<% 'if (Session("Type") <> 1 and Session("Type") <> 5 and Session("Type") <> 28) then Response.Redirect "../Msg.asp?Messaggio1=Restricted access area!!!&Messaggio2=Return to HomePage" 'if Session("UserCount") = "" then Response.Redirect "../Msg.asp?Messaggio1=Error while initialising the quiz!!!&Messaggio2=Return to HomePage" a_capo = chr(13) + chr(10) NumQuestions = 3 RightAnswer1 = "a" RightAnswer2 = "c" RightAnswer3 = "c" currentID = Request("currentID") if currentID = "" then currentID = 1 Answer1 = Request("Question1") if Request("Answer1") <> "" then Answer1 = Request("Answer1") Answer2 = Request("Question2") if Request("Answer2") <> "" then Answer2 = Request("Answer2") Answer3 = Request("Question3") if Request("Answer3") <> "" then Answer3 = Request("Answer3") if currentID = 11 or currentID = 22 then Label = "Continue" elseif currentID = 33 then Label = "Continue" else Label = "Evaluate" end if %> Florian M.E. Wagenlehner, Kurt G. Naber - Case study




The elderly patient with acute mental confusion and arrhythmia

wagenlehner

by Florian M.E. Wagenlehner, Kurt G. Naber
Urology Clinic, St. Elisabeth Hospital, Straubing, Germany

 

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The case

A 71-year-old woman was referred to the Internal Medicine emergency room on April 14th . The accompanying husband explained that she suddenly became confused during the night and later turned somnolent.
Her recent clinical history was uneventful, except for an episode of lower abdominal pain 4 days previously, which improved after scopolamine butylbromide. She had experienced similar symptoms 3 months earlier and was fully asymptomatic in between.
The physical examination showed a confused patient, with a heart rate of 128/min (atrial fibrillation at ECG), low-grade fever (37.8°C), normal auscultation of the lung and abdominal findings, no costovertebral tenderness, no skin abnormalities, no meningism or focal neurological signs.
The patient was admitted to the Intensive Therapy Unit with the tentative diagnosis of apoplexy, atrial fibrillation and fever of unknown origin. Blood and imaging tests, including cerebral CT scan, are reported in table I.
Three days later, while afebrile, she developed an episode of acute psychosis in the absence of meningism or focal neurological signs; she was then transferred to an external psychiatric clinic. However, the following day she developed high fever, up to 41°C, with chills; cerebral CT scan was repeated and was again normal. She was transferred to the Neurological Clinic with the tentative diagnosis of meningo-encephalitis: meningism was present, focal neurological signs were absent.
Further blood tests are reported in table I.


Blood and imaging tests


Microscopy of the liquor showed 420/3 cells (normal up to 5/3) and multiple Gram-negative rods. Liquor glucose was 65 mg/dl, total protein 61 mg/dl (normal 15-45) and lactate was 4.3 mmol/l (normal 1.2-2.1). Empirical antibiotic therapy was started with ceftriaxone, gentamicin and ampicillin; in the following days, in the absence of a clinical response, fosfomycin and metronidazole were added to cover Gram-positive and anaerobic bacteria.

References:




  1. Yoshimura K. Utsunomiya N. Ichioka K. Ueda N. Matsui Y. Terai A. Emergency drainage for urosepsis associated with upper urinary tract calculi. J Urol 2005; 173:458-62.
  2. Mold JW. Vesely SK. Keyl BA. Schenk JB. Roberts M. The prevalence, predictors, and consequences of peripheral sensory neuropathy in older patients. J Am Board Fam Pract 2004; 17:309-18.
  3. Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am 2003 17:303-32.
  4. Martin GS. Mannino DM. Eaton S. Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. NEJM. 2003; 348:1546-54,.
  5. Papadopoulos MC, Davies DC, Moss RF, Tighe D, Bennett ED. Pathophysiology of septic encephalopathy: a review. Critical Care Med 2000; 28:3019-24.
  6. Graham JB, Buffalo MD. Recovery of kidney after ureteral obstruction. JAMA 1962, 181: 993-994.
  7. Better OS, Arieff AI, Massry SG, Kleeman CR, Maxwell MH. Studies on renal function after relief of complete unilateral ureteral obstruction of three months duration in man. Am J Med 1973; 54: 234-40.
  8. Gillenwater JY, Westervelt Jr FB, Vaughan Jr ED, Howards SS. Renal function after release of chronic unilateral hydronephrosis in man. Kidney Int 1975; 7: 179-184.
  9. Johansen TE. The role of imaging in urinary tract infections. World J Urol. 2004;22(5):392-8.
  10. Gandolpho L, Sevillano M, Barbieri A, Ajzen S, Schor N, Ortiz V, Heilberg IP. Scintigraphy and Doppler ultrasonography for the evaluation of obstructive urinary calculi. Braz J Med Biol Res, 2001, 34(6) 745-51.
  11. Zager RA, Johnson AC, Hanson SY, Lund S. Acute nephrotoxic and obstructive injury primes the kidney to endotoxin-driven cytokine/chemokine production. Kidney Int. 2006 Jan 4; [Epub ahead of print]
  12. Docherty NG, O'Sullivan OE, Healy DA, Fitzpatrick JM, Watson RW. Evidence that inhibition of tubular cell apoptosis protects against renal damage and development of fibrosis following ureteric obstruction. Am J Physiol Renal Physiol. 2006;290(1):F4-13.
  13. Ito K, Chen J, El Chaar M, Stern JM, Seshan SV, Khodadadian JJ, Richardson I, Hyman MJ, Vaughan ED Jr, Poppas DP, Felsen D. Renal damage progresses despite improvement of renal function after relief of unilateral ureteral obstruction in adult rats. Am J Physiol Renal Physiol. 2004;287(6):F1283-93.
  14. Pat B, Yang T, Kong C, Watters D, Johnson DW, Gobe G.Activation of ERK in renal fibrosis after unilateral ureteral obstruction: modulation by antioxidants. Kidney Int. 2005;67(3):931-43.
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Question 1) - What important test to discover the cause of sepsis is missing?
(Only ONE answer is correct)

> a) Abdominal ultrasounds
> b) TC scan
> c) PET scan
> d) Granulocyte Scinitgraphy
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One of the most important sources of sepsis in the elderly is from the urinary ways.
The absence of urinary symptoms is a relatively common situation particularly in old or diabetic patients, where pain may be present with insidious patterns (1-2).
The lack of symptoms is indeed one of the relatively few clinical situations in which a disease that is usually self-evident, as secondary or “complicated” urinary tract infections, may go unrecognised, thus significantly retarding diagnosis (1-3).
Therefore, urinary tract infections should always be considered in the presence of fever of unknown origin, especially in females and elderly patients (3). In such a context, the diagnostic pathway should always include abdominal ultrasounds, a low cost, reliable test to identify “complicated” or secondary forms of pyelonephritis and the most common forms of pyelonephritis in the elderly.
Abdominal ultrasound, performed at referral to the Neurology Unit, revealed moderate (grade II) hydronephrosis of the left kidney, finally drawing attention to the urinary tract as the source of the sepsis. The detection of a ureteric stone with plain X-ray further clarified the picture, suggesting that an acute ureteric colic had taken place 3 months earlier, when the patient first experienced an episode of acute abdominal pain, and that subsequent infection of the chronically obstructed kidney led to the uncharacteristic lower abdominal pain reported shortly before referral (figures 1,2).

Plain abdominal X-ray revealing left distal ureteric stone.




45-min urography revealing late excretion of the left kidney with contrasted left ureter down to the ureteric stone.


Blood and urine cultures revealed E. coli (urine: CFU 106/ml), the most common urinary pathogen in the outpatient setting, while liquor cultures were sterile. <% newID = 2 else newID = 11 %>



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Question 2) - For the sake of the differential diagnosis, what is (approximately) the role of urinary tract infections in bacteraemias?
(Only ONE answer is correct)

> a) 1%
> b) 5-8%
> c) 15-20%
> d) over 30%
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In the presence of acute disorientation and sepsis, the differential diagnosis usually starts from haematogenous meningo-encephalitis and septic encephalopathy. However, the urinary tract is a frequent cause of generalised sepsis, with approximately 15-20% of bacteraemias due to complicated urinary tract infections (4). While the diagnosis is self-evident in most cases, due to co-presentation with lower urinary tract symptoms or flank pain (a hallmark of pyelitis and pyelonephritis), the possibility of oligosymptomatic presentations, occasionally dominated by the neurological signs of sepsis, should be kept in mind (5).
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Question 3) - What following therapeutic step would you advise?
(Only ONE answer is correct)

> a) Nephrectomy
> b) Antibiotic therapy for at least two months
> c) Relief of obstruction, and subsequent removal of the stone
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Irreversible deterioration of kidney function is usually considered as a regular occurrence within a few days/weeks of complete or partial obstruction (6-8). The duration and type of obstruction, together with the presence of infection, are important elements in determining the renal outcome. However, the actual capability of a human kidney to recover after obstruction is still matter of study and controversy (9-10). The pathogenesis of the long-term irreversible renal damage is complex and recent studies, in particular in animal models, show a role for complex mechanisms, including anti-oxidant and interleukine pathways and apoptosis that are involved at the molecular level (11-14).
Furthermore, urinary infection will probably not respond to antibiotic therapy in such conditions (9-10). Therefore, the correction of urinary tract obstruction should be considered a medical and surgical emergency, particularly in the elderly febrile patient (9-10).
Since, in cases of significant obstruction, antibiotic therapy alone is unlikely to be successful unless the obstruction is relieved, the patient was treated with a mono-J-stent in the left ureter and antibiotic therapy with ceftriaxone was continued on the basis of the antibiograms.
The patient improved and was transferred on April 29th to the Urology Department for further treatment: the mono-J-stent was substituted with a JJ-stent. She was discharged on May 10th with clinical and laboratory recovery and readmitted two weeks later for a ureteroscopic removal of the ureteric stone. 99mTc-DMSA anterior – posterior showed multiple defects of the left kidney; MAG3-renal scan, performed 1 month later, showed a small, shrunken left kidney, accounting for 15% of overall kidney function (figure 3).

99mTc-DMSA anterior – posterior showing multiple defects of the left kidney

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