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Title : 72 year-old female w/ Fever
Date : February 1, 2011
Contributed by

Young Eun Ha, M.D.
Div. of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine

Patient History
Age/Sex 72 year old female
Chief complaint Fever
Present illness

A 72- year old female who had been well before October 2010 presented with fever, chill, and diarrhea on October 13th. Before admission, she had often worked on the farm in Cheonan, located in the middle of South Korea. She had also picked chestnuts in Cheonan a couple of weeks before admission. On October 9th, she developed acute onset fever, chill and diarrhea which worsened over the several days, and she visited ER on October 13th. Initial V/S were BP 119/59, HR 123/min, RR 20/min, and BT 38.78’C. In review of system, she further complained of general weakness and abdominal pain, physical examination revealed no remarkable finding except abdominal tenderness.

Initial labs are described below. With impression of infectious colitis, she was started on IV ciprofloxacin.

Initial laboratory findings

CBC 13920-15.9-22k (Atypical lymphocyte 4%)

CRP 10.22

PT 30.5, PT(INR) 2.93, APTT 300, Fibrinogen 136, D-dimer 12

Electrolyte 132–3.7-95

Chemistry profile

T-bil /AST/ALT/ALP 1.2/102/53/57

BUN/Cr 22.6/0.93

LD 1428

Lactic acid 4.51

U/A pH 6.5/clear/nitrite-/LE –

Urine microscopy RBC numerous/HPF,

                        WBC 3-5/HPF

Radiologic findings

Initial Adbomen CT>
CT scan of abdomen showed Diffuse layered wall thickening of color which suggests Coliitis,more likely.

Hospital course

On hospital Day 2, she developed shock, tachycardia and respiratory failure, was transferred to ICU. Endotracheal intubation was done, and then inotropics and ventilatory support were given. Soon, her status worsened with oliguric acute renal failure, lactic acid level was elevated up to 11.58, ABGA showing severe metabolic acidosis (pH 6.4, HCO3 8.3, PaO2 92, PCO2 44). Continuous renal replacement therapy was started.  PB smear showed leukocrythroblastic reactions with many atypical lymphocytes.

On the hospital Day 3, shock has recovered, but lactic acid increased up to 16.92, haptoglobin 15.7, LD 4000, with negative Coombs test.

On the day 7, initial two sets of blood culture and other body fluid gram stain and cultures grew no microorganisms. On the day 8, she weaned from ventilator, CRRT was changed to regular hemodialysis. Oliguria persisted for about 2 weeks after shock, and then her urine output began to normalize, and further, increased progressively. On the hospital Day 23, her urine output increased up over 8000cc/day, and then decreased gradually to normal range. During the polyuric period, delicate fluid and electrolyte replacement were done. On the day 43, she discharged from hospital without significant sequelae.

Question - ID Case of the Week ( February 1, 2011 )
What is the most probable diagnosis in this patient?
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