medical grandrounds

MEDICAL GRANDROUNDSJuly 3, 2008

Abigail Cruz-Zaraspe M.D.

OBJECTIVESTo present a case of bacteremia in aplastic anemia

To discuss salmonella nontyphi bacteremia and myositis manifestations, diagnosis and treatment

To discuss briefly the treatment of aplastic anemia

IDENTIFYING DATAA.R.42/MMarriedReal-estate broker

CHIEF COMPLAINTRight thigh pain

HISTORY OF PRESENT ILLNESS5 weeks PTAEasy fatigability, SOB, (+) melena, (+) abdominal pain,(+)palpitations4 weeks PTAsought consult, CBC Pancytopenia admitted for the first time for transfusion

HISTORY OF PRESENT ILLNESSFirst admissionblood transfusionsBMA-hypocellular BM

Dx: Aplastic anemiatreatment options were discussed(discharged-platelet ct 44k)

HISTORY OF PRESENT ILLNESS3 weeks PTAintermittent fever (390C),body malaise, nose bleedingConsult:WBC 1860, PLT 10kTx: Co-amoxyclav 625mg TID x7d, tranexamic acid 500mg TIDGCSF 300mcg

HISTORY OF PRESENT ILLNESS3 weeks PTAgeneralized petechial rashes & gum bleeding and was admitted2nd admissionCBC- pancytopenia Tx: blood & PC transfusions

CBC on SECOND ADMISSION

HISTORY OF PRESENT ILLNESS2nd admissionInitially given Cefepime 1gm Q12

HISTORY OF PRESENT ILLNESS2nd admission+ right thigh & hip pain 5/10 (dull, aching constant)

+direct tendernessno swellingno limitation in ROMno paresthesia

Hip & Thigh painfractureAvascular necrosisinfectionCompartment syndromeneuropathy

NEUROPATHYSevere intractable painUnusual burning, tingling or shock-like qualityTriggered by light touchSensory deficit on area of pain

COMPARTMENT SYNDROMEPain ParasthesiaPulselessnessPallorpressure

HISTORY OF PRESENT ILLNESS2nd admissionPelvis and Right hip xray: no pathologic finding

HISTORY OF PRESENT ILLNESS2nd admissionBlood CS: Salmonella enteritidis Grp CSensitive: CeftriaxoneChloramphenicolCiprofloxacinshifted to Ciprofloxacin 500mg/tab, 1 tab BID

HISTORY OF PRESENT ILLNESS2nd admissionDx: Aplastic anemiaSalmonella nontyphi bacteremia

Advised treatment w/ Anti-thymocyte globulin / cyclosporine

HISTORY OF PRESENT ILLNESS2nd admissionTHM:Ciprofloxacin 500mg/tab, 1 tab BID to complete 7 daysPrednisone 30mg BID,Tranexamic acid & Omeprazole

HISTORY OF PRESENT ILLNESSSince dischargeepisodes of fever & progression R hip & thigh pain on movement & palpationunable to stand

admitted 3rd time

REVIEW OF SYSTEMS(-) headache(-) loss of consciousness(-) cough or colds(-) weight loss (-) chest pain(-) dyspnea(-) palpitations(-) abdominal pain

(-) nausea or vomiting(-) LBM/ constipation(+) melena(-) hematochezia(-) dysuria(-) hematuria

PAST MEDICAL HISTORYNon-hypertensiveNon-diabeticNo known allergies

FAMILY HISTORYNo hypertensionNo diabetesNo asthmaNo blood dyscrasiasNo cancer

PERSONAL AND SOCIAL HISTORYPrevious smoker, stopped in late 90sOccasional beer drinkerLived near an electroplating factoryPreviously worked as a cashier in a gasoline stationReal estate broker

PHYSICAL EXAMINATIONGeneral:conscious, coherent, bed-bound

Vital signs: BP 130/80, HR = 103 bpm, reg, RR = 22/min, T = 390C

HEENT: Pale conjunctivae, icteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy

PHYSICAL EXAMINATIONChest/Lungs: Symmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, tachycardic with regular rhythm, no murmurs

PHYSICAL EXAMINATION

Abdomen:Flabby, normoactive bowel sounds, soft, non-tender, no hepatomegalyno splenomegaly

PHYSICAL EXAMINATIONExtremities:(+) erythema and hyperemia, right thigh extending to mid-leg areaNo discharge, no open woundsno sensory deficitLeft leg was grossly normalpulses: full and equal

SALIENT FEATURES42/MKnown case of aplastic anemiaKnown case of non-typhi salmonella bacteremiaTreated with ciprofloxacin 500mg BID x 1 weekStill febrileRight thigh and hip painErythema and swelling of right lower extremity

AVASCULAR NECROSISresults from infarction of bone trabeculae and marrow cells equal frequency in the femoral and humeral heads The femoral heads more commonly undergo progressive joint destruction as a result of chronic weight bearing. The changes are best detected by MRI

AVASCULAR NECROSIS

Most studies have found that the risk is low (< 3 percent) in patients treated with doses of prednisone less than 15 to 20 mg/dayIn one series, the prednisone dose in the highest month of therapy exceeded 40 mg/day in 93 percent, and 20 mg/day in 100 percent of patients with osteonecrosis.

150 patients with aplastic anemia treated at Clinical Hematology Branch of the National Heart, Lung and Blood Institute (NHLBI) between 1978 and 1990

Infection was documented in 47% of casesrespiratory tract (32 percent)soft tissues (24 percent) blood (22 percent)gastrointestinal tract (17 percent)urinary tract (6 percent).

IMPRESSIONAplastic anemia Salmonella non-typhi bacteremia with secondary myositisr/o Avascular necrosis, osteomyelitis

COURSE IN THE WARDSOn admissionCBC, PT, PTT, UA, CXR, crea, BUN, K, Na were requested. He was placed on a neutropenic diet.He was started on Piperacillin-tazobactam 4.5mg/IV x 1dose then 2.25mg q8 hours

LABS APRIL 12, 2008CXR- normal

Piperacillin-tazobactamFebrile

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5

temperature (celsius)

Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct

hemoglobin and hematocrit

39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc

hemoglobin hematocrit and ANC

labs

blood cs

17-Apr

salmonella enteritidis grp c

rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr

no growth after 5 days

19-May


5-Jun


12-Apr13-Apr15-Apr17-Apr19-Apr23-Apr25-Apr26-Apr28-Apr30-Apr1-May2-May4-May6-May7-May11-May13-May14-May19-May22-May27-May28-May

hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May

colordark yellowyellow

transparencyhazyhazy

pH56

sg1.021.02

glucosetracetrace

albuminnegativetrace

ketonesnegativenegative

nitritesnegativenegative

lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2

12-Apr13-Apr14-Apr15-Apr16-Apr17-Apr18-Apr19-Apr20-Apr21-Apr22-Apr23-Apr24-Apr25-Apr26-Apr27-Apr28-Apr29-Apr30-Apr1-May2-May3-May4-May5-May6-May7-May8-May9-May10-May11-May12-May13-May14-May15-May16-May17-May18-May19-May20-May21-May22-May23-May24-May25-May26-May27-May28-May29-May30-May31-May1-Jun2-Jun3-Jun

37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5

1-May2-May3-May4-May5-May6-May7-May8-May9-May10-May11-May12-May13-May14-May15-May16-May17-May18-May19-May

36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3

20-May21-May22-May23-May24-May25-May26-May27-May28-May29-May30-May31-May1-Jun2-Jun3-Jun

38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature

first admission labs


22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345

platelet ct5000200014000

anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS2nd hospital day+ severe leg pain, unrelieved by Tramadol. referred to Orthopedic serviceImpression: t/c pathologic fracture vs. avascular necrosis, R hip; aplastic anemia.Tx: Ketorolac and Morphine.

COURSE IN THE WARDS2nd hospital dayPelvic MRI was requestedMyositis with fasciitis involving the right gluteal and right thigh muscle and the right obturator internus muscle. Avascular necrosis of the right femoral head considered

COURSE IN THE WARDS2nd hospital daystill with fever and leg painBlood CS:Salmonella Enteritidis Group C sensitive to Ceftriaxone and Ciprofloxacinresistant to Co-trimoxazole and Ampicillin.

COURSE IN THE WARDS5th HDreferred to Infectious Disease service.

Impression: Salmonella nontyphi bacteremia with secondary myositis.Tx: shift Piperacillin-tazobactam to Ciprofloxacin 500mg/tab 2x a day & ceftriaxone 2g/IV OD

PTFebrile CP & CT

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS11th HDpatient was still febrile (Tmax400C)endovascular Salmonella was considered

Ceftriaxone was discontinuedPiperacilin-Tazobactam was resumed & increased to 4.5 IV Q8dexamethasone 4mg/tab 12 hrs

PTFebrile CP+CT CT CPdexa

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS13th HDAfebrilepain decreasedDexamethasone was tapered to 4mg/tab bid.

COURSE IN THE WARDS18th HDCyclosporine (Neoral)100mg/cap BID

ATG 1000mg in PNSS x 4 hrs, once daily until D11 ( 5/9/08)

Febrile CPdexaPTATGCyclo

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS21st HDpatient was afebrile, Piperacillin-tazobactam was discontinued

Febrile CPPTATGCycloPTATG

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS38th HDfever recurredIncreased severity of R thigh painBlood CS: negative after 5 daysCBC still showed pancytopenia.

Febrile CPCyclo

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS41st HDpersistence of fever CXR,urinalysis,CBC were requestedCXR & urinalysis were normalCBC still showed pancytopenia. Piperacillin-tazobactam 4.5g/IV q8 was resumed

Febrile CPCycloPT

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS46th HDBMA: beginning bone marrow recovery. Some section shows good cellularity with myeloid and erythroid precursors, although megakaryocytes are still decreased but present

Febrile CP

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

Chart7

6000

16000

10000

15000

20000

9000

24000

10000

20000

10000

14000

51000

39000

11000

22000

10000

28000

29000

7000

74000

40000

20000

platelet ct

DATE

PLATELET COUNT

PLATELET COUNT

Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

labs

platelet ct

anc

ANC and Platelet levels

temperature

anc

date

anc


platelet ct

DATE

PLATELET COUNT

PLATELET COUNT


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5


22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

Chart4

1929

340

1665

1200

873.8

774

1237.4

1600

1154

2212

1675.8

4192

2531.5

5473

2025

2484

1848

1936

1980

2744

2264

2082

anc

date

anc

Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

labs

platelet ct

anc

ANC and Platelet levels

temperature

anc

date

anc



37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5


37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS47th HDagain had febrile episodesBlood culture: negativeMRI of R leg: myositis, fasciitis & avascular necrosis of the R thigh

Febrile CPCyclo

Chart3

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8

36.3

36.8

36.5

36.7

36.6

37

36.7

36.8

36.5

37

37

37.2

37.6

38.1

37.5

37

37.7

38.5

38.3

38.5

39.5

38.5

36.7

36.8

36

36.1

36.8

38.3

38.2

39

38.3

36.8

37.3

36.5


Chart1

Chart1

19291929

340340

16651665

12001200

873.8873.8

774774

1237.41237.4

16001600

11541154

22122212

1675.81675.8

41924192

2531.52531.5

54735473

20252025

24842484

18481848

19361936

19801980

27442744

22642264

20822082

anc

anc

anc levels

Chart2

8.524.91929

8.626.3340

9.427.71665

6.419.31200

8.224.4873.8

9.629774

6.820.71237.4

8.525.81600

9.8301154

9.328.52212

9.329.11675.8

9274192

8.826.32531.5

9.628.65473

10.4312025

9.827.22484

8.125.31848

11.133.51936

9.829.51980

9.127.42744

8.626.32264

12.938.62082

hgb

hct


39550

39550

39551

39551

39553

39553

39555

39555

39557

39557

39561

39561

39563

39563

39564

39564

39566

39566

39568

39568

39569

39569

39570

39570

39572

39572

39574

39574

39575

39575

39579

39579

39581

39581

39582

39582

39587

39587

39590

39590

39595

39595

39596

39596

8.5

24.9

8.6

26.3

9.4

27.7

6.4

19.3

8.2

24.4

9.6

29

6.8

20.7

8.5

25.8

9.8

30

9.3

28.5

9.3

29.1

9

27

8.8

26.3

9.6

28.6

10.4

31

9.8

27.2

8.1

25.3

11.1

33.5

9.8

29.5

9.1

27.4

8.6

26.3

12.9

38.6

hgb

hct

anc


labs

blood cs

17-Apr


rtmp/smx6

rampicillin6

sceftriaxone24

sciprofloxacin21

24-Apr


19-May


5-Jun



hgb8.58.69.46.48.29.66.88.59.89.39.398.89.610.49.88.111.19.89.18.612.9

hct24.926.327.719.324.42920.725.83028.529.12726.328.63127.225.333.529.527.426.338.6

rbc2.92.93.12.262.93.42.463.243.983.753.83.544.063.943.644.554.023.673.54.89

wbc288013603700286025702,0002,690.00320042901940294058404150842045005520440044004400490056604250

metamyelocytes14

stabs

segmenter67254542343546502959578061654545424445564049

lymphocyte25735050605642376328263730284046474243304939

mono725869111381371111.1411

platelet ct600016000100001500020,000900024,000.0010000200001000014000510003900011000220001000028000290007000740004000020000

anc192934016651200873.87741237.41600115422121675.841922531.5547320252484184819361980274422642082

12-Apr26-Apr6-May

na134

k4.2

bun211818

crea1.20.90.7

ALT21

AST69

albumin1.9

urinalysis

18-Apr22-May



pH56

sg1.021.02

glucosetracetrace




lenegativenegative

blood31

rbc1287

wbc00

epithelial cells11

bacteria11

IMAGING

CXR

22-May

normal chest

Chart4

37.3

38.3

38.2

39.3

40.2

39.6

39.4

39.2

39

39

39.8

37

36.5

36.8

36.5

36.5

36

36.5

36.8


date

temperature

Sheet2


37.338.338.239.340.239.639.439.2393939.83736.536.836.536.53636.536.836.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.338.539.538.536.736.83636.136.838.338.23938.336.837.336.5


36.336.836.536.736.63736.736.836.5373737.237.638.137.53737.738.538.3


38.539.538.536.736.83636.136.838.338.23938.336.837.336.5

Sheet2

date


temperature



22-Mar24-Feb25-Mar

hgb8.5810

hct25.524.430.5

rbc

wbc185029602190

stabs

segmenter547248

lymphocyte402345


anc99921311051

na139

k4.5

bun16

crea1.1

ALT80

AST29

albumin2.9

COURSE IN THE WARDS53rd HDsent homeafebrilemedications:Tranexamic acid, Cyclosporine 100mg BID, ciprofloxacin 500mg BID

FINAL DIAGNOSISAplastic anemia

Salmonella enteritides myositis

Avascular necrosis, femoral head

DISCUSSION

SALMONELLA: MICROBIOLOGYGram-negativenon-spore formingFacultatively anaerobic bacilliProduce acid on glucose fermentationMotileDo not ferment lactose (99%)Differential metabolism of sugars is used to distinguish serotypesS. typhi does not produce gas on sugar fermentation

NON-TYPHOIDAL SALMONELLA: EPIDEMIOLOGY1996-1999 estimated 1.4M cases of NTS in US2004 14.7/100,000 personsTyphimurium 20%Enteritidis 15%Newport 10%

NON-TYPHOIDAL SALMONELLA: EPIDEMIOLOGY - HOST FACTORSImpaired cell-mediated immunityAIDSCorticosteroid useMalignancy

Impaired phagocytic functionHemoglobinopathiesChronic granulomatous diseaseSchistosomiasisHistoplasmosisMalaria

NON-TYPHOIDAL SALMONELLA: EPIDEMIOLOGY - HOST FACTORSExtremes of agesNeonatesElderly

Decreased gastric acidityachlorhydriaAntacids or suppression of gastric acidity

Altered intestinal functionIBDPrior antibiotic therapy

NON-TYPHOIDAL SALMONELLA: EPIDEMIOLOGYSmall but significant numberAssociated with food products (meat, poultry, eggs or dairy products)Associated with shell eggsAssociated with exotic pets, especially reptiles

NON-TYPHOIDAL SALMONELLA: EPIDEMIOLOGY

NON-TYPHOIDAL SALMONELLA: PATHOGENESISIngestion from contaminated food/waterInfectious dose: 103-106 CFUGastric acidity is the initial barrierBacteria mediated endocytosis

NON-TYPHOIDAL SALMONELLA: PATHOGENESISInnate immune systemMay be determining factor for severityDepressed PMN function increases incidenceCell-mediated immunityRole in clearing infection and protecting against subsequent Salmonella infectionHumoral immune responsesProtective immunity

NON-TYPHI SALMONELLA CLINICAL MANIFESTATIONS

GastroenteritisBacteremia and vascular infectionLocalized infectionChronic carrier state

Clinically useful, have no pathogenic nor prognostic significance

NON-TYPHI SALMONELLA BACTEREMIA AND VASCULAR INFECTIONS5% of patients with NTS

Infants, elderly and immunocompromised

Salmonella has high propensity for infection of vascular sites10-25% in persons > 50AortaVenous septic thrombophlebitis

NON-TYPHI SALMONELLA : LOCALIZED INFECTIONOccurs in 5-10% of patients with NTS bacteremia

NON-TYPHI SALMONELLA : LOCALIZED INFECTION

NON-TYPHI SALMONELLA SPECIAL POPULATIONSImmunosuppressionBiliary and urinary tract abnormalitiesHemoglobinopathiesMalariaSchistosomiasisHistoplasmosisAIDS

NON-TYPHI SALMONELLOSIS TREATMENT

Neonates, >50 years of age and in patients with immunosuppresion or valvular/endovascular abnormalitiesOral or IV antimicrobial for 48 to 72 hours or until patient is afebrile

SALMONELLA NON-TYPHI BACTEREMIA TREATMENTEmpiric: 3rd generation cephalosporin and a fluoroquinoloneLow-grade: 7-14 days of TxHigh-grade: 6 weeks IV therapy with -lactam (ampicillin or ceftriaxone) is recommended to treat documented or suspected endovascular infectionIV Ciprofloxacin, followed by prolonged oral therapy

SALMONELLA NON-TYPHI LOCALIZED INFECTION TREATMENTCeftriaxone 2g/d or Cefotaxime 2g q8h

Ciprofloxacin 500mg/tab BID or 400mg/IV BID

Ampicillin 2g/IV q6h

SALMONELLA: ANTIMICROBIAL RESISTANCEWidespread use of over-the-counter antibioticsPlasmid-encoded resistanceEmpirical treatment of febrile syndromes and as growth promoters in animal productionDT104: resistant to ACSSuT: ampicillin, chloramphenicol, streptomycin, sulfonamides and tetracyclinesAcquired from plasmids in Pseudomonas species

SALMONELLA: ANTIMICROBIAL RESISTANCEIncrease in ceftriaxone and fluoroquinolone resistant nontyphoidal Salmonella

SALMONELLA: PREVENTION AND CONTROLHand washingSafe drinking water and effective sewage treatmentImproved food safety practicesGood personal hygienePrudent antimicrobial use

TREATMENT OF APLASTIC ANEMIAHematopoietic stem cell transplantation

ImmunosuppressionAnti-thymocyte globulin induces hematologic recoveryAddition of cyclosporine increases response rate up to 70% esp. in childrenImprovement in leukocyte count apparent within 2 months

TREATMENT OF APLASTIC ANEMIA(IMMUNOSUPPRESSIVE THERAPY)improvement in blood counts occurred in 60 percent of patients after three monthsThe actuarial risk of relapse was 35 percent at five years. Most of the relapsing patients responded to additional courses of immunosuppression, and relapse was not associated with a significant survival disadvantage..Rosenfeld, SJ, Kimball, et.al Intensive immunosuppression with antithymocyte globulin and cyclosporine as treatment forsevere acquired aplastic anemia. Blood 1995; 85:3058.

Treatment of aplastic anemia with antilymphocyte globulin and methylprednisolone with or without cyclosporine. The German Aplastic Anemia Study Group antilymphocyte globulin, methylprednisolone, and cyclosporine appears to be more effective than a regimen of antilymphocyte globulin and methylprednisolone without cyclosporinemay thus represent a treatment of choice for patients who are not eligible for bone marrow transplantation Frickhofen N, Kaltwasser JP, Schrezenmeier H, Raghavachar A, Vogt HG, Herrmann F, Freund M, Meusers P, Salama A, Heimpel H

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TREATMENT OF APLASTIC ANEMIA(IMMUNOSUPPRESSIVE THERAPY)Horse ATG at a dose 40 mg/kg per day in 500 mL of saline given over four to six hours for four consecutive days.Rosenfeld, SJ, Kimball, et.al Intensive immunosuppression with antithymocyte globulin and cyclosporine as treatment forsevere acquired aplastic anemia. Blood 1995; 85:3058.

TREATMENT OF APLASTIC ANEMIA(IMMUNOSUPPRESSIVE THERAPY)Prednisone or methylprednisolone in divided doses of 1 mg/kg per day. Steroids were given for two weeks, with the dose tapered so that the corticosteroids were discontinued by day 30.Rosenfeld, SJ, Kimball, et.al Intensive immunosuppression with antithymocyte globulin and cyclosporine as treatment forsevere acquired aplastic anemia. Blood 1995; 85:3058.

TREATMENT OF APLASTIC ANEMIA(IMMUNOSUPPRESSIVE THERAPY)Cyclosporine, 10-12 mkd, in two equally divided doses, aiming for trough levels of 100 to 200 ng/mL of serum or 500 to 800 ng/mL in whole blood.

Cyclosporine is generally continued for about six months, although the dose may be tapered after one month to trough whole blood levels of 200 to 500 ng/mL.Rosenfeld, SJ, Kimball, et.al Intensive immunosuppression with antithymocyte globulin and cyclosporine as treatment forsevere acquired aplastic anemia. Blood 1995; 85:3058.

Should I put the GCSF???Dose of GCSFShould I put the GCSF???Should I put the GCSF???Should I put the GCSF???Should I put the GCSF???Should I put the GCSF???Should I put the GCSF???Should I put the GCSF???Should I put the GCSF???Hepato splenomegaly????????Day what afebrile???Sickle cell anemia, malaria, schisto, histoplasmosisInfection more severe and prolonged in AIDS, malignancy and with use f glycocorticoidsSickle cell anemia, malaria, schisto, histoplasmosisInfection more severe and prolonged in AIDS, malignancy and with use f glycocorticoidsDT104- greater morbidity and mortality

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