Case of the Month - August 2011

Drs Riaan Writes and Madaleen Jansen van Vuuren – PathCare

Case history

A 51 year old female patient with chronic epigastric pain and reflux was admitted for elective gastric surgery. She was hypertensive on treatment and a smoker. A laparotomy was performed with a Nissen fundoplication, Roux-en-Y with reconstruction, vagotomy and antrectomy. A splenectomy had to be performed secondary to an iatrogenic splenic injury. After initial uneventful postoperative convalescence and discharge from ICU to a general surgical ward on day 5, the patient was readmitted into ICU on day 11 after barium swallow showed total gastric obstruction, anastomotic breakdown and gastric perforation. A second laparotomy was performed to repair the anastomosis, gastric perforation and an oesophageal tear. No mediastinitis was evident. Cefoxitin was used as intra-operative prophylaxis (both operations).

CRP remained high and the patient was started on imipenem and metronidazole postoperatively. She also received TPN. Metronidazole was discontinued after 5 days. Fever spikes were noted from day 5 of ICU admission. Teicoplanin was added on day 6. The patient was intubated on day 9 due to desaturation and possible LRTI. Fluconazole was started on day 10. Low dose IV hydrocortisone was added. Pseudomonas aeruginosa was cultured from tracheal aspirate. The patient was intubated and ventilated for a total of 11 days. Intermittent spiking fevers continued despite the patient being extubated on day 20 and more than 3 weeks of treatment with imipenem, teicoplanin and fluconazole. Several blood cultures taken during this period were negative. The patient developed clinical wound sepsis and fistulas at drain sites. Pus from the fistula isolated Citrobacter freundii, Klebsiella pneumoniae (non-ESBL) & Enterococcus faecalis. Candida was cultured from wound/pus swabs on several occasions. The patient received 2u packed cells (Hb 9) but never had neutropaenia. Repeated contrast visualization studies and abdominal CT-scans revealed no further evidence of perforations, anastomotic breakdown or intra-abdominal fluid collections.

The patient was discharged from ICU to general ward for wound care and resolution of the fistula after 34 days. Documentation of intermittent fever spikes continued. Saccharomyces cerevisiae was isolated from a blood culture taken on day 30 of readmission to ICU. On enquiry it was found that a Probiotic (INTEFLORA® 250) was added to the patient’s prescription on day 4 of readmission to ICU. Inteflora contains Saccharomyces boulardii. The probiotic was discontinued after which the fever subsided. The patient was discharged after spending 10 weeks in hospital and is currently progressing well and gaining weight.
 

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