Pearls from the case:
- For patients with extreme leukocytosis (WBC >30), infection was the underlying cause in ~60% of cases, with “physiological stress” the next most common culprit. Of those infectious etiologies, about 25% had c diff
- A very elevated white count is not specific for certain underlying etiologies, but add c. diff to your differential if it wasn’t there already inpatients with WBC >30!
- Patients with HHS have an average total body water deficit of 9L (!) compared with about 6L for DKA patients.
- Guidelines recommend IVF at 1L/hour for the first 2-3 hours, then continuing resuscitation based on urine output, hydration and electrolytes thereafter.
- For acute stroke, most patients will be hypertensive, which does not require treatment unless the SBP is >220 to allow for good perfusion to the ischemic areas. If a patient has hypotension (as this patient did) then your goal using vasopressors should be normotension with an SBP >140.
Wanahita A, Goldsmith E, Musher D. Conditions Associated with Leukocytosis in a Tertiary Care Hospital, with Particular Attention to the Role of Infection Cause by Clostridium Difficile. Clinical Infectious Diseases 2002;34:1585-92.
Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870.