This case involves a male patient in his late 40s with a past medical history significant for ulcerative colitis, for which the man had been taking immunosuppressive drugs under the supervision of his gastroenterologist. The patient presented to his primary care physician complaining of pain and discomfort in his perianal area, which was diagnosed as an infected hair follicle. The man was given a topical cream without instructions for further follow up. A few days later, the patient presented to the emergency room with complaints of a fever and increasing pain. Labs were performed and the man was discharged with a diagnosis of a likely viral infection. The next day the man returned to the hospital with worsening fever, pain, and weakness. He was admitted and diagnosed with sepsis. Despite treatment the man was forced to undergo multiple amputations due to a systemic staph infection.
Question(s) For Expert Witness
- 1. How often do you treat ulcerative colitis?
- 2. What is the threshold for prescribing antibiotics to patients on immunosuppression?
Expert Witness Response E-110266
The patient has a horrific outcome as a result of a disseminated Staph infection. This is typically seen when the infection source is not well-controlled resulting in the organism to travel into the blood stream and other organs causing severe sepsis. His history almost suggests that he likely has perianal Crohn’s disease rather than ulcerative colitis. Patients with perianal Crohn’s disease can get perianal abscesses (rather than folliculitis). Typically a simple folliculitis would not cause severe sepsis. The perianal abscess is commonly not seen on a colonoscopy. However, an MRI or CT scan would show perirectal fluid collection. The perianal abscess, if not treated adequately with surgical intervention, can result in severe sepsis in this case. the drug that this patient was on does suppress part of the immune system. When patients are on these drugs and have fevers, they need immediate medical attention. At that point, the physician would decide if therapy can be continued, held, or if the patient should be admitted for further workup.