Fever, abd pain in a patient on pred, mtx – pt2

A patient on immunosuppressive drugs for any reason needs serious pan-culturing and pan work-up.  Most infections can be diagnosed easily in a normal patient because the patient will localize the infection, and you will see signs of the infection on your work-up (infiltrate on cxr, e.g.).  In a patient with wbc-altering drugs, you may not see signs of infection on your work-up – even if the patient isn’t neutropenic.  Pneumonia may show up as a normal cxr.  In a patient with intestinal perforation, they may have a normal-ish exam and a normal-ish abd ct because there may not be signs of inflammation.

I scan EVERY pt with cc of abd pain when they’re on immunosuppressives, in addition to BCx x 2-3, ua / u cx, and cxr.  In addition, I ask for a surgical consult on every pt, even if the abd ct is negative.  A good consult will understand why they’re being called.  A bad consult will wonder why they’re being called for a pt with a negative ct.  I have had a handful of pts like this ending up in the OR, even with an initial ct that was negative (most had + ct despite a benign-ish exam).

In addition to the infection work-up, the patient requires a cbc, chem, and lactate.  Lactate is needed because it’s regarded as an indication of quality of medical care in patients with sepsis criteria.  Just like BCx were once regarded as an indication of quality in patients with pneumonia, lactate is a waste of time and money.  Despite my hatred of lactate, I almost always draw it so that the patient don’t have to be stuck a second time.

Perhaps without exception, patients with a high fever on immunosuppressives should be started on iv abx and admitted, regardless of their wbc count.

The patient’s wbc was 21; chem was normal.  The fever of 103 an wbc of 21 got the attention of the surgeons; they actually came to see the pt quickly.  Cxr and ua dip were negative, abd ct was negative.  The ua micro showed bacteria without wbc or rbc.  The patient was admitted for iv abx (and serial abd exams).  This turned out to be a pan-sensitive enterococcus pyelo.  There were no signs of pyelo on the ct (done with iv and po contrast).  The pt spent a week in the hospital and did well.

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