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Kostantinos Vardakas       MD, PhD

Internal Medicine Specialist

Doctorate at Infectious Diseases, University of Crete

School of Medicine

 

 Office Hours

Mon - Fri,

5pm - 9pm

Mr Kostantinos Vardakas accepts patients by appointment

 

A patient with fever, weakness, anorexia and reduced level of consciousness

A 76 years old man with a history of insulin treated diabetes, coronary artery disease (myocardial infarction 8 years ago), heart failure, hypertension, obesity, hyperlipidemia and nephrolithiasis asked our help due to fever that began 5 days ago without other symptoms. Fever rose up to 38.5 ° C, but usually fell after taking simple antipyretics. The day before, he had an episode of vomiting. The patient then consulted another doctor who recommended the use of oral antibiotics for a possible urinary tract infection. The patient started antibiotics but the next morning he was found lying by his front door, feeling weak, he could not get up and disturbed communication.


On clinical examination there was fever (T = 38.4), 96 pulses/min, 34 breaths per minute, and low blood oxygen (SO2 87%). The neurological examination did not reveal any focal deficit. The patient, however, was unable to remember what happened from the time he came out of his house and his reactions were slow and he looked disoriented. His lungs sounded normal except for mild chest sounds in the left base (he said this finding was present since childhood), there was mild tenderness in the left abdomen, and there were no findings of the examination of the kidneys. The rest of the physical examination was unremarkable. After persistent questioning, the patient recalled that he had back pain that worsened during the last few days and was losing blood in his urine for a long but unspecified period of time. Due to his condition the patient was hospitalized.   Blood tests and urine showed severe, complicated pyelonephritis with acute renal failure, distention of the left ureter and nephrolithiasis and deregulation of diabetes. Also, there was anemia resembling anemia due to chronic blood loss. The patient received intravenous antibiotics and hydration with gradual improvement in clinical status and renal function. After urologic consultation pig-tail catheters were placed for drainage of urine in order to remove the stone later. Because of anemia he was transfused with packed red blood cells. The patient refused further investigation for anemia and left the hospital with antibiotics by mouth, but in a review 4 days later fever had reappeared. He was re-admitted to the hospital and received again intravenous antibiotics. The fever subsided again but because of repeated infectious episodes an immediate removal of the stone was proposed. A few days after surgery, the patient was discharged again with antibiotics by mouth. Regularly review the patient was in good condition without fever and without symptoms.


Kidney stones and diabetes are among the major risk factors for the occurrence of pyelonephritis. The stones act as foreign bodies that favor colonization with microbes and diabetes reduces immune defenses. Although in this case the first doctor's diagnosis was correct, an error in the management of the patient was done. Pyelonephritis in a man should be considered by definition as a complicated infection, especially when a history of diabetes and nephrolithiasis is present. Moreover, the presence of vomiting and disorientation are suggestive of severe disease that requires intravenous antibiotics, which was confirmed by severe laboratory findings. At the same time, this case highlights that severe infections in elderly patients often present with poor or even no symptoms to guide the physician towards the correct diagnosis and management.

 

 

Private Practice

11 Taxiarchon st & Ag. Varvaras Ave
Palaio Phaliro, 17563
Athens
Tel.: 211 4037372
Cel.: 694 7939600

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