Case report acute pyelonephritis and hearing loss in scrub typhus – f1000research static electricity vocabulary words


A 52-year-old grandmother 10 gases and their uses of Indian origin, non-compliant to insulin for six months, presented to the Emergency Department of our hospital with fever and rigors, vomiting, headache, bilateral leg pain and myalgia, which had persisted for one week and urinary incontinence for the prior three days. On examination, she was conscious, oriented, toxic, febrile, drowsy, dehydrated with slurred speech, with body-mass index 20.2 kg/m 2, tachycardia, orthostatic hypotension, diminished hearing, with right renal angle fullness and tenderness. Initial investigations ( Table 1) revealed random sugars 435mg/dL, normal renal functions, ketonuria and glycosuria without pyuria, sinus tachycardia (electrocardiogram), and normal echocardiography. Arterial blood gas showed respiratory alkalosis with metabolic acidosis. Intravenous ceftriaxone 2g OD, intravenous fluids, insulin, acetaminophen 500mg electricity out in one room three times a day, multivitamins (B12 1000µg, thiamine 100mg, pyridoxine 100mg, riboflavin 5mg and folate 5mg), pantoprazole 40mg, and domperidone 10mg were commenced for probable acute pyelonephritis. On day 3, piperacillin/tazobactam 4.5g every 8 hours and fluconazole 300mg once a day (OD) were substituted for ceftriaxone 2 g OD; oral amitriptyline 25mg was added to treat the patient’s painful neuropathy.

Diabetes mellitus, due to hyperglycemia, ketoacidosis, vascular insufficiency, and impaired neutrophil and monocyte function, makes patients prone to UTIs 1. Diagnosis of acute pyelonephritis (APN) clinically is a syndrome of fever, chills, vomiting, and flank pain associated with pyuria, and is often radiologically confirmed 2. In a prospective study, only 1/4 th patients had a positive urine culture and only 65% had pyuria 2, echoing the findings in our patient. In total, 14 among 223 patients gas or electricity for heating had diabetes. Even though our patient did not have pyuria, symptoms/signs in a poorly controlled diabetic led us to a diagnosis of APN. Renal abnormalities in scrub typhus range from simple proteinuria/hematuria to acute kidney injury and occasionally, chronic kidney disease 3. Our patient had glycosuria and positive microalbumin (92µg/mg). Mechanisms postulated for renal involvement include rickettsiae-related vasculitis, tubular interstitial proliferation, and tubular necrosis 3. APN in scrub typhus has been reported only once gas laws worksheet with answers, in Chinese medical literature in a 56-year-old Chinese lady who had urgency, flank pain and an eschar 4.

Diabetes is a risk factor for scrub typhus-induced acute kidney injury. Since leukocytosis reduced with ceftriaxone without adequate fever response, we presumed poor control of bacterial/fungal infection and treated her with fluconazole and piperacillin/tazobactum. Since LFT was not performed prior to day 4 due to technical reasons, rickettsioses were not suspected. Though our locality is a high prevalence area for scrub typhus, focal renal signs and symptoms led us to think otherwise 5. We also erred in contributing her hearing impairment to be the result of her toxemia and poor health. Pure tone audiometry was done 48 hours after doxycycline when the patient became self-ambulatory. Improvement of her hearing loss, albeit partial, two weeks after discharge suggests that scrub typhus could have also contributed to her hearing impairment 6. Abdominal CT was also done after doxycycline therapy-whether findings are milder than expected is also debatable. Hypoalbuminemia and rapidly falling hemoglobin over seven days without overt blood or volume loss, could be attributed to hemoconcentration following scrub typhus-related capillary leak syndrome that was observed at initial presentation, and reverted electricity prices per kwh 2013 to premorbid levels after fluid supplementation and antibiotics. In retrospect, fever, absence of pyuria, sterile urine, capillary leak syndrome, and primary respiratory alkalosis in a patient with high sugars and ketonuria should have made us think of an alternative etiological diagnosis. Deranged transaminases nudged us in the right direction.

UTIs in diabetes are common, but scrub typhus as a probable cause of UTI/pyelonephritis has hitherto been unreported in English medical literature. Atypical organisms causing pyelonephritis should be considered in patients types of electricity with multisystem involvement and in those with a UTI but without pyuria. Furthermore, local prevalence of systemic infections such as rickettsioses should always be considered in diabetics with fever, even if symptoms and signs otherwise suggest typical diabetes-related infections.