Re: baffling case
From: Charlie Chambers (cchamber@gorge.net)
Tue May 31 09:29:02 2005
Richard
I'd definitely go with the septic pelvic thrombophlebitis. Unless she
has an abcess which you have clearly looked for, the antibiotic
regimens should have killed most things on the planet.
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Charlie Chambers
Hood River, OR
cchamber@alumni.rice.edu
"Almost anything you do will seem insignificant but it is very important
that you do it....You must be the change you wish to see in the world"
-- Mahatma Ghandi.
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On May 31, 2005, at 7:13 AM, Richard Chudacoff, MD wrote:
>
> 21 yo G1, GBS negative, admitted through the midwife service 12 days
> ago. She arrested in dilation, after IUPC and FSE, and underwent an
> unremarkable low transverse c-section via Pfannenstiel skin incision
> 10 days ago. 36 hours post-op she spike to 103 degrees F and hand a
> tender uterus, and was started on Ampicillin, gentamycin and
> clindamycin (by the resident on call) for post partum endomyometritis.
> 48 hours post op she was still febrile. ID was consulted, after
> another exam which noted a still tender uterus and she was switched to
> vancomycin and meropenem to cover MRSA as well as the usually
> culprits. She has a history of IBD and grew out C. diff on stool
> culture and was started on Flagyl. She also started taking scheduled
> Motrin and Tylenol. She defervesced for 36 hours and the antibiotics
> were stopped, except for the Flagyl, as were the anti-pyretics. 4
> hours later she spiked to 103. Antibiotics and anti-pyrectis were
> restarted. Pelvic U/S was negative. KUB to r/o foreign body was
> negative. CT of pelvis was negative, as was chest x-ray, blood
> cultures and urine culture (from the original workup) and all
> subsequent cultures have been negative. She defervesed, and was
> stable for 24 hours. Anti-pyrectics were stopped 48 hours ago, and she
> then spiked again, despite being on anti-biotics. Repeat CT is
> negative, as is repeat CXR. Doppler studies of the lower extremities
> are negative, with great flow bilaterally. GI consults negative. No
> evidence of cardiac valve abnormalities ruling out SBE.
>
> I’m thinking that the only thing left to try is heparin for septic
> pelvic thrombophelbitis or septic gonadal thrombophelbitis. I thought
> she might have a drug fever, however she did spike after
> discontinuation of the wonder drugs.
>
> Any thoughts, pearls, questions, and acceptance of transfer to your
> service would be appreciated.
>
> Richard Chudacoff, MD, FACOG
>
> Women's Specialists of Houston
> 6624 Fannin Suite 1800
> Houston, TX, 77030
> 713-797-1144
> 713-425-3071
>
> Email: Richard.Chudacoff@obgyn.net
> rchudacoff.md@womenspecialists.com
>
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