Hi everyone,

Sorry for the delay getting back to post. I have still been trying to sort things out, and I was waiting until I could give a reasonably helpful update.

The patient has been back in this area for about 2 1/2 weeks. He came back on Sunday evening, I saw him in the office on Monday, Tuesday morning he had a PICC line put in, and Tuesday evening had his first dose of IV vancomycin. He started with 1 g Q 12 hours, his trough level was a little high, so for the last week he's been on 1250 mg Q 24 hours. Today was day 16 of vanco. He's also on PO rifampin, which gives excellent tissue penetration.

Clinically, he is clearly improving. Fevers are gone, he feels better, feeling stronger, and his appetite is improved.

But night sweats continue, and he continues to lose weight, probably more than would be expected from his lack of appetite.

His sed rate remained unchanged, very high at around 120. How ever, his C reactive protein had been up around five, it's now normal at 0.9.

The clue comes in his CBCs. The last few CBCs have shown white count of about 11,000, but with a preponderance of lymphocytes, a sizable percentage of atypical lymphs, and a few smudge cells. His hemoglobin has consistently been around nine. So CLL seems likely. And this would make diagnosing sepsis more difficult, since he was not able to mount the typical leukocytosis, due to marrow suppression.

Patient will be having blood drawn early next week, this will include flow cytometry.

So the best I can put all this together is as follows:

Patient has been having symptoms, specifically night sweats, from CLL for about two months.

He then coincidently suffered from a large kidney stone, which required instrumentation.

Somewhere, probably related to the kidney stone or instrumentation, he became infected with staph epi. He was immunosuppressed from the CLL. The worst of his symptoms came from this infection. Where was the infection? My guess is still endocarditis.

He has been improving on the antibiotics, so the remaining symptoms, including the elevated sed rate, are from the CLL.

I plan one month of Vanco, which I think should be sufficient. By that time we should have a likely diagnosis of CLL. If that is the case, he probably will require treatment, due to the weight loss and night sweats.

So that's where we stand, and I'm reasonably sure that it's right.

Gene

Gene Nallin MD solo family practice with one PA Cumberland, Md