My Favorite Book: The Yellow River, by I. P. Daley

I will say that never gets old. Yet again, I prove I am really just 12 years old. But let's be honest, deep down, everyone chuckles at jokes about this kind of stuff. So where am I going with this? A 80 something patient presents with acute confusion and a fall, assessment and labs show hyponatremia to 120, AKI, and pancytopenia, WBC 1, RBC 2.1, Hgb 7.2, Plt 40. Cultures grew mold and bacteria (suspected pneumonia) so she is placed on voriconazole and cefepime. The baseline for the patient is alert and oriented to person, place, time, and situation, the family reports normally the patient is lively and active with a large family including 8 grandkids and 2 great grandkids (not relevant but I think it is sweet). Medical history includes CHF, osteoporosis, BMI <16, stress incontinence, UTIs, unspecified malignancy. A PICC is placed in the left arm and the patient improves after getting rid of....... furosemide? Huh. Bone biopsy was negative for malignancy, no other reason was found for the dyscrasia. 

What about the confusion? Hepatic encephalopathy? Stroke? Inter-cranial bleed? TBI? Tumor? UTI? Nutritional deficit? Alzheimer’s? Nope. Keep going  

I remember learning about a lot of meds in pharmacology that has pancytopenia listed in adverse events (how common I never saw) but from what the doctor wrote, furosemide induced pancytopenia is not that super rare. So I know furosemide, brand name Lasix, is a loop diuretic used for edema associated with CHF, liver damage, renal diseases, hypertension, pulmonary edema, increased ICP, hyperkalemia, hypertensive crisis, hypermagnesemia, and hypercalcemia. Whew. 

I also knew that it worked by inhibiting sodium and chloride resorption in the loop of Henle and some tubules. The increase in urination is from the increased need to excrete the not resorbed solutes. Overuse of the drug can cause the opposite effect due to increase compensatory aldosterone production. Looking further into it, all sorts of issues may arise from use of the drug: ototoxicity, vertigo, aplastic anemia, TENS, SJS, hypertriglyceridemia (real word?), among others. So losing all that fluid and subsequent electrolytes may cause the hyponatremia and a change in mental status. Additionally, cefepime is associated with an increased risk of acute encephalopathy. So maybe the confluence of those two facts, along with weight loss due to anorexia may be behind the pancytopenia and the altered mental status. 

After a new diuretic, new antibiotic, and better nutritional intake the patient began to become more aware and on baseline. One of the challenges taking care of a patient in this situation is eating and drinking. Good lord, picky eaters. Yet try again and again, through trial and error the perfect foods were found. It was indeed an emotional process for me as the patient insulted my instant oatmeal. That’s a low blow. But alas, lemon meringue pie was the key. I always new pie was an important food group. All aside it jumpstarted the patients energy and led to a much better diet and fluid intake. Good food really can do some good stuff for people. 

That’s the story. Blame furosemide and cefepime. Eat pie. Drink water. Get better. The only more simple cure for EVERY disease is the military secret of 800mg ibuprofen, water, and new socks. Hope everyone has an excellent day, week, weekend, month or whatever you’re currently having. Please share this if you like it and check out the infrequent podcast. Love y’all. Bye. 

References

Cefepime induced neurotoxicity: a systematic review from Critical Care 2017 by Payne et al.

Furosemide, cefepime, and acute encephalopathy from the NIH

Furosemide from PDR

Furosemide-Induced Thrombin Thrombocytopenia Purpura: A Report of a Rare Case from Cureus 2022 by Chandok et al.

Hyperacute leucopenia associated with furosemide by Ma in BMJ Case Reports 2017

Image from Stepward: Furosemide

Mortality in Elderly Patients Taking Furosemide: Prospective Cohorts Study from International Journal of Hypertension by Rodriguez-Molinero et al., 2022

UpToDate: Approach to the adult with pancytopenia, 2023


Comments

Post a Comment

Popular posts from this blog

What the H?

Image
As far as I can remember, I was never a medically minded person up until Christmas 2019. I knew what food poisoning was, blastomycosis, blood clots,  and cracked ribs were, but that was it. I'm sure I knew of others, but I never gave them a second thought as I was spared much in the way of illness. It's funny how such things shaped my life, and I never gave them any hold in my mind until much later. Not that these diagnoses were as profound as say, a cancer diagnosis, but they impacted me in many ways. All this to say, that was my breadth of awareness of the medical field, the corpsmen (God love them, seriously) were no help to teach me. I do remember vividly for some reason I can't explain, the time I found out about H. pylori, the "H" in the title. I had a buddy at the time with some gnarly, debilitating stomach pain. Boy did I not known what the hell to do about that. Ibuprofen? Acetaminophen? Nah, I know better now. And that. bug, and subsequent complications,...
Read more

Well S*#t

Image
We are just going to keep talking about GI subjects until I get tired of them. Probably after this but who knows? I get to take care of a lot of GI/GU patients at work with some of the "Greatest Hits" of the gut. Diverticulitis, intestinal perforations, colorectal cancer, pancreatitis, bowel obstructions, abscesses, bleeds, and the like. I won't ever be a GI specialist but I do love infections and the big dog at the moment is everyone's favorite, Clostridioides difficile  AKA Clostridium difficile maybe C. diff  or in this mess of words, CD.  CD is a Gram -positive, spore forming, obligate anaerobic, motile, "drumstick-shaped" bacillus. To expand on that, they need low-no oxygen environments (like the gut), create spores that are hardy and able to survive conditions that would kill the live bacteria, and CD creates toxins that cause many of the effects of a CD infection. Though we generally associate CD with the diseases it causes, sometimes called CDAD or C...
Read more

Bacitracin: Bacteria from Tracey

Image
Not even joking. No cap. The solemn truth. On the record. The truth, the whole truth, and nothing but da truth. Bacitracin was named after bacteria from a lady named Margaret Tracey. How is that for useless knowledge taking up space in your brain? Before we get into that story, me thinks the three of you reading this have probably used, or had been the target of use for, bacitracin as a kid. The little packets are ubiquitous in first aid kits across the world. Got a cut? Bacitracin. Burn or scrape? Bacitracin. Ran out of toothpaste? Bacitracin. I really hope that sarcasm was evident, the lack of humor nowadays is stunning. Please don't eat bacitracin.  In 1943, a young girl named Margaret Tracy was seen at a hospital in New York, the precursor to Columbia-Presbyterian Medical Center. She had been hit by a car earlier that day and suffered a compound fracture of her tibia, which collected dirt from the road. The doctors cultures the wound which grew Bacillus subtilis and Staph aureu...
Read more