Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Arterial catheterisation, Atelectasis, Blood creatinine increased, Blood culture negative
Clinical narrative: Sepsis Date of Admission: 2/27/2024, Date of Discharge: 3/6/2024 Patient enrolled in the Janssen study received first study medication (Janssen ad26.CoV2.vaccine) on 8/29/2023 in Segment 1 low responder arm. Patient was recently hospitalization in December of 2023 for sepsis secondary to pyelonephritis of the transplant and kidney complicated by an AKI of the transplant kidney (patient discharged with renally adjusted ertapenem and daptomycin which was completed on January 8, 2024) presented to ER on 2/27/2024 with urinary retention in decreased flow for the past 2 days associated with fever. Patient denies any chest pain, cough, nausea, vomiting, or diarrhea. Outside urine culture from 2/27/2024 noted to be positive for E coli. +fevers overnight. 2/28/2024: Following initial admission to the floor, this patient became hypotensive with blood pressure 80s/30s, as well as febrile up to 102F. Rapid response was consulted, and the patient was examined at bedside. Patient reported no new symptoms aside from dry mouth and was mentating adequately. An arterial line was placed which showed blood pressure is 120/35, and he was given 1 g IV Tylenol for the fever and an additional 2 L of Plasmalyte for fluid resuscitation. CT Abdomen Pelvis without IV Contrast Result Date: 2/28/2024 Impression: 1. Mild to moderate wall thickening and edema of the cecum/ascending colon suspicious for colitis, infectious of inflammatory versus reactive in the setting of possible pyelonephritis. 2. Right lower quadrant renal transplant perinephric fat stranding is stable compared to 12/23/2023, however in the setting of positive urinalysis is suspicious for transplant pyonephritis. DX Chest Portable 1 View Result Date: 2/28/2024 Impression: Diminished lung volumes. Changes of median sternotomy and aortic valve replacement. Bibasilar atelectasis. No pneumothorax or pleural effusion. Stable cardiac silhouette. Summary of hospitalization: Imaging showed no renal abscess. Subject blood pressure gradually improved. His repeat bcx was NGTD and his PICC (inserted in the ICU) remains for outpatient plan of IV ertapenem for a total of 2 weeks (end date March 12th). Patient should receive appropriate antimicrobial prophylaxis (IV ertapenem 24hr before urologic procedure before any urological procedure in the future. Patient should no receive any further BCG intravesical therapy, given immunosuppression status is at risk of disseminated mycobacterial infection. Txp ID also repeated mycobacterium urine culture to rule out infection from his BCG therapy, which is pending at time of transfer. ongoing Acute kidney injury on CKD, his Cr peaked at 7. Txp Nephrology closely followed the patient and managed his immunosuppression regimen and intermittent diuresis with IV lasix. His Cr improved steadily during his stay, with a discharge creatinine of 4.5. losartan was held and in the meanwhile was started on a very low dose of hydralazine for management of blood pressures. Patient will resume losartan as outpatient after follow-up with Nephrology, once creatinine has improved. Patient has mild hypernatremia, that resolved with increasing free water intake. Home health care was arranged, patient will complete ertapenem on 03/12/2024 and PICC line will be removed when completed. Transplant team was approached on the day of discharge, patient's tacrolimus recommended dosing was 1 mg in the morning and 2 mg in the evening. Patient discharged 3/6/2024 to home health care. Discharge diagnosis is Sepsis. Study Principal investigator has assessed the causality as not study related.