A 28 year old man is admitted with two days of vomiting. His illness began with a sore throat but he has become progressively more unwell, developing abdominal pains which became severe, and vomiting. He saw his general practitioner who diagnosed a viral infection and prescribed throat linctus and simple analgesics. However he deteriorated and the following day his wife brought him to the local hospital.
He had been previously healthy and is not taking any drugs. He is a smoker who drinks quite heavily at weekends and sometimes during the week. His work at a local factory does not involve exposure to chemicals. He is a keen fisherman.
On assessment he is thought to be mildly dehydrated. Pulse is 100 and blood pressure 139/85, JVP just visible lying flat.
He appears to be breathless and pulse oximetry shows him to be hypoxic (saturation 90%). His chest X-ray is shown. Today he has developed a dry cough.
Tests show acute renal failure with urea 24 mmol/l, creatinine 230 micromol/l (2.6 mg/dl). Na 138, K 5.4. He is catheterised and his bladder contains 240 mls of quite dark urine which on dipstick testing shows blood + protein +. FBC shows Hb 11.8 g/dl, wbc 11.2, plats 170, film normal. Liver function tests are normal. One of the doctors having read Dr Dorward’s case from October shortness of breath in a 60 year old man, an urgent anti-GBM and ANCA test is sent.
A central venous catheter is inserted and shows CVP of 8cm from the mid-axillary line. Infusion of 1.5 litres of crystalloids raises his CVP to 12 and blood pressure to 145/90 but does not increase his urine output.
Over the next 48 hours his renal function deteriorates further: 410 the next day, 680 the third. His oxygenation also deteriorates and he now requires 80% oxygenation to maintain saturation. His anti-GBM result is reported to be weakly positive. He is transferred to a tertiary centre for dialysis and ventilation.
Have the admitting team done OK so far?
Thanks to Professor Andy Rees for this case.