A 61-year-old woman was evaluated because of 2 days of anuria, fever, anorexia, and progressive decline in mental status. Her medical history included cerebral palsy, and neurogenic bladder without diabetes, and not hypertension, type 2 diabetes, depression, and immunodeficiency. She was treated with indwelling bladder catheter to relieve urinary retention for ten years. She had no medication. The patient was evaluated by her primary care provider at her house. She had a temperature of 38.7C. Her consciousness level was Glasgow coma scale (GCS) E2V2M4. After two hours, she was admitted to the hospital because of fever with a disturbance of consciousness for further evaluation.
On examination, she appeared confused with a GCS score of 8/15 (E2V2M4). Her temperature was 37.8C, blood pressure 151/81 mmHg, heart rate regular at 95 beats per minute, percutaneous oxygen saturation 96% (room air), and respiration rate 26 per minute. The patient mentioned a discomfort in the suprapubic region. Her breath did not smell of alcohol, acetone, and ammonia. Bulbar (palpebral) conjunctivae were not injected or congested without icterus or pallor. The respiratory examination was unremarkable and abdominal examination revealed no stigmata of chronic liver disease or focal tenderness in the suprapubic area or costovertebral angles. A large, non-tender cystic mass was palpable in the suprapubic region. The patient`s neurologic examination revealed that she was slow to answer questions and follow commands, was hard of hearing, and had no asterixis. She could not give any details of her history or symptoms and did not say that she had a headache or stiff neck. The nursing staff noted that there was no urine in her urine bag.
Laboratory analysis at the time of admission are shown in Table 1. Urinalysis showed marked pyuria, a pH of 8.0, specific gravity 1.009, protein >4+, with numerous bacteria, >100 white blood cells, 10-19 red blood cells, 1-4 ammonium magnesium phosphate crystals, and 1-4 epithelial cells per high-power field in the sediment. The white blood cell count was 25,200 /mm3, with 93% neutrophils, 15% band forms, 2% lymphocyte, 1% monocyte; hemoglobin, 11.5 g/dL; hematocrit, 34.6%; and platelet count was 132,000 /mm3. Coagulation test revealed prothrombin time INR 1.44; the serum fibrinogen 447.5 mg/dL, fibrin/fibrinogen degradation products (FDP) 37.5 mug/mL. Biochemical analysis showed aspartate aminotransferase (AST) 43 IU/L, alanine aminotransferase (ALT) 23 IU/L, lactate dehydrogenase (LDH) 275 IU/L, alkaline phosphatase (ALP) 240 IU/L, total bilirubin (TB) 1.09 mg/dL, urea nitrogen (UN) 43.2 mg/dL, creatinine 1.2 mg/dL, creatine kinase (CK) 1222 IU/L, sodium 144 mEq/L, potassium 3.1 mEq/L, and C-reactive protein (CRP) 16.97 mg/dL. Blood ammonia level was elevated (176 mug/dL).
Head computed tomography (CT) and magnetic resonance imaging (MRI) revealed no factor responsible for consciousness disturbance, and chest CT showed no pneumonitis.
Abdominal CT and ultrasonography revealed bilateral hydronephrosis and bladder fullness with wall thickness in spite of indwelling bladder catheter, however, no sign of liver cirrhosis (Fig. 1).
Sepsis was diagnosed on the basis of qSOFA criteria (GCS < 15 and respiratory rate >=22) on admission and a bladder catheter exchange was performed. Her indwelling bladder catheter on admission was obstructed by blood clots. Before antimicrobial therapy was begun, two blood samples and one urine sample had been obtained for cultures. Tazobactam / Piperacillin, 2.25 g intravenously, was administered q6h. Approximately 10 h later, the patient had a temperature of 39.8C, her systolic blood pressure 60/30 mmHg, heart rate at 120 beats per minute, respiration rate 30 per minute, and she appeared ill. Extracellular fluid was administered for volume resuscitation. In addition, intravenous continuous infusion noradrenaline and methylprednisolone was administered. However, her mean arterial pressure (MAP) was 55 mmHg (<65), and lactate was 20 mg/dL (>2 mmol/L). Volume resuscitation, cardiovascular support, antimicrobial administration, and bladder catheterization were continued. Seven days later from admission, two blood cultures, blood clots culture, and one urine culture detected Proteus mirabilis. The P. mirabilis isolates from our patients was susceptible to Cefazolin, Cefotiam, Cefotaxime, Ceftazidime, Ceftriaxone, Cefepime, Piperacillin, Sulbactam / Ampicillin, Tazobactam / piperacillin, Gentamicin, Amikacin, Imipenem, Meropenem, Levofloxacin, and trimethoprim, but less to minocycline. The patient's level of consciousness and general condition improved rapidly and ammonia level had normalized (46 mug/dL). After she received rehabilitation, she was discharged on the 28th hospital day.