March 23, 2026

HyperCRPaemia

HyperCRPaemia
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Season 4

Amie challenges Ben to work through a case of high CRP and fever. 

As you listen, ask yourself: can you figure out the diagnosis? What would you have done in the situation?


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Disclaimer: All patient stories discussed in Home of Medicine are informed by real patient interactions. However, all identifying details have been removed or appropriately modified to protect patient confidentiality. 

This podcast is intended for education and professional development and should not replace independent clinical judgement or specialist consultation.

Transcript
WEBVTT

00:00:11.439 --> 00:00:14.560
Hello and welcome to the Home of Medicine podcast with me, Dr.

00:00:14.640 --> 00:00:15.839
Amy Bearbridge.

00:00:16.399 --> 00:00:17.359
And with me, Dr.

00:00:17.440 --> 00:00:18.160
Ben Lovell.

00:00:18.239 --> 00:00:18.559
Hello.

00:00:18.879 --> 00:00:19.600
Hi, Ben.

00:00:19.679 --> 00:00:25.280
So I forgot to say this is a podcast in association with the Royal College of Physicians, Edinburgh.

00:00:25.440 --> 00:00:27.359
So, Ben, I've got a case for you.

00:00:27.519 --> 00:00:28.480
Are you ready?

00:00:28.719 --> 00:00:29.440
Yes, please.

00:00:29.679 --> 00:00:30.000
Go.

00:00:30.320 --> 00:00:41.280
Okay, so this is a 59-year-old female who presented to the emergency department with a 10-day history of viral symptoms.

00:00:41.600 --> 00:00:51.119
She describes a cough, cold, fever, headache, off of food, generally just feeling grotty.

00:00:51.920 --> 00:00:56.479
Now, I saw this patient in the winter months.

00:00:56.640 --> 00:00:59.679
So you know, we see this a lot, don't we?

00:01:00.159 --> 00:01:03.359
In ED and in AMU and SDEC or wherever we work.

00:01:03.439 --> 00:01:05.280
It's very frequent presentation.

00:01:06.079 --> 00:01:12.560
So whenever I sort of hear this history, my first thought is this is a virus.

00:01:12.799 --> 00:01:14.719
Would you come to hospital with a virus?

00:01:14.959 --> 00:01:16.879
What's what what else is going on?

00:01:16.959 --> 00:01:17.760
What about you?

00:01:18.000 --> 00:01:19.439
Any particular thoughts?

00:01:19.760 --> 00:01:22.879
Was this a referral um from the emergency department?

00:01:23.120 --> 00:01:23.359
It was.

00:01:23.439 --> 00:01:23.680
Absolutely.

00:01:24.560 --> 00:01:24.799
Yeah.

00:01:25.120 --> 00:01:26.560
So so I agree with you.

00:01:26.799 --> 00:01:30.159
10 days of viral like symptoms, it's a virus next.

00:01:30.319 --> 00:01:38.640
But what makes me a little bit intrigued, I guess, is why did our colleagues in the ED feel this necessary to refer on to the uh acute physicians?

00:01:38.799 --> 00:01:44.239
Because there's one thing that ED are very good at, it's sending people home with common organ winter viruses.

00:01:44.640 --> 00:01:52.400
So my question would be, hopefully without any signs of sort of sarcasm or any gender, but why did ED refer this to us?

00:01:52.560 --> 00:01:54.719
Um, what am I missing here?

00:01:55.120 --> 00:02:00.400
Because they need the the bed space and they could have turned this around in a heartbeat.

00:02:00.480 --> 00:02:03.120
So there's obviously a little bit more to the story.

00:02:03.439 --> 00:02:05.920
So I'm only gonna give you one blood test.

00:02:06.159 --> 00:02:06.480
Okay.

00:02:06.640 --> 00:02:06.719
Okay.

00:02:07.200 --> 00:02:08.719
W D Dimer, please.

00:02:08.960 --> 00:02:10.080
No, it's not Dimer.

00:02:10.319 --> 00:02:13.039
But this is the reason for the referral to the medics.

00:02:14.080 --> 00:02:17.280
CRP606.

00:02:18.159 --> 00:02:20.719
Oh, I love cases like these.

00:02:20.960 --> 00:02:29.439
We did an episode like this a long time ago, as they're sort of what is your upper limit, your comfort limit for a CRP, especially for viral infections.

00:02:29.599 --> 00:02:31.039
All right, thank you for that information.

00:02:31.120 --> 00:02:32.800
So that was that the reason for the referral?

00:02:33.039 --> 00:02:37.520
Yeah, well, I mean, she wasn't very well, but there wasn't, you know, sure.

00:02:38.159 --> 00:02:50.960
Observations were okay, but when you look at the CRP of CSO6, I always remember way back when in that episode you said to me, if the CRP is 300 plus, 400 plus, think abdomen.

00:02:51.599 --> 00:02:52.479
Did I say that?

00:02:52.719 --> 00:02:52.960
You did.

00:02:53.199 --> 00:02:54.080
Oh, okay, okay.

00:02:54.479 --> 00:02:54.719
Yeah.

00:02:55.120 --> 00:02:56.159
And I remember that.

00:02:56.319 --> 00:03:05.280
Um, so uh she came down to our MAU and she was on intravenous antibiotics, chemoxyclave, and with a CRP of 606.

00:03:05.599 --> 00:03:13.840
But our role and the reason for EFIR was to try and identify the source of the infection because that had quite been identified.

00:03:14.719 --> 00:03:17.039
So right, okay.

00:03:17.199 --> 00:03:17.759
I love it.

00:03:17.919 --> 00:03:18.159
All right.

00:03:18.719 --> 00:03:21.439
This is the kind of case that really, really interests me.

00:03:21.599 --> 00:03:21.919
Yeah.

00:03:22.080 --> 00:03:23.439
Um absolutely.

00:03:23.680 --> 00:03:28.159
So I need to go and and talk to the woman and say, what is your history?

00:03:28.800 --> 00:03:34.240
And and I I I will ask questions to, but what I'm really asking her is where are you hiding an infection from me?

00:03:34.479 --> 00:03:37.439
Her symptoms I will try and drill down on on.

00:03:37.759 --> 00:03:44.800
The S bar, the hand wave I'm getting is that I got cough, I got cold, I got fever, and I got headache.

00:03:45.039 --> 00:03:47.039
So maybe it was a viral infection.

00:03:47.120 --> 00:03:54.240
And as you know, as my grandma say, it went to her chest and they what we call a superadded respiratory bacterial infection.

00:03:54.479 --> 00:03:59.520
So she might now be in a pneumonic phase or started off as a viral illness.

00:03:59.840 --> 00:04:02.240
Um, cough, cold, fever, headache.

00:04:02.400 --> 00:04:11.520
Ooh, I mean, we've got to make sure she hasn't got herself a meningitis or a CNS infection as well that started off with um uh something like a simple viral infection.

00:04:11.680 --> 00:04:17.360
Um, and of course I will examine the album, but I think this starts with a good old-fashioned history, please.

00:04:17.680 --> 00:04:18.399
Absolutely.

00:04:18.560 --> 00:04:27.439
Okay, so on questioning, the reason she'd come to hospital originally is although she'd been unwell for 10 days, she'd actually had a fall.

00:04:27.759 --> 00:04:32.319
And she'd had a fall and she was unable to mobilize when she'd fell to the floor.

00:04:32.480 --> 00:04:34.639
This was the day before I saw her.

00:04:34.800 --> 00:04:42.240
She'd been on the floor for quite a little while, was unable to get up, wasn't able to mobilize due to weakness and some pain.

00:04:42.959 --> 00:04:50.800
And she eventually managed to call an ambulance, 999, the 999 crew came and they brought her into hospital.

00:04:51.040 --> 00:05:00.399
Now, on further questioning, she said that she was pottering along in the house and she had quite a significant pain in her right hip and she fell.

00:05:01.040 --> 00:05:11.120
And she doesn't remember injuring herself or she didn't bang her head, she doesn't remember losing consciousness, but she just remembers just feeling weak and lying on the floor.

00:05:12.240 --> 00:05:20.079
She denies any chest pain, any shortness of breath, any abdominal pain, any diarrhea, any constipation.

00:05:20.240 --> 00:05:28.319
She had a little bit of urinary frequency, urgency, and dysuria, and her appetite wasn't as good as it normally was.

00:05:29.199 --> 00:05:39.839
But she remembers vividly that she was walking and just sort of I you know sometimes patients will say to me, When they've had a fall, their legs just gave way.

00:05:40.560 --> 00:05:41.839
Like, did you trip over anything?

00:05:41.920 --> 00:05:42.079
No.

00:05:42.240 --> 00:05:43.439
Did you lost lose consciousness?

00:05:43.680 --> 00:05:45.199
No, I just went down.

00:05:46.240 --> 00:05:52.639
So on further questioning, she lived alone and has funny mobile, absolutely no issue.

00:05:52.720 --> 00:06:11.120
She had a past medical history of osteoarthritis and hypertension and took amylodopene and paracetamol PRN, but nothing else of note, had no known allergies that she was aware of, and was a non-smoker, drank alcohol, quite a bit of alcohol, actually.

00:06:11.279 --> 00:06:17.040
Probably she said around two to three bottles of wine per week, but no um smoking.

00:06:17.360 --> 00:06:21.839
She worked full-time, um, a sort of an admin type role.

00:06:22.079 --> 00:06:27.680
No family history of anything significant of note, and hadn't been hospitalized in the past.

00:06:28.879 --> 00:06:30.639
What you're thinking about, Nensa.

00:06:30.959 --> 00:06:35.759
Though um I'm getting the history of presenting pain just fixed in my mind.

00:06:35.920 --> 00:06:44.639
Um, she's 59 and she had a fall with a long lie, and her the reason for the fall is legs gave way and she felt too weak to get up.

00:06:44.720 --> 00:06:47.759
And did you say hip pain pre- or post-fall?

00:06:48.639 --> 00:06:51.360
Difficult to identify, if I'm being honest.

00:06:51.519 --> 00:06:56.480
So she had hip pain, right hip pain, and the pain went down to the knee.

00:06:56.720 --> 00:06:59.759
Now, I was finding it difficult to elucidate.

00:06:59.839 --> 00:07:04.720
Did this pain start before the fall and cause the fall, or did the pain start after the fall?

00:07:04.959 --> 00:07:11.360
Now, when looking at the AE notes, it said patient's right leg is externally rotated.

00:07:11.920 --> 00:07:13.519
Could this be a hip fracture?

00:07:13.680 --> 00:07:16.160
And they'd actually done a CT hip.

00:07:16.480 --> 00:07:17.199
Oh, okay.

00:07:17.439 --> 00:07:18.720
Which is normal.

00:07:20.240 --> 00:07:21.199
Um, all right.

00:07:21.360 --> 00:07:22.480
So she folded it.

00:07:22.720 --> 00:07:26.160
And what I was thinking originally, 59 isn't is is not old.

00:07:26.399 --> 00:07:29.279
And it's too young for someone to have a fall in a long lie.

00:07:29.439 --> 00:07:42.079
And I did wonder, I was going to ask about alcohol because sometimes that can be um uh the factor which means someone who looks on paper to be quite young to fall over and spend a bit of time on the floor in the context of intoxication.

00:07:42.240 --> 00:07:52.399
Um and maybe that's still got something to do with it because 59 it's just just it's too young, really, to to go all week and all wobbly and all of a doo-dar and fall over and not be able to immediately get up and go ow.

00:07:52.560 --> 00:07:57.680
That that that's not doesn't quite fit unless there was um unless there was alcohol in the picture as well.

00:07:57.759 --> 00:07:59.120
So that's one thing I'm thinking.

00:07:59.680 --> 00:08:06.560
Um, and the hip pain, um, which may or may not have been a sequelee of the fall, and the CT hips normal, all right.

00:08:06.639 --> 00:08:10.480
And the CRP, actually, let's park the CRP for now, let's stick with the history.

00:08:11.040 --> 00:08:13.120
Um, anything else I want to ask?

00:08:13.279 --> 00:08:18.160
So, did you say and all of this was on the back end of 10 days of a viral infection?

00:08:18.560 --> 00:08:18.959
Yes.

00:08:19.199 --> 00:08:23.199
Okay, fevers, cough, cold, uh, and all that sort of thing.

00:08:23.519 --> 00:08:24.399
All right, all right.

00:08:24.480 --> 00:08:26.000
I'm happy with that.

00:08:26.160 --> 00:08:28.879
Um, and did she walk into the hospital?

00:08:29.199 --> 00:08:30.639
No, she wasn't able to walk.

00:08:30.879 --> 00:08:41.120
And the ambulance crew um got her up, they put her onto a trolley, and they brought her into the UD department, and she hadn't been able to walk since since she'd been in either a trolley or a bed.

00:08:41.360 --> 00:08:45.120
I find incredibly useful is we have access to the ambulance.

00:08:45.519 --> 00:08:48.240
I was gonna ask, any insights from the truth?

00:08:48.639 --> 00:08:50.480
So write some really cool stuff in there.

00:08:50.799 --> 00:08:51.679
So interesting, yeah.

00:08:51.759 --> 00:09:00.720
And I think when we are clinically reasoning and we're in that sort of first stage of gathering information, that information has to come from everywhere.

00:09:00.960 --> 00:09:06.000
And I find the ambulance information sheet a font of information and knowledge.

00:09:06.240 --> 00:09:08.080
So, yeah, there was some information on there.

00:09:08.159 --> 00:09:15.519
They said that they found her on the floor, that she had a temperature when they saw her, a temperature was 38.4 when the paramedics saw her.

00:09:15.600 --> 00:09:19.679
She had a heart rate of 141 when they saw her and picked her up in the ambulance.

00:09:19.759 --> 00:09:23.759
But her blood pressure was okay, respirator, oxygen saturations were normal.

00:09:24.080 --> 00:09:25.600
GCS was 15.

00:09:25.840 --> 00:09:36.000
They commented that she was unable to weight bear due to generalized pain in the lower back, in the spine, where she looked looked like she'd fell, but also in the right hip and the knee.

00:09:36.080 --> 00:09:39.120
So this hip pain and this knee pain was coming up again.

00:09:39.279 --> 00:10:00.159
But also she was very chrysal, just looked fluy, weak, exhausted, didn't really have any other information on there, apart from the fact that she lived alone, that her house was lovely, you know, there was no safeguarding issues, which sometimes I think it's really helpful when you read the ambulance notes, is they will often comment on what the house is like.

00:10:00.320 --> 00:10:02.000
So is it very clean?

00:10:02.080 --> 00:10:02.720
Is it dirty?

00:10:02.879 --> 00:10:06.000
Does it look like, you know, there's a dirty washing around, are they eating?

00:10:06.159 --> 00:10:07.440
And it's very helpful.

00:10:07.519 --> 00:10:10.639
But no, there was no concerns raised at all.

00:10:12.000 --> 00:10:18.159
All right, so I think I've fleshed out the the um history as much as I'd like now.

00:10:18.320 --> 00:10:25.600
Before we come on to the investigation, such as the CRP and the CT hip, we need to lay our hands upon this patient.

00:10:26.000 --> 00:10:36.559
And I would like to examine her, and I want to examine her chest, and I want to um examine her abdomen, but I want to do a neurological exam of her limbs.

00:10:37.679 --> 00:10:38.240
Yeah.

00:10:38.720 --> 00:10:39.360
Why?

00:10:39.840 --> 00:10:41.120
Well, she's not walked.

00:10:41.279 --> 00:10:42.480
Are her legs working?

00:10:42.960 --> 00:10:48.480
That's gosh, you can tell I'm a high highly trained clinical uh professional, can't you?

00:10:48.720 --> 00:10:50.240
You can tell I'll be neurophobic.

00:10:50.720 --> 00:10:51.600
Neurology need it.

00:10:51.759 --> 00:10:52.159
Why?

00:10:53.279 --> 00:10:54.399
Legs working.

00:10:54.720 --> 00:10:57.840
Has she got a uh a subacute or acute neurological event?

00:10:57.919 --> 00:10:58.639
Has she had a stroke?

00:10:58.799 --> 00:10:59.120
Hey.

00:10:59.200 --> 00:10:59.919
Oh, yeah.

00:11:00.399 --> 00:11:04.240
Has she fallen over and got has she got corder aquina syndrome?

00:11:04.320 --> 00:11:08.000
Has she shructured some vertebrae and she's got spinal canal compression?

00:11:08.159 --> 00:11:12.480
And so so yeah, I want to know why she she hasn't why did she not get up off the floor?

00:11:12.639 --> 00:11:12.879
Yeah.

00:11:13.440 --> 00:11:15.440
Anyone should be able to get up from the floor.

00:11:15.600 --> 00:11:15.759
Yeah.

00:11:15.919 --> 00:11:24.000
And it's just made me think about when you said corder aquina, bowels and bladder, which uh just came into my head was, you know, did she have sensation?

00:11:24.080 --> 00:11:27.039
It's really important, isn't it, to ask about do you know when you need a wee and a poop?

00:11:27.200 --> 00:11:29.120
Which um again, very simple questions.

00:11:29.279 --> 00:11:47.279
Okay, so on examination, when I saw her, her resp rate was 18, her saturations were 96% on air, BP was 118 over 74, her temperature was 37.3, heart rate was 97, GCS 15.

00:11:48.000 --> 00:12:00.639
Okay, chest was clear, heart sounds were normal, there was no palpable lymph adenopathy in the neck that I could identify.

00:12:00.960 --> 00:12:10.960
On examination of the legs, the right leg did look externally rotated, and the knee looked a little bit swollen.

00:12:11.120 --> 00:12:14.879
And she said that the knee was sore and painful after the fall.

00:12:16.240 --> 00:12:22.960
But apart from that, I didn't do a neurological examination, which I should have done.

00:12:23.120 --> 00:12:30.720
Um thank you for highlighting that because you're absolutely right, and I think that's one of the things that I miss, and I'm sure others do.

00:12:31.600 --> 00:12:38.720
And again, it's my fear of neurology, is when somebody has a fall, it's really important to examine their neurological system.

00:12:38.879 --> 00:12:43.039
And I do, but maybe not every time, and I didn't in this case.

00:12:43.279 --> 00:12:44.480
So that is my bad.

00:12:45.200 --> 00:12:50.639
There are a few um there are a few triggers in my head where I just think always do a neuro exam.

00:12:50.799 --> 00:12:54.559
One of them is head headache, one of them is back pain.

00:12:55.840 --> 00:12:58.559
And the um another one is legs gave way.

00:12:58.639 --> 00:13:05.679
Uh and they I always, and I'm not listening you should see my neurological exam, you'd be horrified, but I think I get the data I mean.

00:13:06.799 --> 00:13:08.240
Can you move this foot?

00:13:08.399 --> 00:13:10.000
Can you feel me here?

00:13:10.320 --> 00:13:13.440
Can you uh let your legs can you uh let me hit you with this hammer?

00:13:13.679 --> 00:13:16.399
I'm just gonna tickle the bottom of your foot here and watch what happens.

00:13:16.559 --> 00:13:28.960
But I I I think you know, it does give me some as a screen, some really useful information sometimes, even that's to say um there is no pathology which is related to the cord um in this particular patient, for example.

00:13:29.279 --> 00:13:30.240
Okay, yeah.

00:13:31.440 --> 00:13:32.080
All right.

00:13:32.399 --> 00:13:35.120
So I've got my history, I've got my exam.

00:13:35.279 --> 00:13:38.399
Now I'm gonna do some blood tests, please.

00:13:38.559 --> 00:13:41.519
I know you've already given me some, but I'm just going through it methodically in my head.

00:13:41.600 --> 00:13:43.279
Is the full blood count okay?

00:13:43.840 --> 00:13:46.080
White cell, 22.2.

00:13:46.480 --> 00:13:47.200
Elevated.

00:13:47.519 --> 00:13:50.080
Neutrophil, 20.56.

00:13:50.639 --> 00:13:51.360
Elevated.

00:13:51.679 --> 00:13:53.519
Urea, 22.6.

00:13:53.919 --> 00:13:55.039
Oh, elevated.

00:13:55.360 --> 00:13:57.120
Creatineme 243.

00:13:57.600 --> 00:13:59.360
Okay, that's very abnormal.

00:13:59.440 --> 00:13:59.600
Yep.

00:14:00.639 --> 00:14:03.840
CK, 4834.

00:14:04.000 --> 00:14:05.360
That's a creatine kinase.

00:14:05.600 --> 00:14:06.879
1834.

00:14:07.200 --> 00:14:08.240
Okay, four digits.

00:14:08.480 --> 00:14:08.639
Yeah.

00:14:08.879 --> 00:14:12.159
Lactate on the gas, the VBG was 2.1.

00:14:12.639 --> 00:14:13.039
Yeah.

00:14:13.679 --> 00:14:15.519
PH 7.31.

00:14:16.480 --> 00:14:17.840
7.31.

00:14:18.320 --> 00:14:20.320
Hemoglobin 121.

00:14:22.240 --> 00:14:25.279
LFTs normal, clotting normal.

00:14:26.000 --> 00:14:26.320
Oh.

00:14:28.159 --> 00:14:28.720
All right.

00:14:28.879 --> 00:14:32.879
Do we have any previous renal function for this patient?

00:14:33.279 --> 00:14:38.159
No previous renal function, no hospital admissions, presumed to be normal.

00:14:38.559 --> 00:14:38.879
Okay.

00:14:39.200 --> 00:14:46.639
So she has either an AKI with a creatinine 243, or this could be her normal level as a CKD.

00:14:46.879 --> 00:14:54.799
I think her acute illness um um and the slight metabolic acidosis points more towards this being an AKI.

00:14:55.200 --> 00:15:01.039
Um, in terms of why this could be an AKI, this could be pre-renal because she's volume deplete.

00:15:01.120 --> 00:15:03.600
I don't know how long she spent on the floor not drinking fluids.

00:15:03.759 --> 00:15:05.679
You think it was more than 12 hours?

00:15:06.639 --> 00:15:07.279
I do.

00:15:07.679 --> 00:15:14.879
I wonder whether because uh that CK of nearly 5,000, you wouldn't get that if you're on the floor for like 20 minutes.

00:15:15.200 --> 00:15:22.159
Um, and it's it's difficult to elicit the time frame because she was unaware of when the ambulance came and when she fell.

00:15:22.320 --> 00:15:26.480
She said that it feels like she fell at night, and when the ambulance came, it was in the day.

00:15:26.559 --> 00:15:28.879
So maybe she was on the floor for 12 hours, could have been less.

00:15:29.200 --> 00:15:30.399
It sounds very vague.

00:15:30.639 --> 00:15:37.519
Very vague for someone who's who's middle age, you know, is not old or prone or vulnerable to delirium.

00:15:37.919 --> 00:15:45.039
And I saw this patient with a um, I can't remember, with another doctor, and they were like, I think she's got delirium.

00:15:45.200 --> 00:15:45.919
And I was like, really?

00:15:46.399 --> 00:15:55.120
She doesn't seem like she's delirious, but just not as um, I guess, sharp as I would expected.

00:15:55.360 --> 00:16:00.480
But then she has got AKI, she's got a high CK and the CRP is 606.

00:16:01.200 --> 00:16:02.159
So Right.

00:16:02.240 --> 00:16:02.480
Yeah.

00:16:02.639 --> 00:16:02.879
Yeah.

00:16:03.200 --> 00:16:03.440
Okay.

00:16:03.600 --> 00:16:14.720
So I was saying AKI could be pre-renal due to dehydration if she was on the floor not drinking, due to the CK, which is um toxic to uh nephrons, so that's contributing as well.

00:16:14.960 --> 00:16:18.720
Um, medications-wise, just the amodipines are nothing to blame on there.

00:16:19.039 --> 00:16:22.879
Could it be an intrinsic renal cause of an AKI like an acute glomerulophritis?

00:16:22.960 --> 00:16:24.080
Would it be unlikely?

00:16:24.240 --> 00:16:28.480
Or could it be post-renal, i.e., ishi and urinary retention.

00:16:28.799 --> 00:16:32.320
You didn't feel a big distended bladder or an abdominal exam, did you?

00:16:32.639 --> 00:16:33.919
She did have a big bladder.

00:16:34.080 --> 00:16:34.879
Absolutely.

00:16:35.120 --> 00:16:40.159
And I'm I'm getting you know you're gonna shoot me when I say this, Ben, but I did an ultrasound scale.

00:16:42.000 --> 00:16:42.799
I don't mind you.

00:16:42.960 --> 00:16:44.639
I'll just say, I'm glad you've got a hobby.

00:16:44.799 --> 00:16:45.600
I think it's fantastic.

00:16:45.840 --> 00:16:47.120
My new favourite skills.

00:16:47.200 --> 00:16:51.360
And it's really helpful because you can scan the kidneys to identify if there was hydronephrosis.

00:16:51.519 --> 00:16:58.080
There was no hydronephrosis, but she did have a purple bladder, and you can actually budget how many mils were in the bladder.

00:16:58.240 --> 00:17:00.240
It was around three to four hundred mils, so not a lot.

00:17:00.399 --> 00:17:01.360
Well, that's not so much.

00:17:01.440 --> 00:17:03.919
No, but I I think less than half a liter.

00:17:04.160 --> 00:17:06.640
I tend not to get too too aggravated about that.

00:17:06.880 --> 00:17:10.000
So I think as obstructive uropathy would be less likely here.

00:17:10.079 --> 00:17:13.359
So all right, um, so I think she's got a prerenal AKI.

00:17:13.440 --> 00:17:14.160
That's um number one.

00:17:14.240 --> 00:17:15.759
Let me jot that down here.

00:17:16.319 --> 00:17:17.920
Prereenal AKI.

00:17:18.000 --> 00:17:20.000
That's going in my my assessment at the end.

00:17:20.160 --> 00:17:23.359
Now, then you gave me the CRP, which is 600.

00:17:23.519 --> 00:17:33.759
And at the moment, I'm jotting down after pre-renal AKI, I'm writing down V high CRP of uncertain cause, just as a note to myself.

00:17:33.920 --> 00:17:36.960
Sometimes I do write that as a diagnosis, by the way, in a clerking.

00:17:37.039 --> 00:17:39.920
You I really don't know, but at the moment, aid a memoir.

00:17:40.319 --> 00:17:41.119
All right then.

00:17:41.200 --> 00:17:42.720
So they're my blood results.

00:17:42.799 --> 00:17:44.880
Now, I'd like to do some imaging.

00:17:45.279 --> 00:17:50.559
Um, I think I would like a chest x-ray, please, based on that very high CRP and a recent cough.

00:17:51.039 --> 00:17:51.680
Normal.

00:17:52.400 --> 00:17:53.200
Thank you.

00:17:53.440 --> 00:18:01.279
Um, I know you've given me a CT hip already, but how I would approach it is a plain x-ray of the pelvis and the hip joints to look for a fractured knob.

00:18:01.440 --> 00:18:04.319
And I'm assuming that was normal, hence the subsequent CT.

00:18:05.359 --> 00:18:10.559
So um there was a x-ray of the hip and the pelvis stun earlier.

00:18:10.640 --> 00:18:10.799
Yeah.

00:18:11.119 --> 00:18:18.559
And the report from the CT from the X-ray of the pelvis is normal, and it comments that there's a possible fracture in the patella.

00:18:19.119 --> 00:18:22.079
Uh but in the wall, the patella?

00:18:22.240 --> 00:18:22.400
Yeah.

00:18:22.880 --> 00:18:25.200
Blammy, that that x-ray pelvis went quite low.

00:18:25.440 --> 00:18:26.960
They x-rayed the knee as well.

00:18:27.839 --> 00:18:38.400
But I mean, I am it's not my area of expertise, x-ray knees, um, but it's commented that there's a line through the patella, potentially a fracture.

00:18:38.559 --> 00:18:44.400
Um, but she didn't have the knee Ct'd, she had the hip Ct'd and the pelvis, which as I say was normal.

00:18:44.799 --> 00:18:50.079
Okay, because my next question was I was gonna say x-ray pelvis, x-ray of the knee, please, because you said the knee was swollen.

00:18:50.240 --> 00:18:57.039
Yes, the yeah, the x-ray of the knee suggested a patella fracture, and then subsequently you said CT of pelvis.

00:18:57.200 --> 00:18:58.480
Did you say CT knee as well?

00:18:58.720 --> 00:19:00.400
No, CT knee wasn't done.

00:19:00.880 --> 00:19:02.160
Ct pelvis.

00:19:03.519 --> 00:19:05.519
All right, and that was normal.

00:19:06.880 --> 00:19:07.200
Okay.

00:19:07.519 --> 00:19:16.720
Okay, so let me write down I've got pre-renalic care number one, I've got a very high CRP of uncertain cause, number two, number three, query patellar fraction.

00:19:17.440 --> 00:19:17.759
Right.

00:19:17.839 --> 00:19:25.599
So And imagine when I examined the knee, the knee was painful and it was swollen and it felt quite hot as well to touch.

00:19:25.920 --> 00:19:29.680
And could you have a range of motion at the hips when you examined her?

00:19:30.079 --> 00:19:32.000
The hips were okay.

00:19:32.160 --> 00:19:34.480
So, first of all, I always like to examine the good side.

00:19:34.559 --> 00:19:35.839
So I looked at the left side.

00:19:36.000 --> 00:19:36.240
Yeah.

00:19:36.400 --> 00:19:41.039
And it wasn't a great range of movement because she was unwell and I think she was quite weak.

00:19:41.119 --> 00:19:44.319
But examination of the right knee, she could the right hip, she could move it.

00:19:44.480 --> 00:19:52.400
On examiner of the right knee, it was reduced range of movement, and it was certainly painful to move and and felt warmed to me.

00:19:52.559 --> 00:19:52.720
Yeah.

00:19:53.119 --> 00:19:54.640
With a clinical effusion.

00:19:55.359 --> 00:19:55.519
Yeah.

00:19:55.759 --> 00:19:57.359
Yeah, I thought there was an effusion.

00:19:57.519 --> 00:20:06.559
And from my pre-rheumatology, from my pre-acute medicine days when I was a rheumatology reg, um, I was like, oh yeah, all about 20 mils in there.

00:20:06.720 --> 00:20:09.359
Oh yeah, uh I I don't know how much was in there, but yeah.

00:20:09.599 --> 00:20:09.759
Okay.

00:20:09.920 --> 00:20:11.680
Well, there was definitely an effusion there.

00:20:12.240 --> 00:20:20.720
So what I've got now is pre-renal AKI, very high CRP of unknown cause, possible patello fracture on x-ray, but a painful effusive right knee.

00:20:20.880 --> 00:20:30.480
I'm gonna reorder that slightly and say, and now I'm gonna say working diagnosis, query septic joint, query septic knee needs urgent aspiration.

00:20:30.720 --> 00:20:31.039
Okay.

00:20:31.200 --> 00:20:32.799
That would explain a couple of things.

00:20:32.960 --> 00:20:37.279
That would explain the leg giving away, not being able to stand up again, the high CRP.

00:20:37.680 --> 00:20:41.359
Um I'm gonna say number two, AKI due to septus and dehydration.

00:20:41.519 --> 00:20:45.759
Then I'm gonna say number three, possible patella fracture.

00:20:45.839 --> 00:20:48.880
Um, but that would be weird to have a fracture and an effusion on the same side.

00:20:48.960 --> 00:20:51.599
It could be nothing, but I'm gonna put that in my back pocket for now.

00:20:51.839 --> 00:20:52.000
Okay.

00:20:52.240 --> 00:20:58.880
So I've got to say my plan at the moment would be the CRP I might lay at the door based on what I've got of the knee.

00:20:59.279 --> 00:21:03.039
So I want number one, IV antibiotics.

00:21:03.200 --> 00:21:12.319
Number two, urgent aspiration of knee, um, looking for uh signs of infection or signs of a crystal arthropathy.

00:21:12.480 --> 00:21:17.279
So gout can give you a super duper CRP and painful knee.

00:21:17.359 --> 00:21:17.519
Yeah.

00:21:17.680 --> 00:21:20.000
Um number three, she needs some fluids.

00:21:20.160 --> 00:21:20.319
Yeah.

00:21:20.480 --> 00:21:25.920
So I prescribe some Ivy Hartmans and then check her renal function maybe in 12, 24 hours.

00:21:26.079 --> 00:21:31.440
Number four, I would be monitor her urine output, just make sure she does pass urine.

00:21:31.599 --> 00:21:37.519
Number five, I'd be repeat CK after the first one or two liters of fluid to make sure that it's coming down.

00:21:37.759 --> 00:21:38.079
Yeah.

00:21:38.319 --> 00:21:43.200
Um, and number six, I would say radiology opinion of the x-ray of the knee.

00:21:43.279 --> 00:21:46.000
Query further investigation such as CT required.

00:21:46.240 --> 00:21:46.720
There you go.

00:21:46.799 --> 00:21:48.240
That's my post-take plan.

00:21:48.400 --> 00:21:55.599
Oh, and of course, um patient for full escalation of treatment and uh needs prophylaxis against um VT uh VT prophylaxis.

00:21:55.680 --> 00:21:56.000
So low.

00:21:56.480 --> 00:21:56.720
Okay.

00:21:57.279 --> 00:21:58.240
So two questions.

00:21:58.319 --> 00:21:59.279
You said antibiotics.

00:21:59.359 --> 00:21:59.839
What antibiotics?

00:22:00.480 --> 00:22:01.200
Would you like to use?

00:22:01.519 --> 00:22:01.920
Right.

00:22:02.640 --> 00:22:06.480
I guess if you're thinking septic arthritis, you want to go for something like flu clocks.

00:22:06.559 --> 00:22:11.680
However, I'm going to keep it nice and broad and my hospital, broad spectrum antropolics for fever of unknown origin.

00:22:11.920 --> 00:22:14.960
So septic origin is iV keferoxine.

00:22:15.039 --> 00:22:16.160
So I have some of that, please.

00:22:16.400 --> 00:22:20.000
Okay, so you're gonna need IV kefroxine because you're still not sure where the fever's coming from.

00:22:20.160 --> 00:22:24.079
So you're sort of a fever of a fever and CRP of unknown origin.

00:22:25.920 --> 00:22:28.240
Do you want to do anything with this abdomen?

00:22:28.480 --> 00:22:31.920
Because, you know, I remember you telling me before, hi CRP think abdomen.

00:22:32.880 --> 00:22:42.079
Her abdomen was soft and non-tender with a distended bladder, no organomegaly, um, and obviously no signs of rigidity or peritonism at all.

00:22:42.880 --> 00:22:47.920
Um so you're saying to me, do I want to do a CT abdoelbus as a look on an infection hunt?

00:22:48.079 --> 00:22:48.559
I might.

00:22:48.640 --> 00:22:49.200
But you know what?

00:22:49.279 --> 00:22:50.799
I'm gonna tap the knee first.

00:22:51.119 --> 00:22:53.599
Let's not throw everything at the wall and see what sticks.

00:22:53.680 --> 00:22:56.319
Let's have an orderly a progression of ideas.

00:22:56.640 --> 00:22:56.960
Okay.

00:22:57.279 --> 00:23:01.200
Would you aspirate the knee or would you get some would you get a specialty to do it?

00:23:01.440 --> 00:23:02.880
Ah, good question.

00:23:03.119 --> 00:23:05.200
I think probably I would get a specialist to do it.

00:23:05.279 --> 00:23:07.359
I'd get I'd ask orthopedics to do it.

00:23:07.519 --> 00:23:09.920
Septic arthritis is an emergency.

00:23:10.079 --> 00:23:16.880
Um, I have done the aspirations because I trained when it was on the curriculum as a procedure for a med reg to be able to do.

00:23:17.039 --> 00:23:22.160
Um, and I used to work in a DGH in the late district where you were you did everything.

00:23:22.240 --> 00:23:24.319
Um so you'd stick a needle in and see what happened.

00:23:24.640 --> 00:23:34.480
Whereas now, now I don't think, and rightly so, I don't think patients or hospitals tolerate let's stick a needle in and see what happens.

00:23:34.559 --> 00:23:36.559
That's not how we do things anymore.

00:23:36.720 --> 00:23:40.799
We have people trained up to do things safely and to be successful the first time.

00:23:40.960 --> 00:23:41.519
Yeah.

00:23:41.839 --> 00:23:42.160
Yeah.

00:23:42.400 --> 00:23:43.599
Okay, absolutely.

00:23:43.839 --> 00:23:49.359
So there is nothing I love more than putting a needle in a knee.

00:23:49.599 --> 00:23:53.039
Um, because I was I did do rheumatology and I do still love it.

00:23:53.200 --> 00:23:55.039
I think it's like a bit of a passion of mine.

00:23:55.200 --> 00:23:57.279
So we aspirated the knee.

00:23:57.519 --> 00:24:03.200
And out of this knee, for the first time in my whole career, came Frank Puss.

00:24:03.599 --> 00:24:04.240
Wow.

00:24:04.880 --> 00:24:06.720
I had never seen anything like it.

00:24:06.799 --> 00:24:13.680
So I've had seen a quite a lot of septic arthritis, but I've never seen a pus frank pus like that.

00:24:13.759 --> 00:24:17.839
It's normally been Sun of Your Food, is maybe a bit of turbidity, but this is pure pus.

00:24:18.160 --> 00:24:18.960
What did it look like?

00:24:19.039 --> 00:24:19.680
Just like cream.

00:24:19.839 --> 00:24:23.359
Yeah, it was like cream, it's like really cream, it was like um snot.

00:24:24.079 --> 00:24:24.720
Wow.

00:24:25.279 --> 00:24:25.680
Yeah.

00:24:25.920 --> 00:24:33.200
It was really like, wow, and just on that note, my favourite question why is snot green?

00:24:33.359 --> 00:24:34.559
And why is pushing?

00:24:34.880 --> 00:24:42.960
Oh why is it it's got something to do with myeloperoxidases in bacteria causing green, I don't know.

00:24:43.440 --> 00:24:48.960
Something is so so the cytoplasm of a neutrophil, yeah, where it's green.

00:24:50.160 --> 00:24:57.200
So if you've got huge amounts of neutrophils, which you have in some snobs and in pus, it gives it that greenest tinge.

00:24:57.920 --> 00:25:00.799
Um, so anyway, I've not seen anything like this.

00:25:00.960 --> 00:25:14.400
I was like, and I I we pumped it in some uh we sent it off for analysis, but I made sure that a lot of people around the day saw it because I think it's a really important learning tool to actually see what it looks like.

00:25:15.119 --> 00:25:17.920
Can I if I could just insert a tiny anecdote here?

00:25:18.000 --> 00:25:29.759
I remember a long, long time ago, I was doing a lumbapuncture, and very clearly on a young Polish woman who came with a really bad headache, blinding headache, and I put the needle into the CSF, and the CSF came out and it looked like cream, dressed cream.

00:25:29.839 --> 00:25:32.240
There's Frank Puss, no wonder she had a headache.

00:25:32.319 --> 00:25:34.160
Imagine that all bathing around you in the ninjas.

00:25:34.799 --> 00:25:36.880
I said to her, You're the toughest person I'd ever met.

00:25:36.960 --> 00:25:41.920
Um, but yeah, what you just remind me of that when you talked about your your knee aspiration experience.

00:25:42.160 --> 00:25:44.480
Yeah, it was not seen anything like it.

00:25:44.640 --> 00:25:52.000
So we sent the knee aspiration off and we sent it off for urgent gram stain, um, microscopy culture and sensitivities.

00:25:52.160 --> 00:25:54.240
And we also sent it off for crystals.

00:25:54.559 --> 00:25:59.839
So we look for calcium pyrophosphate and uric acid crystal, so gout and pseudo-gout.

00:26:00.559 --> 00:26:02.640
And um, we started antibiotics.

00:26:02.720 --> 00:26:11.200
She'd already had two doses of intravenous coamoxyclav in the emergency department for a presumed probably UTI potentially.

00:26:11.359 --> 00:26:13.599
Um UTI, okay.

00:26:13.839 --> 00:26:20.640
But I started her on intravenous flucloxicillin and clindamycin, which are actual skidelines for septic arthritis.

00:26:20.960 --> 00:26:26.400
And I did that because I had the pus in front of me and I was convinced that it was a septic arthritis.

00:26:27.039 --> 00:26:36.720
So we sent the uh sample off for analysis and we spoke to the orthopedic doctors, and they came down very rapidly and took her to theater where she had a knee washout.

00:26:37.599 --> 00:26:41.519
Now, what was interesting about this is what it grew.

00:26:42.880 --> 00:26:43.519
Right.

00:26:44.720 --> 00:26:54.880
So one of the most common causative agents that we see in septic arthritis is Staph aureus, and it's the only thing I've ever seen grown in the joint.

00:26:55.519 --> 00:26:58.079
She grew Streptococcus pyogenes.

00:27:00.400 --> 00:27:00.720
Okay.

00:27:01.359 --> 00:27:07.279
So about eight to sixteen percent of septic arthritis is caused by strep pyogenes.

00:27:07.599 --> 00:27:08.960
The rest tends to be staph.

00:27:09.839 --> 00:27:10.079
Okay.

00:27:10.319 --> 00:27:12.559
Well what percent did you say what percentage was strep?

00:27:13.200 --> 00:27:14.559
Eight to sixteen percent.

00:27:14.880 --> 00:27:15.920
Eight to sixteen, okay.

00:27:16.480 --> 00:27:16.799
Yeah.

00:27:17.039 --> 00:27:18.400
Um, is is strep.

00:27:18.720 --> 00:27:20.880
And it's a group strep.

00:27:21.200 --> 00:27:26.000
So horrible septicemia you can get with group strep, as we all know.

00:27:26.559 --> 00:27:37.680
And it's known to have quite a high mortality and morbidity associated with strep pygenes, arthritis, because it can rapidly destroy the patella.

00:27:39.119 --> 00:27:41.039
Ah, how rapidly?

00:27:41.279 --> 00:27:41.839
In days?

00:27:42.480 --> 00:27:42.880
Days.

00:27:43.200 --> 00:27:43.440
Yeah.

00:27:43.759 --> 00:27:44.079
Okay.

00:27:45.039 --> 00:27:52.079
So the notes, however, from the theatre say that the patella didn't look very nice.

00:27:52.240 --> 00:27:54.720
So there must there could have been potentially some damage there.

00:27:55.119 --> 00:27:57.359
So maybe that's what they were seeing on the X-ray then.

00:27:57.839 --> 00:27:59.839
Potentially, yeah, potentially.

00:28:00.400 --> 00:28:01.200
Could have been.

00:28:01.759 --> 00:28:09.519
Um I I just I I really like this case, and I think there's a couple of learning points that I want to pull out from this, I think.

00:28:09.680 --> 00:28:24.079
And um I think number one, we always and I say this all the time, and we've talked about it a lot, you know, when somebody is unwell with a fever and a high CRP, we automatically think urine.

00:28:25.680 --> 00:28:31.359
And um, I think that sometimes stops us from looking at other sources of infection.

00:28:32.160 --> 00:28:46.400
So it was presumed that she had urine and retract infection and she was given antibiotics, commoxiclave as per this, but actually she'd had investigations on her hip and her knee because it was painful.

00:28:46.720 --> 00:28:51.680
Do you think because we don't see septic arthritis very often, that we don't maybe think about it?

00:28:51.759 --> 00:28:56.240
And we go for common things are common, let's treat that.

00:28:57.279 --> 00:29:17.119
Well, I certainly think UTI is overdiagnosed, and one big step change I've noticed in my career is the ditch the dip campaign, uh, which is stop dipping urine in patients over the age of 65 because you end up over-treating um asymptomatic bacteria, and and and it's it's not always a UTI.

00:29:17.279 --> 00:29:30.880
And these poor older patients who may be more frail and more vulnerable, they come to us with all sorts of infections and they get sent home with nitrofurin, toin or trametopim or something because we go um we we immediately go towards you go towards urine.

00:29:30.960 --> 00:29:38.160
And also that whole thing about um when people take the history and say and they notice that the urine was more smelly than usual.

00:29:38.240 --> 00:29:39.519
The patient smells of urine.

00:29:39.599 --> 00:29:44.640
I'm like, you cannot smell nitrites, you cannot smell leukocytes.

00:29:44.880 --> 00:29:59.599
If if someone hasn't has um had the bad fortune to be urinary incontinent and they're still sitting in the same clothes, they will have a strong odor, but you cannot diagnose UTA based on your nostrils, and that's something that I'm always sort of pushing against.

00:29:59.839 --> 00:30:01.119
So I do think we stop.

00:30:01.440 --> 00:30:08.960
I think for for septic joints and things, the patient usually declares to you the joint in quite a loud voice because it's agonizing.

00:30:09.119 --> 00:30:21.680
Um, and it takes quite a lot of determination to ignore a patient whose knee is bright red, cannot be moved a you know a single degree in any direction, uh, and they're saying, ow, my knee, my knee.

00:30:21.920 --> 00:30:26.400
Now, where it goes a bit funny, I think, is sometimes in patients who can't give you that information.

00:30:26.559 --> 00:30:36.559
So patients who are confused, delirious, have dementia, cannot speak for any kind of reason, and it then relies on us actually lowering the bed clothes and having a look ourselves.

00:30:36.799 --> 00:30:44.720
So if you do have a patient with an infection of of unknown origin or even a hyper-CRPemia of unknown origin.

00:30:46.000 --> 00:30:55.359
Yeah, you have to do a proper examination, and that means examining the patient from the heads to their toes, and you'd be amazed at what the patient would be like lying underneath.

00:30:55.440 --> 00:31:01.119
I remember when I was an SHO and my consultant saying, Oh, Ben, you've written down here infection of unknown origin.

00:31:01.440 --> 00:31:05.839
You know there's no such thing, or you've written down as infection and you haven't properly looked.

00:31:06.079 --> 00:31:11.039
Go to the patient's bedside, strip them naked, and examine every inch of them.

00:31:11.200 --> 00:31:15.599
And lo and behold, I found an abscess on his back that I hadn't seen the first time around.

00:31:15.920 --> 00:31:26.000
I don't subscribe to the theory that all infections will be made um identifiable by stripping every patient naked and looking at every you know, every part of their body.

00:31:26.160 --> 00:31:42.240
But I think we do have to be thorough in our investigations, and it is very, very easy to look at CRPs, look at patient demographics, and then jump um to a heuristic in the wrong direction and say, How about I treat you for an acute teromethoprim deficiency and uh sending them home again?

00:31:42.559 --> 00:31:50.079
Yeah, and and what was interesting about this is that when I looked at her knee, it was a bit swollen, it was a bit red.

00:31:50.799 --> 00:31:55.680
But I've seen septic joints which are really painful, really swollen, really red.

00:31:55.839 --> 00:31:58.319
It wasn't, it wasn't that angry, you know.

00:31:58.400 --> 00:32:05.839
It didn't, when I looked at it, it didn't shout septic, septic, septic at all, whereas I have seen some knees in the past or some joints which have.

00:32:06.160 --> 00:32:16.000
But she did, you know, the risk factors of septic arthritis are joint disease, and she did have a little bit of osteoarthritis.

00:32:16.319 --> 00:32:16.559
Yeah.

00:32:16.799 --> 00:32:18.799
So, you know, could this have increased her risk?

00:32:18.960 --> 00:32:23.440
She'd had a recent viral infection, had she got some actually, was this a bacteria?

00:32:23.599 --> 00:32:25.039
Did she have strep throat?

00:32:25.359 --> 00:32:29.920
Um, and did she have some hematogenous spread potentially to the knee?

00:32:30.160 --> 00:32:36.000
Her blood cultures were negative, but again, her knee culture was positive.

00:32:36.400 --> 00:32:36.880
Yeah.

00:32:37.200 --> 00:32:39.680
So she made a very good recovery.

00:32:39.839 --> 00:32:44.640
So she had the operation, she had antibiotics, and she did get a lot better.

00:32:45.279 --> 00:32:54.319
What was interesting is when I I was looking at the uh guidelines for a hot joint, they were last published 20 years ago.

00:32:54.880 --> 00:32:55.680
Okay, good.

00:32:55.920 --> 00:32:57.519
I haven't got to learn anything new, fantastic.

00:32:57.759 --> 00:32:58.799
No, it's a sort of the same.

00:32:59.279 --> 00:32:59.759
Yeah, it's the same.

00:32:59.839 --> 00:33:03.359
So British Society of Rheumatology published the guidelines in 2006.

00:33:03.599 --> 00:33:15.839
They were there was a discussion in 2017 about the utilization of procalcitonin and steroids um in patients with septic arthritis, but there was no consensus.

00:33:16.240 --> 00:33:18.480
They are undergoing revision.

00:33:18.799 --> 00:33:23.119
So they are going to be, the new guidelines are going to be released.

00:33:23.440 --> 00:33:24.240
Potentially this year.

00:33:24.319 --> 00:33:28.319
I'm not entirely sure when, but that's what the uh the BSR website says.

00:33:28.640 --> 00:33:35.599
So the guidelines back in 2006 were exactly what we talked about: aspirate the knee.

00:33:35.839 --> 00:33:42.240
You know, try and do it before you're given antibiotics, but don't delay antibiotics if you're waiting for the reneeaspirate to be done.

00:33:42.640 --> 00:33:57.119
Pain relief is really important and very, very quick utilisation of antibiotics, whichever your trust uses, um, and then send the samples off appropriately for cell count and gram stain.

00:33:57.440 --> 00:34:00.960
Um, so just an interesting case.

00:34:01.039 --> 00:34:09.679
And what what was interesting as well, just another little learning point that I want to pick up on is a hemoglobin steadily dropped throughout admission.

00:34:10.400 --> 00:34:12.639
So why do you think that could be?

00:34:13.760 --> 00:34:17.440
Why did a hemoglobin drop throughout admission?

00:34:18.079 --> 00:34:19.920
How low did it go?

00:34:20.800 --> 00:34:21.840
90.

00:34:22.480 --> 00:34:30.079
And it wasn't just someone got she got very vigorous ivy fluid resuscitation, it was all sort of transient, dilutional.

00:34:30.480 --> 00:34:31.599
Okay, yeah, that could be.

00:34:31.760 --> 00:34:32.000
Yeah.

00:34:32.239 --> 00:34:33.039
That's a really good point.

00:34:33.199 --> 00:34:36.639
Could be dilutional when you could look at the you can look at the hematocrit, can't you?

00:34:36.719 --> 00:34:41.360
And if the hematoquit goes down quickly as well, then that can take dilutional.

00:34:41.440 --> 00:34:42.480
So that's a really good point.

00:34:42.639 --> 00:34:43.440
Could be, yeah.

00:34:43.679 --> 00:34:46.880
Um, any reason why she would hemolyse, I can think of.

00:34:46.960 --> 00:34:48.159
I can't think of anything.

00:34:48.320 --> 00:34:49.760
Is she bleeding from anywhere?

00:34:49.840 --> 00:34:51.360
I can't think of anything.

00:34:51.679 --> 00:34:55.039
Um no, can't think of anything else.

00:34:55.360 --> 00:35:01.039
So there was no acute blood loss that was noted, and hemolysis can happen in infection sepsis.

00:35:02.159 --> 00:35:09.840
So if we if she is hemolysing, we'd do a blood film, and we could also look at LDH levels to see whether there is any hemolysis.

00:35:10.800 --> 00:35:16.000
So there is a condition called anemia of acute infection.

00:35:16.559 --> 00:35:17.360
Oh, right.

00:35:17.599 --> 00:35:24.079
Uh yeah, because the the bacteria consume all of the eye at something like that's where in when they multiply so rapidly.

00:35:24.400 --> 00:35:25.119
So sort of.

00:35:25.199 --> 00:35:29.440
So when you've got an infection, the liver produces hepcidin.

00:35:29.760 --> 00:35:31.119
Yes, I'm it's all coming back to you.

00:35:31.280 --> 00:35:32.639
Are you gonna say macrophages in a minute?

00:35:32.800 --> 00:35:34.079
Yes, I'm gonna say macrophages.

00:35:34.239 --> 00:35:36.400
Yes, the macrophages do something with your iron, but keep going.

00:35:36.480 --> 00:35:37.119
It's all coming back to head.

00:35:37.280 --> 00:35:38.079
They do, absolutely.

00:35:38.320 --> 00:35:40.000
Yeah, so I'm just gonna cover a little bit of this.

00:35:40.079 --> 00:35:48.960
So hepsidin, which is one of my favorite words in medicine, normally regulates iron homeostasis and iron metabolism and keeps it at a beautiful level.

00:35:49.119 --> 00:36:01.519
Now, what happens in infection, sepsis, is you get higher levels of hepsidin triggered by inflammation or infection, normally into leukin 6, which is a pro-inflammatory cytokine.

00:36:02.079 --> 00:36:07.599
What hepcidin does is it inhibits iron from entering the bloodstream.

00:36:08.239 --> 00:36:12.000
And the reason for this is that often bacteria need iron to grow.

00:36:12.159 --> 00:36:24.320
So the body's really clever here and it tries to keep hold of its iron so as it doesn't feed the bacteria, so as it doesn't feed them and you know help them grow.

00:36:24.639 --> 00:36:37.840
But actually, what happens is the hepsidin stops any iron entering the bloodstreams, and therefore, if you haven't got any iron, you've got no transferit, you've got no store, so no ferritin, and you can't produce hemoglobin and you become anemic.

00:36:38.639 --> 00:36:40.480
Do you know something really embarrassing?

00:36:40.719 --> 00:36:44.320
I wrote this on a curriculum for a teaching program about 10 years ago.

00:36:44.480 --> 00:36:51.280
I I've I remember writing like learning materials for an online training module about this exact condition, and it's just gone.

00:36:51.519 --> 00:36:52.559
And I remember now you say it.

00:36:53.679 --> 00:36:54.719
Yeah, yeah.

00:36:55.039 --> 00:36:56.639
So I just find it really interesting.

00:36:56.800 --> 00:37:12.079
I'm not necessarily saying that that's the cause of why she was anemic, but you know, I think when we somebody's in a hospital for a long time and we see their hemoglobin trend down from maybe 120, 130, they've had an infection and it goes down.

00:37:12.239 --> 00:37:15.920
We go, oh my god, they've lost blood, or they why are they anemic?

00:37:16.000 --> 00:37:21.679
But actually, it could be due to this acute um hepsodyemia.

00:37:22.079 --> 00:37:23.280
Brilliant, brilliant.

00:37:23.440 --> 00:37:24.079
I love it.

00:37:24.320 --> 00:37:24.800
Do you know what?

00:37:24.880 --> 00:37:26.320
I really, really enjoyed that case.

00:37:26.400 --> 00:37:28.559
I love cases like this on the acute take.

00:37:28.800 --> 00:37:30.079
I really, really love it.

00:37:30.239 --> 00:37:34.079
Yeah, um, it it feeds something in my soul being able to do this.

00:37:34.159 --> 00:37:38.159
And um, so I'm quite pleased that I sort of got the diagnosis.

00:37:38.239 --> 00:37:41.280
But but it it really is uh it's I find it fun.

00:37:41.440 --> 00:37:47.920
I've it's like playing a game, it's like trying to find out and use your detective skills to work out the diagnosis.

00:37:48.000 --> 00:37:50.960
And it is proper old-fashioned medicine that I really, really enjoy.

00:37:51.119 --> 00:37:53.280
So thank you so much for bringing me this case.

00:37:53.679 --> 00:37:54.880
Thank you so much, Ben.

00:37:55.039 --> 00:37:58.400
And from me, I think I've learned two new things.

00:37:58.719 --> 00:38:00.880
Hyper CRP anemia.

00:38:01.280 --> 00:38:05.920
No, hyper, so isn't it hyper CRPhilia?

00:38:06.400 --> 00:38:08.159
I just said hyper CRPemia.

00:38:08.239 --> 00:38:12.719
It's a word I've made up, but because it's high CRP blood emia.

00:38:13.280 --> 00:38:14.320
High CRP in the blood.

00:38:14.480 --> 00:38:14.880
You see?

00:38:15.840 --> 00:38:16.960
Yeah, you can have that.

00:38:17.119 --> 00:38:17.760
Take that, take that.

00:38:18.079 --> 00:38:18.639
Thank you very much.

00:38:18.800 --> 00:38:19.360
Thank you.

00:38:19.599 --> 00:38:22.400
So a massive thank you, Ben, as ever.

00:38:22.480 --> 00:38:24.320
I hope everybody listening enjoyed that.

00:38:24.480 --> 00:38:28.480
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00:38:28.639 --> 00:38:29.679
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00:38:29.840 --> 00:38:33.840
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00:38:34.000 --> 00:38:41.039
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00:38:41.199 --> 00:38:42.400
So thank you, Ben.

00:38:42.559 --> 00:38:43.679
Thank you to everybody out there.

00:38:43.840 --> 00:38:45.039
Thanks for listening.

00:38:45.360 --> 00:38:46.000
Bye.