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Endgames Case Report

An “unforeseen” complication of urinary tract infection in a patient with diabetes

BMJ 2010; 341 doi: (Published 18 August 2010) Cite this as: BMJ 2010;341:c3073
  1. Michele Mae Ann Yuen, resident1,
  2. Terence Chi Chun Tam, resident1,
  3. Winnie Wai Ying Lau, resident2,
  4. Jasper Fuk Woo Chan, resident3,
  5. Wing Sun Chow, associate consultant1,
  6. Karen Siu Ling Lam, professor1
  1. 1Department of Medicine, Queen Mary Hospital, Hong Kong Special Administrative Region, China
  2. 2Hong Kong Eye Hospital, Hong Kong Special Administrative Region, China
  3. 3Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
  1. Correspondence to: MMA Yuen micheleyuen{at}

    A 56 year old man with a three year history of untreated type 2 diabetes and normal baseline visual acuity was admitted with a one day history of acute, non-traumatic, non-painful vision loss in his left eye. This was preceded by a one week history of low grade fever, dysuria, and urinary frequency. The patient had previously had a carbuncle on his neck that required debridement and full thickness skin graft at diagnosis of his diabetes. Otherwise, he had no additional past medical problems or ophthalmological history. He was not on any regular medication before the current episode.

    On examination, the patient’s temperature was 38.4°C, blood pressure was 93/54 mm Hg, and pulse was in sinus rhythm with a rate of 108 beats a minute. His oxygen saturation was 90% on room air and improved to 95% after 2 litres of oxygen were administered via a nasal cannula. His left eye had a 4 mm hypopyon with extensive fibrin reaction in the anterior chamber, obscuring any view of the fundus and causing loss of the red reflex on direct ophthalmoscopy. His right eye was grossly normal with moderate non-proliferative diabetic retinopathy on fundal examination. B-scan ocular ultrasound of the patient’s left eye showed superior choroidal swelling, hyperechoic responses in the vitreous humour, and a flat retina. Bilateral lower zone crepitations were noted on chest auscultation, but other systemic examinations were unremarkable with no evidence of fluid overload.

    Initial blood tests showed a white cell count of 21.23×109/l (neutrophil count 18.47×109/l), normal serum creatinine, and a random (untimed sample) glucose concentration of 17.0 mmol/l. The patient was stabilised with intravenous fluid and was empirically given intravenous cefuroxime. Four hours into admission, the patient developed increasing distress, with tachypnoea of approximately 20 breaths a minute and a drop …

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