Triage: Stroke code. LKW 2 hours ago. A & 0x4 at baseline, now only responsive to pain. EMS reported slurred speech and global weakness.
History of Present Illness: A woman in her late 40s with a history of DM is brought to the ER by medics for generalized weakness and slurred speech for the past 2 hours. Patient is too altered to provide any history. Family noted no focal weakness but stated she had a temperature of 102.0. Family also notes she has been complaining of abdominal pain and vomiting for the past 12-24 hours. There has been no reported headache, photophobia, cough, sore throat or other complaints.
Vital Signs: T: 38.4 °C (Oral) HR: 109, RR: 22, BP: 106/50, SpO2: 96%
Physical Exam: GENERAL: Comatose. Does not move either arm or legs to sternal rub but responds only with cries and moans, which continue for prolonged amount of time after sternal rub.
°NEUROLOGIC: No clonus. Toes downgoing. Cannot adequately assess for focal findings. GCS initially 4 but soon after improved steadily and is up to 11 within 20 minutes.
Initial Diagnostic Testing:
- CBC essentially normal, but CRP elevated at 11 and lactic acid elevated at 3.7.
- Metabolic panel shows potassium 3.2, bicarb 15, and creatinine 1.3.
- UA pending
- Code brain called: CT angio head shows no large vessel occlusion and CT of the head shows no hemorrhage.
- CXR normal except low volumes.
- CT abdomen cut shown below
What is the most likely cause of the fever?
- A) CVA
- B) UTI
- C) AAA
- D) SBO
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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
- Emergency Medicine 1-Minute Consult, 5th edition
- A-to-Z EM Pharmacopoeia & Antibiotic Guide, 5th edition
- 8-in-1 Emergency Department Quick Reference, 5th edition
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What is the most likely cause of the fever?
- A) CVA – not ruled out with testing so far but extremely unlikely to cause fever
- B) UTI – CORRECT – Pretest probability is high and CT scan shows hydronephrosis, increasing the risk
- C) AAA – not seen, doesn’;t cause fever
- D) SBO – not seen. Fever or hypothermia would be a late finding
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
CASE CONCLUSION: CT shows hydronephrosis on the left. Lower cuts showed an obstructing 3 to 4 mm left UVJ stone. The UA was negative for leukocyte esterase and nitrites, and had 0-5 wbc and moderate bacteria. Lack of pyuria should not be used to rule out UTI if clinical suspicion is otherwise hight, especially when there is bacteria and the patient is septic as pyuria is <90% sensitive for UTI, even in severe cases and especially in immune compromised patients or those with ureteral obstruction. The urine and blood cultures both grew >100,000 cfu/ml of E. coli. She ended up on 4 pressors in the ICU after urology took her to the OR at midnight for a ureteral stent. After 3 days she was well enough for discharge home.
CASE LESSONS:
- Pyuria should not be used to rule out UTI: sensitivity is <90% even in sepsis
- CT head rules out bleeds not strokes: You need a delayed MRI to rule out a stroke
- CBC is poorly sensitive for serious infection: only about 50% but likely closer to 70% if you used PMN <70% as part of your normal criteria
- Test Performance for SBI in Adult ED patient
- Fever 50% sensitive / 90% specific
- ¯ Sodium often low in bad infections
- WBC 70% sensitive / 70% specific
- ESR 75% sensitive / 75% specific
- SIRS criteria 85% sensitive / 60% specific
- PMN 85% sensitive / 75% specific
- Procalcitonin 85% sensitive / 85% specific
- CRP 90% sensitive / 90% specific