled with urine and faeces on the floor.
On admission, she was clinically dry, weak and delirious with tender lower abdomen. Laboratory results showed blood glucose of 25 mmol/L, lactate rising from 2.5 to 2.85 mmol/L, and ketones at 0.6 mmol/L. Urine analysis showed leukocytes 3+ and negative nitrites. Creatinine was 141 µmol/L, urea 6.6 mmol/L, CRP elevated at 222 mg/L, platelets 202 x10^9/L, haemoglobin 12.2 g/dL, and INR 1.22. She was treated for urinary tract infection and uncontrolled diabetes complicated by lactic acidosis.
Blood and urine cultures grew Streptococcus agalactiae bacteraemia. She was initially treated with intravenous Rocephin for four days, then switched to benzylpenicillin. While in ward, she had a fever spike but otherwise maintained a good appetite, not delirious, participated in physiotherapy activities, and was able to ambulate to the toilet independently. Her CRP decreased from 155 to 26 mg/L, and her renal profile further improved.
Subsequent abdominal ultrasound revealed a right ureteric stone (Figure 2), which was then stented. During the RPG stent procedure, urine cultures grew Pseudomonas veronii. The infectious diseases team recommended completing one week of Fortum (ceftazidime) therapy.
Discussion questions
1. How would you approach an elderly patient who stays alone with multiple comorbidities, especially when there is poor adherence to insulin therapy?
2. What is the possible cause of her lactate acidosis and how do we manage an older diabetic patient presenting with infection and metabolic disturbances?
3. In elderly patients with polymicrobial urinary infections identified during invasive procedures, should we treat organisms isolated from intra-procedural urine cultures if the patient is clinically stable and improving?
4. What clinical criteria help distinguish between asymptomatic bacteriuria and symptomatic urinary tract infection in older adults, and how should this influence antibiotic prescribing?
Summary
Both cases highlight elderly patients presenting with urosepsis complicated by significant findings—prostate abscess and ureteric stones. Although patients clinically appeared to be improving, subtle signs such as vague symptoms, delirium, and poor appetite suggested underlying unresolved pathology. Our persistence in obtaining thorough imaging revealed these critical findings.
Advocating for an ultrasound was challenging but ultimately essential; it identified a simple hydronephrosis that might have been overlooked due to the improving renal profile. RPG stenting uncovered pus infected by a different organism, highlighting the complexity of the infection.
After all, duration of antibiotic therapy should be guided by the adequacy of treatment and effective source control rather than fixed timelines alone. These cases emphasize that, in older adults, infection management should not rely solely on fever, white cell count, or CRP levels. Comprehensive clinical assessment and timely investigations remain vital to uncover hidden complications and guide appropriate treatment.
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