Sepsis with negative CRP/ferritin?

[Medic_90x]

Case on the floor that I thought I'd ask about here since it may be the best place for knowledgeable insight.

65 y/o F - hx of COPD, very controlled T2DM, heavy smoker. Can't afford home meds (htn and copd meds). Comes in somewhat altered (unknown baseline, but likely normal from clinic notes). New O2 requirement of 3L. Doesn't endorse specific complaints.

Vitals: afebrile, normotensive, 92% on 3L, pulse 100
Exam: Somewhat tachypnea. Coughing. Lungs sound junky. Abdomen is normal. No CVA. No cellulitis.

Labs: WBC 25, Creatinine 5.1 (baseline is 1.1), Transaminitis in 150-250s, troponin 0.09 (threshold range is <0.10 and no chest pain or EKG changes), lipase 150, lactate 2.3, VBG normal. BNP 4000 (no previous one)
CT brain - normal. CT abd without contrast is normal. CXR no acute signs.
Urine later shows signs of UTI + prerenal AKI. Hep panel negative. Ethanol 0. Tylenol level zero.
COVID is negative! and no risk factors.

So treating her as sepsis of unknown origin --> urosepsis once urine came back. And also treating for COPD minus prednisone.

Here's my question - I added a CRP and ferritin for ****s and giggles and it came back at <0.5 and a completely normal (almost low) ferritin. Can you have such profound acute signs of end organ damage from sepsis and have that normal of a CRP and ferritin (acute phase reactants) ???

We have a WBC of 25. We have an intense AKI with Cr of 5.1. We got very solid transaminitis. We even got a lipase up. All this from sepsis but completely normal CRP/ferritin?

Any thoughts?

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[chessknt]

Not sure if this kind of post is allowed since most people don't want to be construed as giving medical advice.

I would say as a general point not related to this case that the right context with covid negative x1 doesn't convince me it isn't covid. x3 negative I'll believe. As another unrelated point a non-con CT a/p can miss quite a few diagnoses.

 

[Medic_90x]

Not sure if this kind of post is allowed since most people don't want to be construed as giving medical advice.

I would say as a general point not related to this case that the right context with covid negative x1 doesn't convince me it isn't covid. x3 negative I'll believe. As another unrelated point a non-con CT a/p can miss quite a few diagnoses.

No intention of applying anything in this post to real life. We've had some very detailed similar posts.

But main question would be if sepsis with just profound end organ damage is even possible with a 100% normal CRP/ferritin and of note - slightly elevated albumin level of 5.0.

Just an odd combination of numbers.

Of note - this is in the setting of an upward trending lactate (2.3 --> 4.2).

 

[chessknt]

No intention of applying anything in this post to real life. We've had some very detailed similar posts.

But main question would be if sepsis with just profound end organ damage is even possible with a 100% normal CRP/ferritin and of note - slightly elevated albumin level of 5.0.

Just an odd combination of numbers.

Of note - this is in the setting of an upward trending lactate (2.3 --> 4.2).

I don't use either of these routinely and haven't checked it in enough sepsis patients to know what normal is. I would assume there is variation and having normals wouldn't exclude anything except maybe osteomyelitis (crp) or hlh (ferritin).

 

[dingdong28]

I'm not a physician or went to medial school. I've been working as a medical lab tech for a little over 6 years now.

Looking at her physical exam results, it doesn't look like she has SIRS with her being afebrile and tachypnea, although she needs oxygen support (my guess from having COPD and hx of being a heavy smoker). What did the rest of her CBC and differential look like? Platelet count decreased? Differential showing a left shift (bands, metas, myelos)? Coags normal or elevated? Without knowing anything else, I'm more suspicious of this being an infection than sepsis

How long was the patient on the floor before a CRP was added on? CRP begins to rise 4-6 hours after stimulation due to an infection/inflammation. CRP levels usually double every 8 hours and peak at 36-50 hours. Don't forget that CRP doesn't have high specificity (multiple factors can cause a CRP to be elevated). My next question would be at what time/day the CRP was added on or collected. If the patient was already receiving antibiotic treatments and the patient is responding to those antibiotics and a CRP was collected, the CRP may no longer be elevated and will begin to decrease or return to normal.

Was a urine culture sent/added on to the UA? Did the urine culture come back positive/identify anything? Were blood cultures ever collected?

A procalcitonin may have been more useful than the ferritin; I don't know much about ferritin being used for sepsis, but will read about it more.

I apologize if you knew all of this already.

 

[chocomorsel]

Not sure if this kind of post is allowed since most people don't want to be construed as giving medical advice.

I would say as a general point not related to this case that the right context with covid negative x1 doesn't convince me it isn't covid. x3 negative I'll believe. As another unrelated point a non-con CT a/p can miss quite a few diagnoses.

It’s a typical clinical discussion. Why would it not be allowed? What makes this post any different than any other case discussion?

 

[chocomorsel]

I think you have to look at this patients age and comorbidities as well. She is older and immunocompromised and CRP is not very specific or that sensitive.
What is the differentials on the WBC? Was she on home steroids recently for COPD exacerbation? Was procalcitonin checked at all? What is growing in the urine?
As far as Ferritin, were we checking Ferritin levels in the past the way we are now with Covid? I could be wrong but I don’t think people were. So who’s to say how high people’s Ferritin levels got or didn’t get in sepsis? Maybe IM-CCM people do this regularly?
You have other markers of sepsis, and you treat accordingly. Sometimes not all the check marks are checked but you treat based on clinical exam and judgement and whatever other markers you have available to guide you. Also, did you do a CT head and abdomen and skip the chest for some reason in a COPD with increased requirements? Recheck the Covid although I haven’t yet seen a Covid patient without elevated Ferritins. But I am no expert.

So the answer to your question is most likely yes.

 

[CCM-MD]

I think you have to look at this patients age and comorbidities as well. She is older and immunocompromised and CRP is not very specific or that sensitive.
What is the differentials on the WBC? Was she on home steroids recently for COPD exacerbation? Was procalcitonin checked at all? What is growing in the urine?
As far as Ferritin, were we checking Ferritin levels in the past the way we are now with Covid? I could be wrong but I don’t think people were. So who’s to say how high people’s Ferritin levels got or didn’t get in sepsis? Maybe IM-CCM people do this regularly?
You have other markers of sepsis, and you treat accordingly. Sometimes not all the check marks are checked but you treat based on clinical exam and judgement and whatever other markers you have available to guide you. Also, did you do a CT head and abdomen and skip the chest for some reason in a COPD with increased requirements? Recheck the Covid although I haven’t yet seen a Covid patient without elevated Ferritins. But I am no expert.

So the answer to your question is most likely yes.

I don’t check ferritin in sepsis. Some people like to trend it in COVID, I don’t do it routinely. Doesn’t usually change my management. I also don’t check CRP much. I had an attending that always said CRP has a missing A, I tend to agree with that.

 

[Radetzky]

Don’t understand all the CRP hate. It’s an incredibly sensitive marker even in immunocompromised (not in the first few hours, but by 24 hours definitely). A good rule out test when you have low-moderate clinical suspicion (remember Bayes theorem!)

Why are you so convinced this is sepsis? Plenty of Comorbid 65 yr olds have colonised urine.

 

[chessknt]

It’s a typical clinical discussion. Why would it not be allowed? What makes this post any different than any other case discussion?

His first post made it sound like pt was admitted undergoing active workup which could be construed as medical advice

 

[chocomorsel]

His first post made it sound like pt was admitted undergoing active workup which could be construed as medical advice

It’s medical advice if you are asking for your own self is my understanding.
Not getting ideas for a clinical case. Maybe I am wrong?
Honestly, I have never read the TOS and have been here like 15 years.

 

[aafisahar]

Leading differential is sepsis or heart failure, with the caveat that unless the heart failure is horrible, it won't give you a creatinine of 5. CRP is sensitive, but it ain't perfect. Likewise, no one really knows what ferritin does in infection and what the kinetics are.

Pore over the med list looking for offenders of AIN/CIN, does he/she abuse NSAIDs? Recent contrast bolus (with the caveat that contrast nephropathy might not be a thing)?

 

[Tuloste]

Leukocytes rise quickly after the onset of inflammation, while CRP lags behind somewhat (6-8 hours? not sure), so it is possible for a hyperacute infection to present as you've outlined. But if that CRP is not elevated come next morning, you can be certain that the patient did not have sepsis regardless of any treatment they might've received.

 

[CaliforniaAppli]

Eh this patient doesn’t seem that septic to me. The term has become so loose thanks to SIRs. SIRS does not equal sepsis.

 

[WheezyBaby]

Yeah the case sounds more heart than infectious to me.

Regardless, I've had a negative procal with mrsa bacteremia. Never make decisions solely on biomarkers

 

[Instatewaiter]

Do you have an echo?

Rare to see a bnp (not nt probnp) of 4000 in just renal failure without any cardiac involvement.

 

[Instatewaiter]

Yeah the case sounds more heart than infectious to me.

Regardless, I've had a negative procal with mrsa bacteremia. Never make decisions solely on biomarkers

But don't consult me because, although it may be more heart than infectious, I certainly won't say that in a consult unless it is so hit-you over-the-head obvious that the janitorial staff know it's a cardiac issue.

 

[CCM-MD]

But don't consult me because, although it may be more heart than infectious, I certainly won't say that in a consult unless it is so hit-you over-the-head obvious that the janitorial staff know it's a cardiac issue.

Of course.

I just saw a lady who had CABG and valve replacement 4 weeks ago. Comes in SOB with b/l opacities and pleural effusions. Ends up on the vent. BNP 2000. COVID neg x 2. Cardiologist says "resp failure due to possible ILD".

 

[chocomorsel]

Of course.

I just saw a lady who had CABG and valve replacement 4 weeks ago. Comes in SOB with b/l opacities and pleural effusions. Ends up on the vent. BNP 2000. COVID neg x 2. Cardiologist says "resp failure due to possible ILD".

So did you consult the pulmonary docs? What did they have to say.
Or did you ask the Cardiologist if his probe was broke?

 

[WheezyBaby]

But don't consult me because, although it may be more heart than infectious, I certainly won't say that in a consult unless it is so hit-you over-the-head obvious that the janitorial staff know it's a cardiac issue.

It's just too bad the trop was miraculously negative in this patient with an egfr of 5 and strained myocardium, would have been a slam dunk ACS consult!

 

[CCM-MD]

So did you consult the pulmonary docs? What did they have to say.
Or did you ask the Cardiologist if his probe was broke?

I managed the respiratory failure and got the patient extubated. Got em out of the unit pronto.

You're probably right though. I should have called pulm for a bronch with biopsy, IR for thoracentesis and rheum cuz why not. I'm such a bad doctor. Not to worry though, I am sure the hospitalist will do better with consulting everyone and their mother.

 

[Instatewaiter]

Of course.

I just saw a lady who had CABG and valve replacement 4 weeks ago. Comes in SOB with b/l opacities and pleural effusions. Ends up on the vent. BNP 2000. COVID neg x 2. Cardiologist says "resp failure due to possible ILD".

Truthfully that may be him being nice to the surgeon bc if it is heart failure within 30 days of surgery, the sts numbers take a hit.

Also it was obviously a noncardiac issue. That was a demand leak of BNP