Patient is a 68-year-old male, initially admitted to an outside hospital for a 4 week productive cough, and 3 day fever (100-104F / 37.8-40C). Review of system was positive for chills, nausea, vomiting, diarrhea, dizziness, generalized weakness, and presyncopal symptoms.
T: 101F / 38C, BP: 90/45, HR: 95, RR: 15, SpO2: 99% on RA
Weight: 150 lb / 68 kg, Height 165 cm, BMI: 25 kg/m2
Constitutional: shivering, mildly ill appearing
Cardiovascular: tachycardia, no murmur
Pulmonary/chest: breath sounds are normal, no crackles
Abdominal: soft, no tenderness, no hepatosplenomegaly
Musculoskeletal: normal range of motion, no joint swelling, erythema
Skin: warm and dry
Neurological: alert, oriented, no focal deficits
Laboratory and other data:
WBC: 0.9 k/microliter, Hb: 13 mg/dl, Platelets: 130 k/microliter
Na: 140, K: 3.5, CO2: 24, BUN: 20, serum creatinine: 1 mg/dl
Glucose: 105, AST: 20, ALT: 20
SG: 1.025, Moderate Blood, Protein, 30 mg/dL, no WBC, RBC: 5-10
CXR: vascular congestion
CT of abdomen without IV contrast: Mild wall thickening of the descending and sigmoid colon which may be seen in colitis. Small right pleural effusion and trace left pleural effusion.
Patient was admitted and started on broad spectrum antibiotics. Infectious workup remained negative. Hypotension, fever, and neutropenia resolved.
However, ongoing decline in renal function over subsequent days (1 mg/dl -> 1.7 mg/dl -> 3 mg/dl -> 3.5 mg/dl) prompted renal evaluation.
Additional work up:
C3 – 11 (82-193 mg/dL)
C4 – 3 (15-57 mg/dL)
ANA, dsDNA, ANCA, RF neg, Anti SS-A &B, Scl-70 negative
CRP 2.5 (0.00-1.00 mg/dL)
SPEP & UPEP negative
Transient thrombocytopenia with a nadir of 35 k/microliter
Serum kappa 50 (3.3-19.4 mg/L); Lambda 40 (5.7 -26.3 mg/L); ratio 1.26 (normal ratio)
EBV IgG/IgM, CMV IgM negative
Mycoplasma IgG: 1.52 (ref range 0-1.1), IgM 77 (<770)
Cryoglobulin negative, rheumatoid factor: negative
24 hour urine protein 500 mg
Renal Ultrasound: small kidneys (9.4-9.5 cm), no hydronephrosis, echogenicity is within normal limits