Fall is upon us, the season of pumpkin pie, pumpkin spice latte, pumpkin everything and most importantly: Halloween!
Being an avid horror movie fan, you can instantly deduce how October 31st is special to me… I always wanted to throw a Halloween party with crazy decorations… This year I made my dream come true by throwing the party during Morning Report!
So let me tell you about my curious case of bun cellulitis:
Once upon a time, on a quiet call day, the intern me admitted a 68 year-old patient with a history of uncontrolled HTN and cocaine/alcohol dependence… The patient apparently had two fifths of Vodka two days prior to admission (a fifth is a whole bottle, FYI…) and passed out on his back for at least six hours with his wallet in the back pocket. His reason for coming into the hospital was paresthesia of the right foot. He was started on Vancomycin/Cefepime for what we were told a right buttock cellulitis…
The thought sounded outlandish at the time, however I went down to see the patient, I was trying to link the cellulitis and the numbness of the foot, I didn’t have a logical connection then…
Examining the “cellulitis”, the right bun was mildly erythematous and not warm to touch, however there was an induration that you wouldn’t expect in such a circumstance. The labs looked funny: Acute kidney injury (from a previous CKD stage 2), hyperkalemia of 5.8 and hypocalcemia (corrected calcium was 7)… Now Hercule Poirot’s voice was in my brain “Use your little gray cells, mon amie!”, I could see his satisfied smile when the UA showed the tell-tale positive blood with absent RBCs
You know what I am talking about, right? I could see the soft smile on your face!
So a patient who passed out from alcohol for long time, combined with a sprinkle of cocaine who is coming in with AKI, hyperkalemia, hyperphosphatemia and hypocalcemia, with a UA that is showing blood and no RBCs would be having rhabdomyolytis. We ordered a CPK that was > 50,ooo confirming our suspicions!
Now, let’s talk treatment! You would flush them with fluids (aiming for 200 mL/hr of urinary output, you can give anything between 400 to 1000 mL per hour), however after many liters, progressively rising CPK, minimal to absent urine output, rising potassium and signs of pulmonary edema nephrology started the patient on hemodialysis. Keep in mind that dialysis in rahbdo is indicated when you have severe or progressing hyperkalemia, fluid overload and decreased urinary output. The patient recovered his baseline kidney functions and didn’t require continuous dialysis!