PATIENT CASE

A 44-year-old female, TW, with a history of poorly controlled diabetes was admitted today with symptoms of increased urinary frequency/urgency and a fever. Upon initial examination, she complained of flank pain. Vital signs during the initial examination were unremarkable, except for a fever of 102.1◦F. When collecting a urine sample, the urine was noted to have a strong smell. Test Result Reference range Hgb 13 g/dL 12-15 g/dL Hct 39% 36-47% LDH 53 U/L 50-150 U/L Labs performed at the time of admission: Urinalysis: <5 epithelial cells, positive for nitrite, 4+ bacteria, 2+ leukocytes, 20-30 WBCs, and trace blood. Home Med list: -metformin 1000mg PO BID -Tresiba 20 units SC qAM Allergies: NKDA Empirically, Piperacillin-Tazobactam antibiotic therapy was initiated (3.75 g IV every 6 hours) for the treatment of complicated, acute pyelonephritis. Urine culture results later demonstrated E. coli sensitive to piperacillin-tazobactam. On day five of the IV antibiotic therapy, the patient experienced nausea, vomiting, weakness, and dizziness. Physical examination revealed elevated heart rate (105/min), normal blood pressure, pale skin, and yellowish discoloration of the eyes. Labs performed on day five of IV antibiotic therapy: Test Result Reference range Hgb 6.3 g/dL 12-15 g/dL Hct 14% 36-47% LDH 452 U/L 50-150 U/L Concisely answer each of the following 8 questions by referring to specific lab results and case details. A complete explanation for each question is required for full credit. Question 1. Based on the patient’s vital signs and the most recent test results, what general changes in RBC and serum Bilirubin (Bi) levels would you expect (i.e., increased, decreased, normal)? Question 2. What medical condition is indicated by comparing both sets of lab results? Explain your answer by using the lab test values.

Sample Solution

Question 1: Expected Changes in RBC and Serum Bilirubin Levels

RBC: Based on the significant drop in hemoglobin (Hgb) and hematocrit (Hct) from admission to day five (13 g/dL & 39% to 6.3 g/dL & 14%), we would expect a decrease in RBC count. This indicates severe anemia.

Serum Bilirubin: Considering the patient's symptoms like pale skin and yellowish discoloration of the eyes (jaundice), alongside the elevated LDH, we would expect an increase in bilirubin levels, particularly indirect bilirubin. This suggests hemolysis, i.e., the excessive breakdown of red blood cells, causing bilirubin buildup in the bloodstream.

Question 2: Medical Condition Based on Compared Lab Results

Comparing the initial and day five lab results suggests the potential development of acute hemolytic anemia, likely triggered by the antibiotic Piperacillin-Tazobactam. The evidence for this includes:

Full Answer Section

Severe drop in hemoglobin and hematocrit: Suggests significant red blood cell destruction.
Elevated LDH: LDH is an enzyme released from damaged cells, including red blood cells. Its significant increase points towards ongoing hemolysis.
Nausea, vomiting, weakness, dizziness, pale skin, and jaundice: These are classic symptoms of hemolytic anemia and indicate potential liver involvement due to bilirubin buildup.
Timing: The symptoms and lab abnormalities appeared after five days of Piperacillin-Tazobactam therapy, suggesting a possible drug-induced reaction.

However, additional investigations are crucial to confirm the diagnosis and identify the specific mechanism of hemolysis. This might involve:

Direct and indirect bilirubin levels: To differentiate between hemolytic and non-hemolytic causes of jaundice.
Coombs test: To check for autoimmune antibodies targeting red blood cells.
Reticulocyte count: To assess the bone marrow's response to red blood cell destruction.
Review of past medical history and medications: To explore potential co-factors or other drug reactions.

Based on the above evidence and potential further investigations, a diagnosis of drug-induced hemolytic anemia due to Piperacillin-Tazobactam is highly suspected, requiring immediate discontinuation of the antibiotic and initiation of appropriate supportive and targeted treatment for the anemia.

It's important to note that this analysis is based on the provided information and should not be considered a definitive diagnosis. Consulting a healthcare professional is necessary for accurate diagnosis and optimal management of the patient's condition.

We are here to help

We have crazy offers

It’s quick and easy to place an order. We have an efficient customer service that works 24/7 to assist you.It’s quick and easy to place an order. We have an efficient customer service that works 24/7 to assist you.

We are here and ready to help

Order Now