Rational Fluid Resuscitation in Sepsis for the Hospitalist: A Narrative Review.

Administration of fluid is a cornerstone of supportive care for sepsis. Current guidelines suggest a protocolized approach to fluid resuscitation in sepsis despite a lack of strong physiological or clinical evidence to support it. Both initial and ongoing fluid resuscitation requires careful consideration, as fluid overload has been shown to be associated with increased risk for mortality. Initial fluid resuscitation should favor balanced crystalloids over isotonic saline, as the former is associated with decreased risk of renal dysfunction. Traditionally selected resuscitation targets, such as lactate elevation, are fraught with limitations. For developing or established septic shock, a focused hemodynamic assessment is needed to determine if fluid is likely to be beneficial. When initial fluid therapy is unable to achieve the blood pressure goal, initiation of early vasopressors and admission to intensive care should be favored over repetitive administration of fluid.

Human Granulocytic Anaplasmosis presenting as Subacute Abdominal Pain and Hyponatremia.

Human Granulocytic Anaplasmosis (HGA) is an acute febrile tick-borne illness caused by the organism Anaplasma phagocytophilum. Patients often present with fever and a flu-like symptoms following a tick bite. In this case, the patient presented with subacute abdominal pain and severe hyponatremia consistent with SIADH. The patient was started on appropriate empiric antibiotics given the patient's tick exposure. Blood smear confirmed findings consistent with HGA and the patient continued antibiotic treatment with resolution of his symptoms. This case is unique in that the patient presented with severe hyponatremia that improved with treatment of the HGA. He also had subacute abdominal pain which is also a rare presentation of HGA. Our hope is that our case highlights the value of empiric treatment with appropriate monitoring to prevent downstream, severe sequelae from undiagnosed HGA. In the setting of climate change, increased duration of Ixodes spp. tick life cycles with emerging regional distribution of the ticks, coinfections with Borrelia burgdorferi and increased incidence of HGA in the last two decades, it is important to recognize this entity.

Hospitalizations for tuberculous peritonitis in the United States: Results from the national inpatient sample database from 2002 to 2014.

Background: Tuberculosis (TB) is an uncommon disease in the Western hemisphere that can present with peritoneal involvement, as tuberculous peritonitis(TBP) causing abdominal pain and fever. The healthcare and economic burden of TBP in the United States remains unknown. Methods: The National Inpatient Sample database was utilized to investigate TBP hospitalizations from 2002 to 2014. Economic expenditures, patient and hospital demographics, and associations of certain comorbidities with TBP were analyzed. Results: A total of 5878 hospitalizations for TBP occurred over the 12-year duration, with $420 million in-hospital charges. The median patient age was 45 years (interquartile range: 31.1-61.7), with the majority being Hispanic (27.15%). Hospitalizations occurred primarily in the Western (31.3%) and Southern (31.7%) United States. Patient comorbidities and the respective odds ratio associated with TBP included HIV (33.56), continuous peritoneal dialysis (10.49), malnutrition (7.38), liver cirrhosis (6.87), and liver cirrhosis sequelae (6.91). Nearly 6.37% of TBP hospitalizations also had active pulmonary TB. Conclusion: Although TBP is uncommon in the United States, it should be considered in patients presenting with abdominal pain and fever and a history of HIV, continuous peritoneal dialysis, malnutrition, liver cirrhosis, or liver cirrhosis sequelae.