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Answers on p 379.
A 57 year old woman with cirrhosis was admitted to the emergency room because of hepatic encephalopathy. She had a 10 year history of multiple myeloma but she tolerated chemotherapy poorly and had required plasmapheresis twice in the past year. In her last evaluation three months previously her IgG concentration was 146.0 g/l (reference range 8.0–18.0 g/l) with low concentrations of IgM and IgA and a monoclonal spike on serum protein electrophoresis. Because her glucose levels were in the range of 15 to 21 mmol/l (4.2–6.6 mmol/l), insulin treatment was initiated.
One week after hospitalisation, despite appropriate treatment for hepatic encephalopathy and some improvement, her condition worsened again. She was unresponsive to verbal commands. On physical examination lower abdominal tenderness was present without any rebound. Because the patient has no detectable ascites, paracentesis was not performed. Laboratory findings at this point were as follows: total protein 85 g/l (60–78 g/l), albumin 22 g/l (32–48 g/l), total bilirubin 67.6 μmol/l (2–21 μmol/l), creatinine 16.7 μmol/l (50–100 μmol/l), glucose 7.32 mmol/l (4.2–6.6 mmol/l), international normalised ratio 1.81 (0.75–1.5), alanine aminotransferase 1.92 μkat/l (0.1–0.8 μkat/l), and aspartate aminotransferase 0.58 μkat/l (0.16–0.66 μkat/l). Bladder catheterisation yielded foul smelling and red coloured urine. Analysis revealed marked pyuria (90 white blood cells/high power field) and haematuria (1927 red blood cells/high power field).
In order to identify the cause of abdominal pain in this diabetic myeloma patient with Child C cirrhosis, abdominal computed tomography and direct x ray abdominal radiography were carried out (see figs 1 and 2).
Radiological studies revealed gas within the bladder wall and a urinary tract infection was suspected. After obtaining a urine culture, empiric antibiotic therapy with piperacillin 4 g plus tazobactam 0.5 g four times a day was initiated. A bladder catheter was left in place and blood glucose levels were strictly regulated.
Urine culture subsequently revealed Proteus vulgaris. Three days later a control urine culture was negative and abdominal pain improved.
What is the differential diagnosis?
What abnormalities are seen on the radiographs?
What are the predisposing factors?
How would you treat this condition?