HyperCRPaemia

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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• RCPE Education: rcpe.ac.uk/education

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• Email: a.burbridge@nhs.net
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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

SPEAKER_00 0:11

Hello and welcome to the Home of Medicine podcast with me, Dr. Amy Bearbridge.

SPEAKER_01 0:16

And with me, Dr. Ben Lovell. Hello.

SPEAKER_00 0:18

Hi, Ben. So I forgot to say this is a podcast in association with the Royal College of Physicians, Edinburgh. So, Ben, I've got a case for you. Are you ready?

SPEAKER_01 0:28

Yes, please. Go.

SPEAKER_00 0:30

Okay, so this is a 59-year-old female who presented to the emergency department with a 10-day history of viral symptoms. She describes a cough, cold, fever, headache, off of food, generally just feeling grotty. Now, I saw this patient in the winter months. So you know, we see this a lot, don't we? In ED and in AMU and SDEC or wherever we work. It's very frequent presentation. So whenever I sort of hear this history, my first thought is this is a virus. Would you come to hospital with a virus? What's what what else is going on? What about you? Any particular thoughts?

SPEAKER_01 1:19

Was this a referral um from the emergency department?

SPEAKER_00 1:23

It was. Absolutely.

SPEAKER_01 1:24

Yeah. So so I agree with you. 10 days of viral like symptoms, it's a virus next. 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? Because there's one thing that ED are very good at, it's sending people home with common organ winter viruses. So my question would be, hopefully without any signs of sort of sarcasm or any gender, but why did ED refer this to us? Um, what am I missing here? Because they need the the bed space and they could have turned this around in a heartbeat. So there's obviously a little bit more to the story.

SPEAKER_00 2:03

So I'm only gonna give you one blood test. Okay. Okay.

SPEAKER_01 2:07

W D Dimer, please.

SPEAKER_00 2:08

No, it's not Dimer. But this is the reason for the referral to the medics. CRP606.

SPEAKER_01 2:18

Oh, I love cases like these. 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. All right, thank you for that information. So that was that the reason for the referral?

SPEAKER_00 2:33

Yeah, well, I mean, she wasn't very well, but there wasn't, you know, sure. 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.

SPEAKER_01 2:51

Did I say that? You did. Oh, okay, okay. Yeah.

SPEAKER_00 2:55

And I remember that. Um, so uh she came down to our MAU and she was on intravenous antibiotics, chemoxyclave, and with a CRP of 606. But our role and the reason for EFIR was to try and identify the source of the infection because that had quite been identified.

SPEAKER_01 3:14

So right, okay. I love it. All right. This is the kind of case that really, really interests me.

SPEAKER_00 3:21

Yeah. Um absolutely.

SPEAKER_01 3:23

So I need to go and and talk to the woman and say, what is your history? 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? Her symptoms I will try and drill down on on. The S bar, the hand wave I'm getting is that I got cough, I got cold, I got fever, and I got headache. So maybe it was a viral infection. And as you know, as my grandma say, it went to her chest and they what we call a superadded respiratory bacterial infection. So she might now be in a pneumonic phase or started off as a viral illness. Um, cough, cold, fever, headache. 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. Um, and of course I will examine the album, but I think this starts with a good old-fashioned history, please.

SPEAKER_00 4:17

Absolutely. 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. And she'd had a fall and she was unable to mobilize when she'd fell to the floor. This was the day before I saw her. 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. And she eventually managed to call an ambulance, 999, the 999 crew came and they brought her into hospital. 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. 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. She denies any chest pain, any shortness of breath, any abdominal pain, any diarrhea, any constipation. She had a little bit of urinary frequency, urgency, and dysuria, and her appetite wasn't as good as it normally was. 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. Like, did you trip over anything? No. Did you lost lose consciousness? No, I just went down. So on further questioning, she lived alone and has funny mobile, absolutely no issue. 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. Probably she said around two to three bottles of wine per week, but no um smoking. She worked full-time, um, a sort of an admin type role. No family history of anything significant of note, and hadn't been hospitalized in the past. What you're thinking about, Nensa.

SPEAKER_01 6:30

Though um I'm getting the history of presenting pain just fixed in my mind. 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. And did you say hip pain pre- or post-fall?

SPEAKER_00 6:48

Difficult to identify, if I'm being honest. So she had hip pain, right hip pain, and the pain went down to the knee. Now, I was finding it difficult to elucidate. Did this pain start before the fall and cause the fall, or did the pain start after the fall? Now, when looking at the AE notes, it said patient's right leg is externally rotated. Could this be a hip fracture? And they'd actually done a CT hip.

SPEAKER_01 7:16

Oh, okay.

SPEAKER_00 7:17

Which is normal.

SPEAKER_01 7:20

Um, all right. So she folded it. And what I was thinking originally, 59 isn't is is not old. And it's too young for someone to have a fall in a long lie. 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. 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. That that that's not doesn't quite fit unless there was um unless there was alcohol in the picture as well. So that's one thing I'm thinking. 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. And the CRP, actually, let's park the CRP for now, let's stick with the history. Um, anything else I want to ask? So, did you say and all of this was on the back end of 10 days of a viral infection? Yes. Okay, fevers, cough, cold, uh, and all that sort of thing. All right, all right. I'm happy with that. Um, and did she walk into the hospital?

SPEAKER_00 8:29

No, she wasn't able to walk. 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. I find incredibly useful is we have access to the ambulance.

SPEAKER_01 8:45

I was gonna ask, any insights from the truth? So write some really cool stuff in there.

SPEAKER_00 8:50

So interesting, yeah. 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. And I find the ambulance information sheet a font of information and knowledge. So, yeah, there was some information on there. 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. She had a heart rate of 141 when they saw her and picked her up in the ambulance. But her blood pressure was okay, respirator, oxygen saturations were normal. GCS was 15. 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. So this hip pain and this knee pain was coming up again. 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. So is it very clean? Is it dirty? Does it look like, you know, there's a dirty washing around, are they eating? And it's very helpful. But no, there was no concerns raised at all.

SPEAKER_01 10:12

All right, so I think I've fleshed out the the um history as much as I'd like now. Before we come on to the investigation, such as the CRP and the CT hip, we need to lay our hands upon this patient. 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. Yeah.

SPEAKER_02 10:38

Why?

SPEAKER_01 10:39

Well, she's not walked. Are her legs working? That's gosh, you can tell I'm a high highly trained clinical uh professional, can't you?

SPEAKER_00 10:48

You can tell I'll be neurophobic. Neurology need it. Why?

SPEAKER_01 10:53

Legs working. Has she got a uh a subacute or acute neurological event? Has she had a stroke?

SPEAKER_00 10:58

Hey. Oh, yeah.

SPEAKER_01 11:00

Has she fallen over and got has she got corder aquina syndrome? Has she shructured some vertebrae and she's got spinal canal compression? And so so yeah, I want to know why she she hasn't why did she not get up off the floor?

SPEAKER_00 11:12

Yeah.

SPEAKER_01 11:13

Anyone should be able to get up from the floor.

SPEAKER_00 11:15

Yeah. 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? It's really important, isn't it, to ask about do you know when you need a wee and a poop? Which um again, very simple questions. 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. Okay, chest was clear, heart sounds were normal, there was no palpable lymph adenopathy in the neck that I could identify. On examination of the legs, the right leg did look externally rotated, and the knee looked a little bit swollen. And she said that the knee was sore and painful after the fall. But apart from that, I didn't do a neurological examination, which I should have done. 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. And again, it's my fear of neurology, is when somebody has a fall, it's really important to examine their neurological system. And I do, but maybe not every time, and I didn't in this case. So that is my bad.

SPEAKER_01 12:45

There are a few um there are a few triggers in my head where I just think always do a neuro exam. One of them is head headache, one of them is back pain. And the um another one is legs gave way. 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. Can you move this foot? Can you feel me here? Can you uh let your legs can you uh let me hit you with this hammer? I'm just gonna tickle the bottom of your foot here and watch what happens. 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.

SPEAKER_00 13:29

Okay, yeah.

SPEAKER_01 13:31

All right. So I've got my history, I've got my exam. Now I'm gonna do some blood tests, please. I know you've already given me some, but I'm just going through it methodically in my head. Is the full blood count okay?

SPEAKER_00 13:43

White cell, 22.2.

SPEAKER_01 13:46

Elevated.

SPEAKER_00 13:47

Neutrophil, 20.56.

SPEAKER_01 13:50

Elevated.

SPEAKER_00 13:51

Urea, 22.6.

SPEAKER_01 13:53

Oh, elevated.

SPEAKER_00 13:55

Creatineme 243.

SPEAKER_01 13:57

Okay, that's very abnormal. Yep.

SPEAKER_00 14:00

CK, 4834. That's a creatine kinase.

SPEAKER_01 14:05

1834. Okay, four digits. Yeah.

SPEAKER_00 14:08

Lactate on the gas, the VBG was 2.1.

SPEAKER_01 14:12

Yeah.

SPEAKER_00 14:13

PH 7.31.

SPEAKER_01 14:16

7.31.

SPEAKER_00 14:18

Hemoglobin 121. LFTs normal, clotting normal.

SPEAKER_01 14:26

Oh. All right. Do we have any previous renal function for this patient?

SPEAKER_00 14:33

No previous renal function, no hospital admissions, presumed to be normal.

SPEAKER_01 14:38

Okay. So she has either an AKI with a creatinine 243, or this could be her normal level as a CKD. I think her acute illness um um and the slight metabolic acidosis points more towards this being an AKI. Um, in terms of why this could be an AKI, this could be pre-renal because she's volume deplete. I don't know how long she spent on the floor not drinking fluids. You think it was more than 12 hours?

SPEAKER_00 15:06

I do. 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. 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. She said that it feels like she fell at night, and when the ambulance came, it was in the day. So maybe she was on the floor for 12 hours, could have been less.

SPEAKER_01 15:29

It sounds very vague. Very vague for someone who's who's middle age, you know, is not old or prone or vulnerable to delirium.

SPEAKER_00 15:37

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. And I was like, really? She doesn't seem like she's delirious, but just not as um, I guess, sharp as I would expected. But then she has got AKI, she's got a high CK and the CRP is 606. So Right.

SPEAKER_01 16:02

Yeah. Yeah. Okay. 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. Um, medications-wise, just the amodipines are nothing to blame on there. Could it be an intrinsic renal cause of an AKI like an acute glomerulophritis? Would it be unlikely? Or could it be post-renal, i.e., ishi and urinary retention. You didn't feel a big distended bladder or an abdominal exam, did you?

SPEAKER_00 16:32

She did have a big bladder. Absolutely. And I'm I'm getting you know you're gonna shoot me when I say this, Ben, but I did an ultrasound scale.

SPEAKER_01 16:42

I don't mind you. I'll just say, I'm glad you've got a hobby.

SPEAKER_00 16:44

I think it's fantastic. My new favourite skills. And it's really helpful because you can scan the kidneys to identify if there was hydronephrosis. There was no hydronephrosis, but she did have a purple bladder, and you can actually budget how many mils were in the bladder. It was around three to four hundred mils, so not a lot.

SPEAKER_01 17:00

Well, that's not so much. No, but I I think less than half a liter. I tend not to get too too aggravated about that. So I think as obstructive uropathy would be less likely here. So all right, um, so I think she's got a prerenal AKI. That's um number one. Let me jot that down here. Prereenal AKI. That's going in my my assessment at the end. Now, then you gave me the CRP, which is 600. 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. Sometimes I do write that as a diagnosis, by the way, in a clerking. You I really don't know, but at the moment, aid a memoir. All right then. So they're my blood results. Now, I'd like to do some imaging. Um, I think I would like a chest x-ray, please, based on that very high CRP and a recent cough. Normal. Thank you. 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. And I'm assuming that was normal, hence the subsequent CT.

SPEAKER_00 18:05

So um there was a x-ray of the hip and the pelvis stun earlier. Yeah. 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.

SPEAKER_01 18:19

Uh but in the wall, the patella?

SPEAKER_00 18:22

Yeah.

SPEAKER_01 18:22

Blammy, that that x-ray pelvis went quite low.

SPEAKER_00 18:25

They x-rayed the knee as well. 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. 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.

SPEAKER_01 18:44

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. Yes, the yeah, the x-ray of the knee suggested a patella fracture, and then subsequently you said CT of pelvis. Did you say CT knee as well?

SPEAKER_00 18:58

No, CT knee wasn't done.

SPEAKER_01 19:00

Ct pelvis. All right, and that was normal. Okay. 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. Right.

SPEAKER_00 19:17

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.

SPEAKER_01 19:25

And could you have a range of motion at the hips when you examined her?

SPEAKER_00 19:30

The hips were okay. So, first of all, I always like to examine the good side. So I looked at the left side. Yeah. And it wasn't a great range of movement because she was unwell and I think she was quite weak. But examination of the right knee, she could the right hip, she could move it. 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. Yeah.

SPEAKER_01 19:53

With a clinical effusion. Yeah.

SPEAKER_00 19:55

Yeah, I thought there was an effusion. 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. Oh yeah, uh I I don't know how much was in there, but yeah.

SPEAKER_01 20:09

Okay.

SPEAKER_00 20:09

Well, there was definitely an effusion there.

SPEAKER_01 20:12

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. 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. Okay. That would explain a couple of things. That would explain the leg giving away, not being able to stand up again, the high CRP. Um I'm gonna say number two, AKI due to septus and dehydration. Then I'm gonna say number three, possible patella fracture. Um, but that would be weird to have a fracture and an effusion on the same side. It could be nothing, but I'm gonna put that in my back pocket for now.

SPEAKER_02 20:51

Okay.

SPEAKER_01 20:52

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. So I want number one, IV antibiotics. Number two, urgent aspiration of knee, um, looking for uh signs of infection or signs of a crystal arthropathy. So gout can give you a super duper CRP and painful knee.

SPEAKER_02 21:17

Yeah.

SPEAKER_01 21:17

Um number three, she needs some fluids. Yeah. So I prescribe some Ivy Hartmans and then check her renal function maybe in 12, 24 hours. Number four, I would be monitor her urine output, just make sure she does pass urine. Number five, I'd be repeat CK after the first one or two liters of fluid to make sure that it's coming down. Yeah. Um, and number six, I would say radiology opinion of the x-ray of the knee. Query further investigation such as CT required. There you go. That's my post-take plan. Oh, and of course, um patient for full escalation of treatment and uh needs prophylaxis against um VT uh VT prophylaxis. So low.

SPEAKER_00 21:56

Okay. So two questions. You said antibiotics. What antibiotics? Would you like to use?

SPEAKER_01 22:01

Right. I guess if you're thinking septic arthritis, you want to go for something like flu clocks. However, I'm going to keep it nice and broad and my hospital, broad spectrum antropolics for fever of unknown origin. So septic origin is iV keferoxine. So I have some of that, please.

SPEAKER_00 22:16

Okay, so you're gonna need IV kefroxine because you're still not sure where the fever's coming from. So you're sort of a fever of a fever and CRP of unknown origin. Do you want to do anything with this abdomen? Because, you know, I remember you telling me before, hi CRP think abdomen.

SPEAKER_01 22:32

Her abdomen was soft and non-tender with a distended bladder, no organomegaly, um, and obviously no signs of rigidity or peritonism at all. Um so you're saying to me, do I want to do a CT abdoelbus as a look on an infection hunt? I might. But you know what? I'm gonna tap the knee first. Let's not throw everything at the wall and see what sticks. Let's have an orderly a progression of ideas.

SPEAKER_00 22:56

Okay. Would you aspirate the knee or would you get some would you get a specialty to do it?

SPEAKER_01 23:01

Ah, good question. I think probably I would get a specialist to do it. I'd get I'd ask orthopedics to do it. Septic arthritis is an emergency. 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. Um, and I used to work in a DGH in the late district where you were you did everything. Um so you'd stick a needle in and see what happened. 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. That's not how we do things anymore. We have people trained up to do things safely and to be successful the first time. Yeah.

SPEAKER_00 23:41

Yeah. Okay, absolutely. So there is nothing I love more than putting a needle in a knee. Um, because I was I did do rheumatology and I do still love it. I think it's like a bit of a passion of mine. So we aspirated the knee. And out of this knee, for the first time in my whole career, came Frank Puss.

SPEAKER_01 24:03

Wow.

SPEAKER_00 24:04

I had never seen anything like it. So I've had seen a quite a lot of septic arthritis, but I've never seen a pus frank pus like that. It's normally been Sun of Your Food, is maybe a bit of turbidity, but this is pure pus.

SPEAKER_01 24:18

What did it look like? Just like cream.

SPEAKER_00 24:19

Yeah, it was like cream, it's like really cream, it was like um snot.

SPEAKER_01 24:24

Wow.

SPEAKER_00 24:25

Yeah. It was really like, wow, and just on that note, my favourite question why is snot green? And why is pushing?

SPEAKER_01 24:34

Oh why is it it's got something to do with myeloperoxidases in bacteria causing green, I don't know.

SPEAKER_00 24:43

Something is so so the cytoplasm of a neutrophil, yeah, where it's green. So if you've got huge amounts of neutrophils, which you have in some snobs and in pus, it gives it that greenest tinge. Um, so anyway, I've not seen anything like this. 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.

SPEAKER_01 25:15

Can I if I could just insert a tiny anecdote here? 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. There's Frank Puss, no wonder she had a headache. Imagine that all bathing around you in the ninjas. I said to her, You're the toughest person I'd ever met. Um, but yeah, what you just remind me of that when you talked about your your knee aspiration experience.

SPEAKER_00 25:42

Yeah, it was not seen anything like it. So we sent the knee aspiration off and we sent it off for urgent gram stain, um, microscopy culture and sensitivities. And we also sent it off for crystals. So we look for calcium pyrophosphate and uric acid crystal, so gout and pseudo-gout. And um, we started antibiotics. She'd already had two doses of intravenous coamoxyclav in the emergency department for a presumed probably UTI potentially. Um UTI, okay. But I started her on intravenous flucloxicillin and clindamycin, which are actual skidelines for septic arthritis. And I did that because I had the pus in front of me and I was convinced that it was a septic arthritis. 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. Now, what was interesting about this is what it grew.

SPEAKER_02 26:42

Right.

SPEAKER_00 26:44

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. She grew Streptococcus pyogenes.

SPEAKER_01 27:00

Okay.

SPEAKER_00 27:01

So about eight to sixteen percent of septic arthritis is caused by strep pyogenes. The rest tends to be staph.

SPEAKER_01 27:09

Okay. Well what percent did you say what percentage was strep?

SPEAKER_00 27:13

Eight to sixteen percent.

SPEAKER_01 27:14

Eight to sixteen, okay.

SPEAKER_00 27:16

Yeah. Um, is is strep. And it's a group strep. So horrible septicemia you can get with group strep, as we all know. And it's known to have quite a high mortality and morbidity associated with strep pygenes, arthritis, because it can rapidly destroy the patella.

SPEAKER_01 27:39

Ah, how rapidly? In days?

SPEAKER_00 27:42

Days. Yeah.

SPEAKER_01 27:43

Okay.

SPEAKER_00 27:45

So the notes, however, from the theatre say that the patella didn't look very nice. So there must there could have been potentially some damage there.

SPEAKER_01 27:55

So maybe that's what they were seeing on the X-ray then.

SPEAKER_00 27:57

Potentially, yeah, potentially. Could have been. 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. 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. And um, I think that sometimes stops us from looking at other sources of infection. 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. Do you think because we don't see septic arthritis very often, that we don't maybe think about it? And we go for common things are common, let's treat that.

SPEAKER_01 28:57

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. 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. 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. The patient smells of urine. I'm like, you cannot smell nitrites, you cannot smell leukocytes. 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. So I do think we stop. 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. 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. Now, where it goes a bit funny, I think, is sometimes in patients who can't give you that information. 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. So if you do have a patient with an infection of of unknown origin or even a hyper-CRPemia of unknown origin. 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. I remember when I was an SHO and my consultant saying, Oh, Ben, you've written down here infection of unknown origin. You know there's no such thing, or you've written down as infection and you haven't properly looked. Go to the patient's bedside, strip them naked, and examine every inch of them. And lo and behold, I found an abscess on his back that I hadn't seen the first time around. 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. 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?

SPEAKER_00 31:42

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. But I've seen septic joints which are really painful, really swollen, really red. It wasn't, it wasn't that angry, you know. 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. But she did, you know, the risk factors of septic arthritis are joint disease, and she did have a little bit of osteoarthritis.

SPEAKER_02 32:16

Yeah.

SPEAKER_00 32:16

So, you know, could this have increased her risk? She'd had a recent viral infection, had she got some actually, was this a bacteria? Did she have strep throat? Um, and did she have some hematogenous spread potentially to the knee? Her blood cultures were negative, but again, her knee culture was positive.

SPEAKER_01 32:36

Yeah.

SPEAKER_00 32:37

So she made a very good recovery. So she had the operation, she had antibiotics, and she did get a lot better. What was interesting is when I I was looking at the uh guidelines for a hot joint, they were last published 20 years ago.

SPEAKER_01 32:54

Okay, good. I haven't got to learn anything new, fantastic. No, it's a sort of the same.

SPEAKER_00 32:59

Yeah, it's the same. So British Society of Rheumatology published the guidelines in 2006. 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. They are undergoing revision. So they are going to be, the new guidelines are going to be released. Potentially this year. I'm not entirely sure when, but that's what the uh the BSR website says. So the guidelines back in 2006 were exactly what we talked about: aspirate the knee. 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. 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. Um, so just an interesting case. 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. So why do you think that could be?

SPEAKER_01 34:13

Why did a hemoglobin drop throughout admission? How low did it go?

SPEAKER_00 34:20

90.

SPEAKER_01 34:22

And it wasn't just someone got she got very vigorous ivy fluid resuscitation, it was all sort of transient, dilutional.

SPEAKER_00 34:30

Okay, yeah, that could be. Yeah. That's a really good point. Could be dilutional when you could look at the you can look at the hematocrit, can't you? And if the hematoquit goes down quickly as well, then that can take dilutional. So that's a really good point. Could be, yeah.

SPEAKER_01 34:43

Um, any reason why she would hemolyse, I can think of. I can't think of anything. Is she bleeding from anywhere? I can't think of anything. Um no, can't think of anything else.

SPEAKER_00 34:55

So there was no acute blood loss that was noted, and hemolysis can happen in infection sepsis. 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. So there is a condition called anemia of acute infection.

SPEAKER_01 35:16

Oh, right. Uh yeah, because the the bacteria consume all of the eye at something like that's where in when they multiply so rapidly.

SPEAKER_00 35:24

So sort of. So when you've got an infection, the liver produces hepcidin.

SPEAKER_01 35:29

Yes, I'm it's all coming back to you. Are you gonna say macrophages in a minute?

SPEAKER_00 35:32

Yes, I'm gonna say macrophages.

SPEAKER_01 35:34

Yes, the macrophages do something with your iron, but keep going. It's all coming back to head. They do, absolutely.

SPEAKER_00 35:38

Yeah, so I'm just gonna cover a little bit of this. 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. 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. What hepcidin does is it inhibits iron from entering the bloodstream. And the reason for this is that often bacteria need iron to grow. 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. 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.

SPEAKER_01 36:38

Do you know something really embarrassing? I wrote this on a curriculum for a teaching program about 10 years ago. I I've I remember writing like learning materials for an online training module about this exact condition, and it's just gone. And I remember now you say it.

SPEAKER_00 36:53

Yeah, yeah. So I just find it really interesting. 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. We go, oh my god, they've lost blood, or they why are they anemic? But actually, it could be due to this acute um hepsodyemia.

SPEAKER_01 37:22

Brilliant, brilliant. I love it. Do you know what? I really, really enjoyed that case. I love cases like this on the acute take. I really, really love it. Yeah, um, it it feeds something in my soul being able to do this. And um, so I'm quite pleased that I sort of got the diagnosis. But but it it really is uh it's I find it fun. 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. And it is proper old-fashioned medicine that I really, really enjoy. So thank you so much for bringing me this case.

SPEAKER_00 37:53

Thank you so much, Ben. And from me, I think I've learned two new things. Hyper CRP anemia. No, hyper, so isn't it hyper CRPhilia?

SPEAKER_01 38:06

I just said hyper CRPemia. It's a word I've made up, but because it's high CRP blood emia. High CRP in the blood. You see? Yeah, you can have that. Take that, take that.

SPEAKER_00 38:18

Thank you very much. Thank you. So a massive thank you, Ben, as ever. I hope everybody listening enjoyed that. Please rate, review, subscribe to our podcast. Please get in touch. We absolutely love hearing from you, and we do reply to all the emails. And if you've got any suggestions about anything that you'd like us to cover in the podcast, we would be more than open to suggestions. So thank you, Ben. Thank you to everybody out there. Thanks for listening.

SPEAKER_02 38:45

Bye.