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Cystic Fibrosis, Small Bowel Obstruction, Fatty Liver, Sepsis, High WBC Count, Pain. Help Appreciated.

Posted on Sun, 24 Jun 2012

Question: I am concerned about my wife. She is 37 years old and has cystic fibrosis, she was admitted to the hospital in September 2011 and has been in the hospital since. She had a small bowel obstruction in September and since then has not recovered fully. In November there was concern about something that showed up in the liver, it seemed to be fatty liver, that is what we were told by Ultra Sound and CT scans. She ended up with Sepsis and was treated for Candida Albacans and Glabrada in the blood starting 11/30/11. The Candida has not cultured in the blood since 12/6/11 but did culture in fluid that was removed from her abdomen. They recently did an abdominal scan again and said that the mass in the liver is still considered fatty liver but despite numerous antibiotics her WBC count has not gone below 25,000. They did a tag white cell scan and nothing showed in the liver but I was also told these were not very reliable in some patients. When she had her gall bladder removed she did not preset with symtoms accept pain and when they removed it it was completely infected. If you could please help me out I would greatly appreciate it. Thank you for your time in advance. Also, she is currently on IV Tobromycin, IV Cirpofloxin, IV Vancomycin, IV Micafungin, oral Vancomycin, IV Bactrim, oral Refaxamin

Answered by Dr. Ajit Naniksingh Kukreja (2 hours later)

Hi,

Thanks for posting your query.

Firstly let me appreciate your patience in this grim situation.

You have very nicely described the treatment given and the current treatment, but what we are interested is in the general condition of the patient like consciousness, orientation, vital parameters, any support, nutrition etc.

Let us consider each factor individually:

The fungal infection in the abdominal fluid is a concern, with so many antibiotics and reduced immunity we have usually observed anaerobic and opportunistic infections creeping in.

When was the gallbladder removed? Infected Gallbladder usually has anaerobic culture, was a culture of bile from the removed Gallbladder done?

How long is the patient on the treatment mentioned?
Considering the volume of antibiotics that are going on, I wonder if the treatment is according to a sensitivity report or on presumptions.

Are the Liver and Renal functions normal? What about proteins and Electrolytes?
Have they considered giving fresh blood?

Considering her medical history, it definitely is a tough patient to treat, yet a cool mind while considering the treatment usually help.

Please get back to me with the clarifications and if possible a scanned sensitivity report, that will help us suggest some line of management.

Till then we will remember your patient in our prayers and pray for her speedy recovery.

Get well soon.

Above answer was peer-reviewed by : Dr. Shanthi.E

Follow up: Dr. Ajit Naniksingh Kukreja (7 hours later)

XXXXXXX is very alert, her vitals are HR around 100, BP 113/53 (77), 02 saturation 97% on 40%, on continuous dialysis currently, LFT are elevated (alkphos 1300), antibiotics are based on sensitivities, she has been on this course of antibiotics for 7 days, Gall Bladder was removed about 7 years ago.

Answered by Dr. Ajit Naniksingh Kukreja (30 minutes later)

Thanks for the followup query

As the primary culprit is cystic fibrosis, Considering all the aspects of treatment and lab reports wait and watch is the best policy

As the Vitals are favorable, except for Liver function

It is usually presumed that antibiotics would take around 14-21 days to give a good response in this type of patients[ No need to change as the antibiotics are as per sensitivity report]

An antioxidant would be of some help

This is all anyone would suggest in this case

Yet if you have any further query please revert back, and if not do accept my response

wishing your wife a speedy recovery.

Regards.

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Ajit Naniksingh Kukreja (1 hour later)

Is there a possibility that a liver abscess could present as a fatty liver deposit? The part of the liver they say is fatty liver is about 4cm x 9cm and as of this morning her WBC went up again from 25,000 to 32,000 and has been going back and forth like this for a couple weeks.

Answered by Dr. Ajit Naniksingh Kukreja (16 minutes later)

Hi

Thanks for a followup query

There are very remote possibilities of it being a Liver Abcess

Reason Being :
Fatty liver is a known entity in Cystic fibrosis
The echo pattern on ultrasound for the abcess is very typical and any experienced sonologist won't miss it
The size of the lesion may misguide us but a ultrasound and CT would confirm a diagnosis if it would have been an abcess

The variation in the counts is definitely due to septicemia and reduces immunity because of multiple factors

Anyway hope for the best and keep praying

Anything in coming days do drop in a line, will try my level best to get a satisfactory reply to you

Wishing your wife a speedy recovery

Note: For further follow up on digestive issues share your reports here and Click here.

Above answer was peer-reviewed by : Dr. Yogesh D