Age: 68.0
Sex: U
Vaccine: COVID19
Symptoms: Bladder cancer, Blood bicarbonate normal, Blood calcium normal, Blood creatinine increased, Blood lactic acid normal
Clinical narrative: Worsening Pyelonephritis Date of Admission: 6/24/2024, Date of Discharge: 6/28/24 Subject enrolled in the Janssen study received first dose of study medication (Janssen ad26.CoV2. vaccine) on 8/29/2023 in Segment 1 low responder arm. 6/24/2024 Patient with nonmuscle invasive bladder cancer, ongoing intravesical gemcitabine/docetaxel instillation once weekly to complete 6 sessions. He presented for his final instillation session on 6/24/24 after lunch when he abruptly felt unwell and was sent back home. He subsequently experienced fevers, chills, nausea and an episode of nonbloody nonbilious emesis. He also noted a two-day history of dysuria and urinary urgency along with cloudy urine without urinary hesitation or urinary frequency. Of note, recent urine cultures growing Klebsiella pneumoniae and Proteus mirabilis on 06/10. He was prescribed ciprofloxacin on 6/13/2024. On admission he was on day 11 of treatment, reporting compliance with antibiotic. He states that his symptoms initially improved on ciprofloxacin but then returned 2 days ago. He denies any abdominal pain, flank pain, changes in bowel movement, hematuria, incomplete bladder emptying. Patient reports typically getting UTIs shortly after bladder instillation, however in this case his instillation was due this morning which he was unable to complete due to his symptoms. Of note, the patient has a longstanding history of recurrent E coli MDR/ESBL UTIs with multiple hospitalizations. ER Labs notable for stable normocytic anemia with hemoglobin 12.0, leukocytosis with WBC 10.2 with neutrophilic shift, bicarb21, creatinine 3.37, calcium 10.3. Lactate normal. LFTs within normal limit. Urinalysis with grade 2 proteinuria, large leukocyte esterase, many bacteria, positive nitrite, significant pyuria with WBC clumps and hematuria. Renal ultrasound pending. Chest x-ray unremarkable, flu and COVID testing negative. Patient was given 1 L fluids, 2 g cefepime and Tylenol, and admitted to medicine service for further management. On 6/25/2024, based on prior cultures and history patient was initiated on IV ertapenem. Renel allograft ultrasound completed with visible but not robust flow, unchanged from prior, stable borderline elevated resistive indices with patient vasculature. Renel pelviectasis without overt hydronephrosis noted. No additional IVF administered, creatinine improving. Immunosuppression continued. Transplant nephrology and transplant ID consulted. He was transferred to ACH for further management. Urine culture susceptibilities finalized, which noted ESBL and susceptibility to ertapenem. Patient was continued on ertapenem. He made a good clinical improvement with antibiotic treatment. He had slight bump in creatinine to 3.57 the day prior to discharge, which had improved to 3.2 on discharge. His tacrolimus levels were closely monitored, and the dosing was adjusted by renal transplant team. Discussed on the day of discharge with transplant team who recommended continuing 6 mg and they will follow-up with him in the next week. Home health antibiotic infusion was arranged by case management. Patient discharged 6/28/2024. Discharged diagnosis is Recurrent Pyelonephritis Study Principal investigator has assessed the causality as not study related.