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C. G. Kaide, C. E. San Miguel (eds.)Case Studies in Emergency Medicinehttps://doi.org/10.1007/978-3-030-22445-5_25

25. Hemolytic Uremic Syndrome: Another FAT RN?

Seth Klein¹ and Colin G. Kaide¹

(1)

Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

Seth Klein

Email: Seth.klein2@osumc.edu

Colin G. Kaide (Corresponding author)

Email: Colin.kaide@osumc.edu

Keywords

Hemolytic uremic syndromeShiga toxinAtypical hemolytic uremic syndromeE. coli 0157:H7PlasmapheresisAutoimmuneComplement system

Case 1

Bad Burger-Barn

Pertinent History

A 23-year-old male presents with complaints of abdominal pain and diarrhea. His symptoms started 5 days ago. He began to notice some blood in his stool not only on the toilet paper but also in the toilet. He complains of significant cramping and a low-grade fever up to 100.5 °F for a few days. He was seen in an urgent care 2 days ago and received a single dose of levofloxacin for persistent diarrhea. Since then, the diarrhea had become a bit worse. He complains of associated fatigue, lightheadedness, and dizziness. He reported decreased appetite despite his attempt to eat. He denies any other symptoms at this time. He said his girlfriend had similar symptoms but improved significantly after a few days.

PMH

Type 1 diabetes mellitus (T1DM)–well controlled

SH

No tobacco, recreational alcohol, or drug use

FH

T1DM, HTN

Pertinent Physical Exam

Vital Signs:

BP 160/95 mmHg, HR 110 beats per minute, Temp 99.4 °F (37.4 °C), RR 18

Except as noted below, the findings of the complete physical exam are within normal limits.

General:

Ill-appearing male who appears uncomfortable.

Abdomen:

Soft with diffuse tenderness and mild guarding. No rebound.

Rectal Exam:

Grossly bloody stool noted

Skin:

Pale appearing but warm and dry. No rash noted.

Pertinent Diagnostic Testing

Test	Result	Units	Normal range
WBC	11.7 ↑	K/μL	3.8–11.0 10³ cells/ mm³
Hgb	10.1 ↓	g/dL	(Male) 14–18 g/dL (Female) 11–16 g/dL
Platelets	68 ↓	K/μL	140–450 K/μL
Sodium	143	mEq/L	135–148 mEq/L
Potassium	4.9	mEq/L	3.5–5.5 mEq/L
Chloride	110	mEq/L	96–112 mEq/L
Bicarbonate	22	mEq/L	21–34 mEq/L
BUN	65 ↑	mg/dL	6–23 mg/dL
Creatinine	4.3 ↑	mg/dL	0.6–1.5 mg/dL
Glucose	231 ↑	mg/dL	65–99 mg/dL
ALT	45 ↑	IU/L	8–32 IU/L
AST	36 ↑	IU/L	6–21 IU/L
Alk Phos	88	IU/L	32–110 IU/L
Albumin	4.0	g/dL	3.5–5.0 g/dL
Total Bili	5.1 ↑	mg/dL	0.2–1.4 mg/dL
Direct Bili	1.1 ↑	mg/dL	0.0–0.4 mg/dL
INR	1.1	–	≤1.1
PTT	28 s	seconds	21–35 s

Emergency Department Course

The patient appeared dehydrated and received 2 L of normal saline. When the initial labs returned showing thrombocytopenia, low hemoglobin, and renal failure, suspicion was raised for thrombotic thrombocytopenic purpura (TTP) or HUS. Additional questions were asked regarding possible food exposures for the diarrhea and patient recalled eating at a “farmer’s market” hamburger stand that advertised locally grown beef, processed on site. He and his girlfriend both ate hamburgers from the vendor. Additional testing was done showing the following results.

Test	Result	Units	Normal range
LDH	1586	U/L	50–150 U/L
Haptoglobin	<30	mg/dL	30–200 mg/dL

Update 1

An internal medicine resident, rotating in the ED, volunteered to look at the peripheral smear since there was no pathologist on call to verify a manual differential on the CBC. The findings are given below.

Schistocytes on Peripheral Smear

../images/463721_1_En_25_Chapter/463721_1_En_25_Figa_HTML.jpg — Image courtesy of Colin Kaide, MD. (Published with kind permission of © Colin G. Kaide 2019. All Rights Reserved)

Update 2

Given the findings of thrombocytopenia, hemolytic anemia with schistocytes (microangiopathic hemolytic anemia), and new renal failure, presumptive diagnosis of hemolytic uremic syndrome was given. The bloody diarrhea in conjunction with HUS suggested a shiga toxin–producing bacteria as the cause. Stool was sent for shiga toxin assay and culture.

Case 2

Pertinent History

A 21-year-old female presents with nausea and vomiting. She states she has not been feeling well for the last few days and threw up seven times yesterday and two times this morning. The vomit was nonbilious. She has not been able to eat or drink. Patient does not remember eating anything that triggered her nausea. Patient denies pain but does complain of stomach cramps. She also had watery diarrhea prior to her current symptoms one to two times over the past 4 days. She noticed new “red dotted” rashes over her chest and extremities. She denies any known sick exposures but was around a lot of people at an outdoor festival 5 days ago. She denies eating anything unusual recently. She started taking birthcontrol pills 2 months ago but did not have any other new medications, recent travel, or animal exposure. She is not sexually active and has never had any STIs. She has never done recreational drugs and does not have any tattoos. She denies personal or family history of known hematological processes.

PMH: Asthma, migraines
SH: No tobacco or drug use. Social drinker of alcohol.
FH: Breast cancer in her maternal grandmother. Prostate cancer in her father. Thyroid cancer in her paternal grandmother.

Pertinent Physical Exam

Vital Signs: BP 157/87 mmHg, HR 95 beats per minute, Temp 98.1 °F (36.7 °C), RR 18

Except as noted below, the findings of the complete physical exam are within normal limits.

General:

Oriented to person, place, and time. Appears well developed and well nourished. No distress.

Cardiovascular:

Normal rate, rhythm, and heart sounds.

Pulmonary/Chest:

Effort and breath sounds normal.

Abdominal:

Soft. No distension or mass. No tenderness. Hypoactive bowel sounds.

Musculoskeletal:

Normal range of motion. No edema or deformity.

Neurological:

Alert and oriented to person, place, and time.

Skin:

Warm and dry. Petechiae over chest/stomach/back/extremities.

Diagnostic Studies

Test	Result	Units	Normal range
WBC	10.2	K/μL	3.8–11.0 10³ cells/mm³
Hgb	8.8 ↓	g/dL	(Male) 14–18 g/dL (Female) 11–16 g/dL
Platelets	35 ↓	K/μL	140–450 K/μL
Sodium	136	mEq/L	135–148 mEq/L
Potassium	4.4	mEq/L	3.5–5.5 mEq/L
Chloride	104	mEq/L	96–112 mEq/L
Bicarbonate	20 ↓	mEq/L	21–34 mEq/L
BUN	69 ↑	mg/dL	6–23 mg/dL
Creatinine	5.0 ↑	mg/dL	0.6–1.5 mg/dL
Glucose	105 ↑	mg/dL	65–99 mg/dL
ALT	19	IU/L	8–32 IU/L
AST	46 ↑	IU/L	6–21 IU/L
Alk Phos	37	IU/L	32–110 IU/L
Albumin	3.5	g/dL	3.5–5.0 g/dL
Total Bili	2.5 ↑	mg/dL	0.2–1.4 mg/dL
Direct Bili	0.5 ↑	mg/dL	0.0–0.4 mg/dL
INR	1.1	–	≤1.1
PTT	28 s	seconds	21–35 s
HcG	Negative	–	Negative
LDH	1629 ↑	U/L	50–150 U/L
Haptoglobin	< 30 ↑	g/dL	30–200 mg/dL

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Mar 15, 2021 | Posted by admin in EMERGENCY MEDICINE | Comments Off

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Uremic Syndrome: Another FAT RN?