Re: baffling case
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Tue May 31 21:22:50 2005
Fully agree.
Garry
At Tue, 31 May 2005, Charlie Chambers wrote:
>
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>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.
>
>************************************************************************
>****
>************************************************************************
>
>--
>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.
>************************************************************************
>*******
>************************************************************************
>
>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
>>
>> <unknown.jpg>This message is confidential, intended only for the named
>> recipient(s) and may contain information that is privileged or exempt
>> from disclosure under applicable law. If you are not the intended
>> recipient(s), you are notified that the dissemination, distribution or
>> copying of the messages is strictly prohibited. If you receive this
>> message in error, or are not the named recipient(s), please notify the
>> sender at either the e-mail address or telephone number above and
>> delete this e-mail from your computer.
>>
>
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><fontfamily><param>Lucida Grande</param>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.
>
></fontfamily>
>
>><fontfamily><param>Helvetica</param>************************************* **************************************
>
><fontfamily><param>Helvetica</param>************************************* **************************************
>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.
>
>>************************************************************************* *****
>
>************************************************************************* *****
></fontfamily>
>
><fontfamily><param>Lucida Grande</param>On</fontfamily>
><fontfamily><param>Lucida Grande</param>May</fontfamily> 31, 2005,
><fontfamily><param>Lucida Grande</param>at</fontfamily> 7:13
><fontfamily><param>Lucida Grande</param>AM</fontfamily>,
><fontfamily><param>Lucida Grande</param>Richard</fontfamily>
><fontfamily><param>Lucida Grande</param>Chudacoff</fontfamily>,
><fontfamily><param>Lucida Grande</param>MD</fontfamily>
><fontfamily><param>Lucida Grande</param>wrote</fontfamily>:
>
><excerpt>
>
><fontfamily><param>Arial</param><x-tad-smaller>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.</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
><fontfamily><param>Arial</param><x-tad-smaller>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.</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
><fontfamily><param>Arial</param><x-tad-smaller>Any thoughts, pearls,
>questions, and acceptance of transfer to your service would be
>appreciated.</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
><fontfamily><param>Arial</param><x-tad-smaller>Richard Chudacoff, MD,
>FACOG</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
><fontfamily><param>Arial</param><x-tad-smaller>Women's Specialists of
>Houston</x-tad-smaller></fontfamily>
>
><fontfamily><param>Arial</param><x-tad-smaller>6624 Fannin Suite 1800</x-tad-smaller></fontfamily>
>
><fontfamily><param>Arial</param><x-tad-smaller>Houston, TX, 77030</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller>713-797-1144</x-tad-smalle ></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller>713-425-3071</x-tad-smalle ></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
><fontfamily><param>Arial</param><x-tad-smaller>Email:
>Richard.Chudacoff@obgyn.net</x-tad-smaller></fontfamily>
>
><fontfamily><param>Arial</param><x-tad-smaller>
>rchudacoff.md@womenspecialists.com</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf mily>
>
><<<fontfamily><param>Lucida Grande</param>unknown.jpg></fontfamily><fontfamily><param>Arial</param><x tad-smaller>This
>message is confidential, intended only for the named recipient(s) and
>may contain information that is privileged or exempt from disclosure
>under applicable law. If you are not the intended recipient(s), you
>are notified that the dissemination, distribution or copying of the
>messages is strictly prohibited. If you receive this message in error,
>or are not the named recipient(s), please notify the sender at either
>the e-mail address or telephone number above and delete this e-mail
>from your computer.</x-tad-smaller></fontfamily>
>
><fontfamily><param>Times New Roman</param><bigger> </bigger></fontfamily>
>
></excerpt
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--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
