A 45 year Old Man Taking Immunosuppressant Drugs presents With Jaundice And Fever

A 45 year old man with a 7 year history of rheumatoid arthritis presents with cough, high fever and a painless jaundice. Over the past 16 months his symptoms of joint pain were not controlled by NSAIDs alone and so he was switched to immunosuppressant drugs which helped in controlling his symptoms. Patient is a non smoker and consumes less than 2 units of alcohol per week.
On examination;

•  patient looks unwell and deeply jaundiced.

• He had a temperature of 102 F. 
• Examination of the oral cavity shows yeast infection.

• On auscultation of the lung fields there were coarse crackles at the right lung base. 
• On abdominal examination spleen was palpable 3 cm below the left costal margin.

Investigations done are shown below:

• Hb = 7.1 g/dl
• WBC = 1400/cmm
• Platelets = 33,000/cmm
• ESR 70 mm/hr
• Bilirubin = 180 micro mole/l
• AST = 180 iu/l
• Alkaline phosphatase = 450 iu/l

Answer the following questing related to the above case....

 Q1: Give three possible causes for this patient's presentation?

Answer;

• Septicemia secondary to respiratory infection precipitated by methotrexate induced neutropenia
• Septicemia secondary to respiratory infection precipitated  by azathiprine induced neutropenia
• Septicemia secondary to respiratory infection due to felty's syndrome.

Q2: What six investigations would you perform on admission?

Answer:

1. Chest X ray
2. Oxygen saturation
3. Blood culture
4. Urine culture
5. Throat swab for culture
6. Hebatobiliary ultrasound.

Q3: List two immediate management steps?

Answer:

1. Stop the immunosuppressant drug.
2. Start broad spectrum intravenous antibiotics( usually a combination of penicillin and aminoglycoside)