Authors: Aaron Woofter, MD; Richard Goodgame, MD Series Editor: Richard Goodgame, MD


August 22, 2006

Case Presentation

The patient is a 36-year-old man who has been in the intensive care unit (ICU) for 10 days and now has upper gastrointestinal bleeding.

The patient had been in a prison facility and had no prior serious medical problems. While incarcerated, he experienced trauma to his left knee. Over a period of several days the knee became swollen and painful. He developed high fever, lethargy, and somnolence. He was transferred to our hospital. Initial evaluation revealed high fever, hypotension, tachycardia, and mental confusion. The knee and left leg were red, hot, swollen and tender. Complete blood count was normal, but bicarbonate was 14 meq/L and creatinine level was 6.5 mg/dL. Liver chemistries were mildly elevated and the coagulation profile was normal. He was admitted to the medical ICU for presumed systemic sepsis and treated with vigorous volume resuscitation, vasopressors, and antibiotics (vancomycin and cefepime). Blood cultures were positive for Streptococcus. Over 24 hours the left thigh and inguinal region developed intense swelling. Surgical consult diagnosed necrotizing fasciitis and recommended debridement. After the operation, the patient was transferred to the surgical ICU. Mechanical ventilation was necessary for 2 days following surgery. Renal failure progressed and he was started on hemodialysis for acute tubular necrosis. International normalized ratio (INR) was 1.2. Famotidine (20 mg intravenously twice daily) was ordered. He was started on nasogastric tube feedings, but this was associated with abdominal distension and large gastric residual volume. Vasopressors were stopped on hospital day 7 and hemodynamics were normal. During the first 9 days of hospitalization, serum hemoglobin declined from 15 g/dL to 10 g/dL without signs of gastrointestinal blood loss. The fall in hemoglobin level was attributed to acute illness, renal failure, and changes in intravascular volume. On the 10th hospital day, bright red blood appeared in the nasogastric tube and melena developed. He was transfused with 2 units of blood and was started on intravenous pantoprazole (80 mg rapid infusion and 8 mg/hour constant infusion). A gastroenterology consultation was requested.

Prior medical history was negative for serious illnesses, hospitalizations, or operations. The patient had a long history of heavy smoking and alcohol use.

Physical examination revealed the following vital signs: blood pressure, 128/70; heart rate, 126 beats per minute, lying; respiratory rate, 16 breaths per minute; and temperature, 98.6°F. He was awake, alert, but unable to answer questions appropriately. Bright red blood was in the nasogastric tube and it did not clear with 500 cc lavage. The skin was normal but the left lower extremity was extensively wrapped. There was no jaundice or stigmata of chronic liver disease. The lungs demonstrated diffuse rhonchi bilaterally. The cardiac examination showed only tachycardia and a hyperdynamic circulation. There was no abdominal tenderness, mass, or organomegaly. Digital rectal examination revealed no mass or tenderness, but melenic stool coated the exam glove.

Routine laboratory studies were normal except for the following: hemoglobin, 8 gm/dL; platelets, 185 x 109/L; blood urea nitrogen, 106 mg/dL; creatinine, 8 mg/dL; albumin, 1.9 g/dL; total bilirubin, 3 mg/dL; direct bilirubin, 2 mg/dL; alkaline phosphatase, 156 U/L; alanine aminotransferase, 90 U/L; aspartate aminotransferase, 172 U/L; and INR, 1.7.




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