A 44-year-old female, TW, with a history of poorly controlled diabetes was admitted today with symptoms of increased urinary frequency/urgency and a fever. Upon initial examination, she complained of flank pain. Vital signs during the initial examination were unremarkable, except for a fever of 102.1◦F. When collecting a urine sample, the urine was noted to have a strong smell.
| Test | Result | Reference range |
| Hgb | 13 g/dL | 12-15 g/dL |
| Hct | 39% | 36-47% |
| LDH | 53 U/L | 50-150 U/L |
Labs performed at the time of admission:
Urinalysis: <5 epithelial cells, positive for nitrite, 4+ bacteria, 2+ leukocytes, 20-30 WBCs, and trace blood.
Home Med list:
-metformin 1000mg PO BID
-Tresiba 20 units SC qAM
Allergies: NKDA
Empirically, Piperacillin-Tazobactam antibiotic therapy was initiated (3.75 g IV every 6 hours) for the treatment of complicated, acute pyelonephritis. Urine culture results later demonstrated E. coli sensitive to piperacillin-tazobactam. On day five of the IV antibiotic therapy, the patient experienced nausea, vomiting, weakness, and dizziness. Physical examination revealed elevated heart rate (105/min), normal blood pressure, pale skin, and yellowish discoloration of the eyes.
Labs performed on day five of IV antibiotic therapy:
| Test | Result | Reference range |
| Hgb | 6.3 g/dL | 12-15 g/dL |
| Hct | 14% | 36-47% |
| LDH | 452 U/L | 50-150 U/L |
Concisely answer each of the following 8 questions by referring to specific lab results and case details. A complete explanation for each question is required for full credit.
Question 1. Based on the patient’s vital signs and the most recent test results, what general changes in RBC and serum Bilirubin (Bi) levels would you expect (i.e., increased, decreased, normal)?
Question 2. What medical condition is indicated by comparing both sets of lab results. Explain your answer by using the lab test values.
Question 3. What is the likely immunological mechanism underlying the changes in Hgb, Htc, LDH? Describe the immune mechanism in detail.
Question 4. Based on the immune mechanism you described in Question 3, what type of hypersensitivity reaction is this (e.g., Type I, II, III, or IV)?
Question 5. What is the likely cause of TW’s medical condition that you described in Question 2?
Question 6. What is the appropriate treatment for this type of hypersensitivity?
Question 7. Given TW’s current medical condition, how would you treat her pyelonephritis?
Question 8. Calculate the Naranjo Score, for TW’s medical condition from Question 2, using the information provided in the case and the additional information that her condition improved after the appropriate treatments selected in the two previous questions. Select “Do Not Know” for any questions you don’t have enough information to answer yes or no. What is your conclusion about the likelihood of of your answer to Question 5 causing the condition from Question 2? Poorly Controlled Diabetes
| Naranjo Nomogram | Yes | No | Do Not Know |
| Are there previous conclusive reports on this reaction? | +1 | 0 | 0 |
| Did the adverse event appear after the suspected drug was administered? | +2 | -1 | 0 |
| Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered? | +1 | 0 | 0 |
| Did the adverse reaction reappear when the drug was re-administered? | +2 | -1 | 0 |
| Are there alternative causes (other than the drug) that could on their own have caused the reaction? | -1 | +2 | 0 |
| Did the reaction appear when a placebo was given? | -1 | +1 | 0 |
| Was the drug detected in the blood (or other fluids) in concentrations known to be toxic? | +1 | 0 | 0 |
| Was the reaction more severe when the dose was increased, or less severe when dose decreased? | +1 | 0 | 0 |
| Did the patient have a similar reaction to the same or similar drugs in any previous exposure? | +1 | 0 | 0 |
| Was the adverse event confirmed by any objective evidence? | +1 | 0 | 0 |
