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Problem case
경희의료원 감염내과
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증례1
History
Chief complaint
Fever
Both leg pain (onset: 2 day ago)
Present illness
M/59, 평소 건강히 지내던 자로
내원 1주전 생선회덮밥 먹은 후 내원 3일전부터
general weakness, fatigue 있었고 2일전부터
both leg pain, 1일전부터 fever 생겨 ER 내원
Past medical history
DM/ HTN/ Hepatitis/ Pulmonary Tb (-/-/±/-)
Hepatitis-20대에 우연히 B형 간염보균자라 들음
Personal history
Smoking (-) alcohol (-)
Occupation history
운수업
Review of system

General : fatigue (+)
fever (+) chill (+) Malaise (+)

H&N
: headache (-) sore throat (-) visual opacity (-)

Chest
: chest pain (-) palpitation (-)
cough (-) sputum (-) dyspnea (-)

GI
: Anorexia/N/V/D/C (+/-/-/-/-)
abdominal pain (-)

Urinary
: dysuria (-) frequency (-) urgency (-)
voiding difficulty (-)

Musculoskeletal : both leg pain (+) LBP (-)
Physical Examination

V/S
60/30 mmHg-108 회/min-20 회/min-36.9 °C

Height:

General
: Drowsy mentality

SKIN
: purpura or patch on both lower leg and back

H/N
: no thyroid gland enlargement
175 cm
BW: 70.5 Kg
no cervical LN enlargement
no neck vein engorgement

E/ENT
: isocoric pupil with PLR(++/++)
pinkish conjunctiva with clear sclerae

Chest
: Coarse breath sound with BLL crackle
Rapid heart beat without murmur

Abdomen : soft and flat abdomen
hypoactive B.S.

B/Ext
: CVA tenderness(-/-)
Both leg swelling(++)
abdominal Td/RT(-/-)
Shifting dullness(-)
pitting edema(-/-)
purpura on lower leg
Initial Lab Finding



CBC/DC
:1,210/mm3-10.7g/dL-33.3%-27K (seg 81.7%)
INR 2.33
aPTT 60.5
Chemistry :
Prot/alb
5.6/2.0 g/dL
TB/DB
2.81/0.85 mg/dL
AST/ALT 82/28 U/L
ALP/rGT
49/14 mg/dL
Ca/P/Mg
8.2/3.3/1.5 mg/dL
BUN/Cr
5.6/2.0 mg/dL
2.2/108 mg/dL
Na/K/Cl
130/3.9/103 mmol/L CRP/Glu
LDH/Uric acid 599/4.9
mg/dL CK/Myoglobin 992/2678.9 ng/dL
U/A :
RBC 5-9/HPF
PH

5.0
WBC 10-29/HPF
Specific gravity 1.015
Protein(++)
Occult blood (++)
many bacteria(+)
ABGA: 7.313 - 39.4 - 33.0 - 19.5 - 53.2%(RA)  VBGA 가능성!
EKG
Chest AP
Initial problem lists
 1. hypotension with
tachycardia, hypoxia, metabolic acidosis, pancytopenia
 septic shock
 2. both leg pain with
increased muscle enzyme, azotemia
 3. Previous Hx. Of HBV
Initial Assessment & Plan
1. Hypotension with
tachycardia, hypoxia, metabolic acidosis, pancytopenia
A)
Septic shock
최근 sea food intake Hx., HBV carrier의 Hx., skin lesion
 Vibrio septic shock 가능성
P)
W/U
Blood & urine culture Korean antibody 4종
Legionella, Mycoplasma antibody
Adequate hydration, Vasopressor
ABGA f/u,
Bicarbonate
Antibiotics: Vancomycin, ciprofloxacin, doxycyline
2. both leg pain with
increased muscle enzyme, azotemia
A) Rhabdomyolysis d/t infection
ARF (Ccr=33mL/min) d/t septic shock, rhabdomyolysis
P) W/U
Spot urine Na Cr BUN for FENa FEUN
(FENa=0.084, FEUN=10.68)
Abd US
Adequate hydration
Urine alkalinization
Diuretics
3. Previous Hx. Of HBV
A) if LC  Child C (total 11~12)
Septic shock에 의한 liver function악화
P)W/U
Viral Marker
Abd US or Abd CT
Abd US
Coarse liver parenchyma  LC more likely
HBsAg/HBcAb/HbsAb (+/+/-) Anti-HCV (-)
#3.
B viral LC, Child C (total 10 or 11)
liver function deterioration d/t sepsis
Both leg (입원 11시간후)
Both leg pain
LDH (U/L) CK (U/L)
4:00
599
992↑
13:00
960
6890↑↑
leg swelling↑↑
Palpation: soft and tense
Dorsalis pedis pulse(±)
 # 2. Soft tissue infection with
rhabdomyolysis
Compartment syndrome possible
 OS consult for fasciotomy
입원 17시간 후
ABGA
pH
pCO2
pO2
HCO3
SaO2
O2
5:00
7.30
29.8
98.3
14.4
96.8
4L
8:42
7.18
25.9
105.8
9.5
96.7
4L
21:00
7.11
43.3
74.5
13.7
89.7
2L
23:01
7.03
21.38
101.9
5.6
94.5
4L
2:43
6.84
34.3
95.9
5.7
90.1
4L
내원 당시
Normal anion gap
Metabolic acidosis
(serum AG=10)
점차 High anion gap
Metabolic acidosis
Bicarbonate 투여에도 반응
하지 않는 acidosis로 발전
Hospital course
 Septic shock으로 adm.
 Both leg hemorrhagic bullae: 내원 11시간
 Uncontrolled metabolic acidosis: 내원 20시간
Both leg compartment syn.으로 fasciotomy계획
 Expire: 내원 25시간
Isolated Bacteria
 Wound Culture
: Vibrio alginolyticus
2개
 Blood Culture
: Vibrio alginolyticus
3쌍
#1. Vibrio
alginolyticus
septic shock
증례2
History
Chief complaint
Both leg pain (onset: 1 day ago)
Present illness
M/46, heavy alcoholics로서 1년 전 건강검진에서
DM 및 fatty liver 진단
내원 1주전 충남 당진에서 전어회, 새우회 먹었고
내원 1일전 부터 Lt. leg & Rt. foot edema, pain 생
겨 2차 병원 경유하여 본원 ER 내원
Past medical history
DM/ HTN/ Hepatitis/ Pulmonary Tb (+/-/-/-)
DM- No med
Personal history
Smoking (-)
alcohol (+): 매일 소주 1병
Occupation history
건축업(담 쌓는 일)
Review of system

General : fatigue (-)
fever (-) chill (-) Malaise (+)

H&N
: headache (+) sore throat (-) visual opacity (-)

Chest
: chest pain (-) palpitation (-)
cough (-) sputum (-) dyspnea (-)

GI
: A/N/V/D/C (-/-/-/-/-)
abdominal pain (-)

Urinary
: dysuria (-) frequency (-) urgency(-)
voiding difficulty (-)

Musculoskeletal : both leg pain (+) LBP(-)
Physical Examination

V/S
70/50 mmHg-92 회/min-20 회/min-36.0 °C

Height:
175 cm

General
: Alert

SKIN
: patch, purpura on both lower leg (especially Lt. leg)

H/N
: no thyroid gland enlargement
BW: 70 kg
no cervical LN enlargement
no neck vein engorgement

E/ENT
: isocoric pupil with PLR(++/++)
pinkish conjunctiva with clear sclerae

Chest
: CBS without crackle
Regular heart beat without murmur

Abdomen : soft and flat abdomen
hypoactive B.S.

B/Ext
: CVA tenderness(-/-)
Both leg swelling(++)
abdominal Td/RT(-/-)
Shifting dullness(-)
pitting edema(-/-)
purpura on lower leg
Lt lower leg skin lesion: 내원 당시
Initial Lab Finding



CBC/DC
:37,530/mm3-13.1g/dL-39.5%-226K (seg 92.9%)
INR 1.18
aPTT 54.7
Chemistry:
Prot/alb
5.0/2.4 g/dL
TB/DB
3.26/1.55 mg/dL
AST/ALT 241/224 U/L
ALP/rGT
105/346 mg/dL
Ca/P/Mg
8.2/3.3/1.5 mg/dL
BUN/Cr
13/1.8 mg/dL
14.9/162 mg/dL
Na/K/Cl
134/3.4/102 mmol/L CRP/Glu
LDH/Uric acid 594/3.4
mg/dL CK/Myoglobin 493/853.3 ng/dL
U/A :
RBC 5-9/HPF
PH

5.0
WBC 5-9/HPF
Specific gravity 1.025
Protein(++)
Occult blood (+++)
ABGA: 7.479 - 20.3 – 105.6 - 14.7 - 98.2% (RA)
EKG
Chest AP
Initial problem lists
 1. hypotension with CRP & leukocytosis↑
 septic shock
 2. both leg pain with
increased muscle enzyme, azotemia
both leg skin lesion
 3. LFT elevation
 4. DM
Initial Assessment & Plan
1. hypotension with CRP & leukocytosis↑
A)
Septic shock
최근 sea food intake Hx, daily alcohol intake, skin
lesion
 Vibrio septic shock 가능성
P) W/U
Blood & urine culture
Legionella, Mycoplasma antibody
Adequate hydration & Vasopressor
Antibiotics: iv ciprofloxacin, doxycycline
2. both leg pain with
increased muscle enzyme, azotemia & both leg skin lesion
A) Rhabdomyolysis d/t infection
ARF (Ccr=51mL/min) d/t septic shock, rhabdomyolysis
P) W/U
Spot urine Na Cr BUN for FENa FEUN
(FENa=0.02, FEUN=7.33)
Abd US
Adequate hydration
Urine alkalinization
Diuretics
skin lesion culture
 3. LFT elevation
A)
P) w/u
alcoholic hepatitis
alcoholic LC, possible
abd US
viral marker
 4. DM
A) DM
P) W/U
HbA1C  6.8%
OGTT
insulin injection
Leg lesion
내원 1일 후
내원 3일 후