Bizarre Case- Any guesses?

Nurses General Nursing

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Specializes in ER/Forensics/Disaster.

Recently had a bizarre case on my unit where I was acting as charge. I have never seen anything like this- and am dying to hear ideas as to what it might have been!

Male patient in 30's originally came into ER to detox from Suboxone(apparently), but was found to be in a bit of alkalosis, with a uti. Appeared very ill on arrival to our floor, and we ended up calling a rapid response team on him a couple hours later when he drenched the bed with sweat(so much so that none of us, including the docs had ever seen anyone THIS diaphoretic). MD determined that he must have simply been in withdrawals, but felt something else was going on- but couldn't figure it out. Vitals were stable, labs decent(no changes), sat's 100%. We were all stumped. So he remained on our floor, in very poor condition.

This is the bizarre part.. Within a THREE hour timeframe.. his labs did the following..

K+ from 6.0 to 7.0 (Note: this is after patient received insulin, calcium, bicarb to treat the high K, it continued to climb!)

WBC from 23 to 78!

Mag was high, but I cannot recall the number.

Platelets from 99 to 33!

pH from 7.4 to 7.0

Temperature from 101 to 94!!

Sats from 100% on NC to 80% on NRB

So we transferred to ICU, and he was intubated. The docs remained stumped last I heard.

I have never seen anything like this, and am dying to know what would cause such bizarre changes in such a short period of time. Any ideas/thoughts would be helpful, I'd love to discuss this!

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Specializes in Med-Surg/Oncology.

WBC and temp could point to sepsis but that wouldn't explain the mag and K+.

Platelets... was a PT, PTT, D-dimer ever drawn on the pt?

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Specializes in ER/Forensics/Disaster.

I agree, I do think he was septic to some extent. But I've never seen WBC's change that quickly! 23 to 78 in three hours! The temp went down to 94..

PT/PTT were ok.

D-dimer I do not think was drawn.

We were discussing(nurses and I) that he might be in some severe renal failure, but that doesn't explain all of this. Plus the infection.

One of the docs mentioned something about -- possibly this guy could be HIV or Hep positive, without knowing it-- which could have contributed to his body's inability to fight it off. But this dramatic and rapid of a change in labs is insane to me!

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Specializes in LTC, Subacute Rehab.

Well, he's obviously wicked septic... The platelet levels make me think DIC.

With the rapidly rising K+ I'm wondering about rhabdomyolysis. Maybe secondary to rigors, bedridden state, excessive ETOH?

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Specializes in ER/Forensics/Disaster.

But the rest of the picture doesn't fit with DIC.

I work on a cardiac stepdown unit, we get patients with rhabdo all the time- but never like this. I've never seen a K+ rise despite such treatment, and the other dramatic changes don't fit with the rhabdo.

What about the drop in temp to 94?

He wasn't in a bedridden state, typical young male until this particular day. Possible ETOH abuse, according to the family- no, but no one really knows but him.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

Sounds like bacterial cell lysis syndrome. It is a catastrophic response to the admnistration of IV antibiotics where the bacterial cell wall basically ruptures dumping endotoxins into the blood stream. It can affect every body system and has a high mortality rate. The patient also sounds like he is going into DIC (AEB the rapidly decreasing platelet count). Very scary to have a patient with this. Some of the sickest people I have ever taken care of.

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Specializes in cardaiac telemetry, neuro, case manageme.

In response to an acute infection, trauma, or inflammation, white blood cells release a substance called colony-stimulating factor (CSF). CSF stimulates the bone marrow to increase white blood cell production. In a person with normally functioning bone marrow, the numbers of white blood cells can double within hours if needed. An increase in the number of circulating leukocytes is rarely due to an increase in all five types of leukocytes. When this occurs, it is most often due to dehydration and hemoconcentration. In some diseases, such as measles, pertussis and sepsis, the increase in white blood cells is so dramatic that the picture resembles leukemia. Leukemoid reaction, leukocytosis of a temporary nature, must be differentiated from leukemia, where the leukocytosis is both permanent and progressive. This is from http://www.rnceus.com/cbc/cbcwbc.html. Remember there is hot and cold sepsis--- it is possible that you caught him in transition and early kidney failure-- that is because of continued cell break down (highter K) and acidosis from lack of bicarb. Also the severe acidosis would account for needing the higher and higher O2.. Just an idea-- but I have seen patients go from sepsis to MODS (multi organ dysfunction syndrome). Have you found out any more?

PS if he was immunocompromized he would not have been able to increase wbcs so rapidly in my opinion.

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Specializes in ER/Forensics/Disaster.

Does that go by another name? I'm trying to google "bacterial cell lysis syndrome" and not finding much. This sounds like it could very well be the case here!

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

Try antibiotic induced bacterial cell lysis. Oh, and try PubMed. I'll check out what I fondly refer to as "Dr. Uptodatee" and see if there is anything there.

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Specializes in ER/Forensics/Disaster.

FloridaNurse- Good information. Thanks! You sure know your stuff:)! Very interesting. I didn't realize there was a cold sepsis! I'll have to check that out as well. But no, haven't heard anything else. I hope someone gets the story on how it turned out, because this is an interesting one.

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Specializes in cardaiac telemetry, neuro, case manageme.

Now I am curious too...

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Specializes in ER/Forensics/Disaster.

I'll update if I find out the end result! He is definitely a very sick puppy. One of the sickest appearing patients I've seen.

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