Case 2: Introduction

Richard Wilson, a 54-year old man presents to the Emergency Department. He has a 3-day history of fever, tiredness and feeling generally unwell. His medical background is significant for Type 2 diabetes mellitus (tablet controlled) and hypertension.

He also reports burning when passing urine and foul smelling urine. A urinalysis is positive for leucocytes and nitrites.

A diagnosis of sepsis secondary to a presumed urinary tract infection is made. The medical team starts empirical antibiotics to cover the likely source.

Unfortunately, he continues to deteriorate with falling blood pressure and rising lactate. Despite intravenous antibiotics and fluid, he remains haemodynamically unstable.

The patient is transferred to the Intensive Care Unit. There, a central venous catheter is inserted, along with invasive blood pressure monitoring. Antibiotic treatment with broader spectrum antibiotics is started and after 24 hours his fevers start to settle. Other parameters also stabilise.

Mr Wilson remains on the ICU for a further 4 days. He is noted to be stable and is slowly improving over this time but requires insulin to manage his blood glucose levels. There are concerns regarding his kidney function and he is put on urine output monitoring.

However, 5 days after admission, the patient develops pyrexia again. His blood pressure remains stable but heart rate is marginally elevated.

The medical team review the microbiology results. His urine taken at presentation has grown Escherichia coli which is susceptible to the antibiotics he is receiving.

Clinical examination reveals no significant findings. A further urinalysis did not show evidence of an UTI. An ultrasound of the abdomen and renal tract showed no significant abnormalities.

His chest x-ray is shown below:

The medical team on the ICU consider their next course of action…