A Case Study of Disseminated Histoplasmosis in

Immunocompetent Patient

Zachary Siemieniak
Andrews University Dietetic Internship
April 26th, 2018
 Introduction
• E.C. 41-year-old female presents to the ED on
1/31/18 for complaints of abd pain that has been
ongoing since Nov 2017.
• Admit ht 62 inches (5' 2"), wt 49.5 kg (109 lb 1.6
oz), and IBW 50 kg (110 lbs). BMI 19.95 kg/m²
• Pt reports diagnosed with disseminated
histoplasmosis in Dec 2017, via duodenal biopsy.
 Introduction cont.
• Pt was chosen as the topic of a major case study b/c of her incredibly
unique disease state, one that is not commonly taught in nutrition
related courses.
• Histoplasmosis is disease caused by the fungus, Histoplasma
capsulatum.
• Very complicated case, and is still ongoing (after multiple admissions
and discharges, patient remains admitted to the ICU since 4/15/18, is
vented/sedated, and continues to receive extensive medical care)
• It would be particularly useful to provide additional investigation for
RD’s to modify their MNT to better improve the overall care of the pt
being studied.
• The focus of this study is to review the dx, treatment and physiology
of disseminated histoplasmosis, as well as provide current MNT to
best facilitate the recovery of said pt being studied.
 Social history
• E.C. married 3 years, no children and identifies as a
Catholic. She works as a court clerk at the BC courthouse
who handles driver ticket offenses.
• E.C. originally from Pennsylvania and has since lived in MI
for 7 years. She lives near Paw Paw Lake in Berrien County,
MI, in a generally suburban setting.
• Hx obtained from M & F, as well as husband. All clueless as
to how she became infected with Histoplasma capsulatum.1
• Don’t frequent areas where Histoplasma capsulatum is
typically transmitted. Upon admission to the ED, the family
was questioned as to how E.C. could have contracted the
fungus.
• Pt is avid runner who for 3 years gets up at 0530 to run 8
miles. Weight trains at PF multiple days per week after
work.
 Social history cont.
• When SOB developed as she ran, limiting her ability to physical
perform, E.C. and husband began to question her state of health.
• E.C. is an otherwise immunocompetent and healthy individual
• no hx of smoking/ smokeless tobacco, with the occasional few
alcoholic drinks per week.
• Tell funny tooth story, and husband report of origin
• Something was wrong at the end of November 2017
• Broken/damaged a tooth bad breathhypothesis
• Looking back he suspects fungus growth originating in the lungs
(inhalation of fungus is #1 cause of histoplasmosis) could be the
cause of her unbearable breath.
• When disseminated, her tainted breath miraculously went
away.
• E.C. husband has visited her nearly every day after work since
her latest admission on 4/15/18.
 Normal Anatomy & Physiology of Applicable Body Functions

• Histoplasmosis caused by a fungus,

called Histoplasma.1 The fungus lives in the soil, and
inhalation is method of transmition2
• Most people show no s/s and may never know they are
infected. The disease can’t be transmitted from person
to person.
• Histoplasmosis can be serious for people with
weakened immune systems or who have chronic
diseases, or for infants.3
• Rarely, it can lead to death. 500,000 people are
exposed to H. capsulatum each year in the US.3 Many
people living in the OH and MS river valleys of the US
have been infected with Histoplasma
• It grows in moist soil that is rich in N+, or in places
contaminated with bird or bat droppings
 Normal Anatomy & Physiology of Applicable Body Functions cont.
• When other organs are affected, the disease is called
disseminated histoplasmosis, which can be life-threatening if
left untreated.
• People breathe the spores of fungus into the lungs, where they
grow. In people with healthy immune systems, they usually do
not spread to other parts of the body.
• In those with weakened immune systems, however, the spores
may spread to the lymph nodes, liver, spleen, bone marrow,
adrenal glands, and digestive system.5 Those most at risk of
becoming infected include:
• Farmers and poultry farmers, Construction workers, Spelunkers
(Christian Bale), Geologists and archeologists, Landscapers and
gardeners, People who have contact with bats (batman)
• Those at risk of severe infection include:
• People with weakened immune systems (from HIV,
corticosteroid therapy, organ transplantation, and
chemotherapy).5 Very young children, Senior adults, People
with chronic diseases, such as lung disease, etc.
 Normal Anatomy & Physiology of Applicable Body Functions cont.
• Most people with histo don’t have no s/s making it
hard to detect. In addition to a physical exam, your
doctor may do the following tests:
• Fungal culture -- can take several weeks to confirm
diagnosis, so this test is not used if someone needs
immediate treatment.6
• Fungal stain or blood test.6
• Chest x-ray or computerized tomography (CT) scan.6
• Mild cases of histoplasmosis may not need to be
treated.
• Doctors treat more serious cases, with symptoms that
include high fever, trouble breathing, loss of appetite,
and malaise, with antifungal medications.6
 Normal Anatomy & Physiology of Applicable Body Functions cont.
• Meds stop fungus from growing in the body. Dr’s often
use meds in severe cases when the infection has spread
to other organs and tissues throughout the body.
• Amphotericin B (Fungizone IV, Abelcet) -- given
intravenously (IV). Your doctor may start with this drug,
then switch to itraconazole.7
• Itraconazole (Sporanox) -- taken by mouth.
• Because the drug [Amphotericin] can be very toxic to
the kidneys and liver, the function of these organs
needs to be monitored with regular blood tests during
treatment.7 As soon as feasible, patients should be
switched to a less toxic oral drug, such as itraconazole.
 Past Medical Hx cont.
• E.C. dx with Disseminated Histoplasmosis as an
outpt via duodenal biopsy, on itraconazole prior to
admission (Dr. Wang).
• She presented on 1/31 with abd pain and n/v
which had been going on for several months but
has become worse more recently. From 1/31/18 to
2/26/18 the following findings were discovered:
Abdominal X-ray/CT scan showed ileus likely due to
diffuse lymphadenopathy from histoplasmosis. Also
noted to have ascites. GI/General Surgery were
consulted.
 Past Medical Hx cont.
• Patient kept NPO, started on TPN and placed on
liposomal amphotericin B per recs from ID
• She completed 17 days of amphotericin B and
subsequently transitioned back to itraconazole.
• Pt has had improvement in s/s and diet advanced
to soft diet, however pt would still have
intermittent abdominal pain and she was not felt to
be taking in enough nutrition by po to support
nutritional needs.
• As such, plan is to discharge with TPN home care
visits as an outpatient.
 Past Medical Hx cont.
• Regarding ascites, paracentesis done on 2/2/18 and
again on 2/5 with fluid studies negative for infection.
• Etiology of ascites likely 2/2 to severe
malnutrition/hypoalbuminemia. TPN should help
address malnutrition until she is able to meet her
nutritional recs via po. Pt also had biopsy of skin lesion
on 2/1 with path results showing results consistent
with histoplasmosis.
• On 3/8/18 E.C. presented to the ED w/ SOB and chills.
Pt states that she was at the potassium infusion center
earlier that day and had SOB as she was receiving IV
infusion. A rapid response was called and the patient
was examined. Pt found to be hemodynamically stable,
however, the pt was sent to the Waterviliet ER for
further evaluation.
 Past Medical Hx cont.
• Pt states that she has been feeling fatigued and SOB the
whole week. Pt admits to n/v with TPN. Klebsiella Bacteremia
was positive and most likely 2/2 to aspiration pneumonia.
• E.C. instructed to continue Ceftriaxone 2 g daily through till
3/25/2018 thereby completing a 14 day antibiotic course
after the last negative blood culture.
• Bilateral pleural effusions were performed s/p thoracentesis
on 3/9 with fluid cultures negative. Pt instructed to continue
spironolactone (which will also help with hypokalemia).
• Hypokalemia/Hypomagnesemia were repleted via PO/ IV
riders. Pt indicated of severe protein calorie malnutrition with
prealbumin of 5. TPN resumed 3/13 with full diet. Diuretic
provided to resolve ascites. Pt experienced abd pain due to
hepatomegaly and ascites. Pain controlled while on Morphine
+ Neurontin combination.
• E.C. discharged on 3/16/18.
 PMHx cont.
• E.C. admitted on 4/1/18 (AGAIN!) with post prandial
vomiting for over 1-2 weeks with every meal in the
setting of anorexia.
• She was evaluated by GI - had multiple studies
which ruled out any acute process. She was
transitioned to oral Reglan for presumed
gastroparesis which was effective.
• She was discharged in stable condition on 4/5/18
with outpatient follow up. Her prior documented
Klebsiella bacteremia was resolved as blood
cultures were negative.
 Present Medical Status and Treatment
• Pt re-admitted to the hospital on 4/15/18 due to
increased lethargy, and "weakness while trying to
type" at the computer.
• She has had n/v with associated watery diarrhea at
home. Husband reports she has vomited up some
of the Itraconazole prior to admission.
• Pt was transferred from floor to PCU to ICU
overnight for increasing respiratory distress,
persistent hypoglycemia, sepsis, AKI, and abdominal
pain.
• PTA, pt was receiving TPN from 2100 to 0900 due to
malnutrition and inability to tolerate any other form
of nutrition.
 Present Medical Status and Treatment
• Recent events are as follows:
• 4/16/18: Pt transferred to ICU for further management. Pt
intubated in the am of 4/16/18 for hypoxic respiratory failure
with tachypena. She remains on dopamine and levophed.
Consults were placed to infectious disease and general
surgery. Overnight with movement the patient removed her
tunneled R IJ central line. The ICU placed a right femoral
central line.
• 4/17/18: Pt had R sided paracentesis 4/16 with
approximately 2 L turbid fluid removed. Many nucleated cells
seen, no organisms, no yeast. Culture pending. She
developed leukocytosis overnight but is afebrile. She remains
on dopamine and levophed. ID and Surgery following. Et tube
advanced again overnight. Will wean sedation and pain meds
as appropriate today. US to rule out DVT today. Tube feeds to
start today in consult with GI.
 Present Medical Status and Treatment
• 4/19/18: Febrile overnight with T-max of 101.1F, pt continues to
demonstrate significant high residuals, proximally 800 mL, nasogastric tube
switched to low intermittent suction due to concerns of aspiration. Plan
gradual, incremental reduction and sedation. Interval chest x-ray reveals
some right sided interstitial opacities and slight worsening from previous
day in the perihilar area on the right. Goal to wean dopamine to off.
• 4/23/18: TPN infusing at goal rate via right femoral CVC. Peptamen infusing
at 10ml/hr with attempt to titrate again today. Residuals have been
between 10ml-100 ml. Nutrition-related Meds being administered include:
senna, miralax, reglan, zofran, relistor 4/22, magnesium sulfate rider 4/23,
lasix, hydrocortisone, nimbex, diprivan 6.8ml/hr.
• E.C. continues to remain on mechanical ventilation to protect her airway
from aspiration risk. Patient currently receiving Clinimix 5/15 E @ 60ml/hr,
Peptamen Intense @ 10ml/hr, 50ml water Q 4 hours. At 60 ml/hr, TPN
provides: 1022 + 240= 1262 kcals/day, 94 g protein/day, 1940 ml fluid/day
(TPN + free water from EN + flushes) + 163 kcals diprivan = 1425 kcals.
• Pt continues to be followed daily by RD's to ensure TPN notes are properly
written and to keep electrolytes within manageable limits.
• E.C. has been hospitalized since 4/15/18 and remains on the CCU.
 Medical Nutrition Therapy
• E.C. consumes a primarily plant-based/vegetarian diet with
chicken as the only meat source in her diet; she sometimes
eats fish and shellfish.
• She denies consumption of red meat, poultry (with exception
of chicken), pork, ham, deep fried foods, processed meats
such as hotdogs.
• Pt reports to drinking a minimum of 64 oz of water daily, in
which she measures at the beginning of every morning, to
track her intake. She does not keep sugary foods in the house.
• Once per week, typically on Sunday, she has a cheat day. Such
days consist of less desirable food choices such as chips,
crackers, cheese pizza, etc.
• She eats at home for breakfast and dinner alongside her
husband, and typically eats lunch out or at the workplace.
E.C. enjoyed cooking and up until her condition became
worsened, limiting her involvement in preparing foods.
Medical Nutrition Therapy cont.

Patient 24-hour dietary recall is as follows:

Breakfast - 8 oz glass of Gatorade

- medium pear/banana
- banana
Lunch - water
- chicken teriyaki sub from Jimmy
Johns
- Rice
- Pasta
Dinner - Chicken
- Veggie burgers
- Gatorade
- Skim milk
- Large mixed salad
Snacks - Carrots, bananas, and other fruits
 Medical Nutrition Therapy cont.
• Estimated daily calorie intake could not be determined, as the
patient was unable to decipher the exact portions of the food she
consumes. As a dedicated runner, she typically consumes larger
portions of food towards dinner time, and lesser portions early on
in the day. She does not monitor food intake as she is typically very
lean and needs as much fuel as possible to maintain her physical
fitness.
• E.C.'s diet order has changed multiple times throughout her
medical care over consecutive admissions/discharges. Initially she
was prescribed clear liquids for gastrointestinal testing, with the
end goal of being placed on a general diet to improve overall
intake.
• Abdominal X-ray/CT scans showed ileus likely due to diffuse
lymphadenopathy r/t histoplasmosis. E.C. also noted to have
ascites. GI/General Surgery were consulted.
• Patient kept NPO, started on TPN to meet estimated needs.
Patient has had improvement in symptoms and diet was able to be
advanced to soft diet, however patient would still have
intermittent abdominal pain and she was not felt to be taking in
enough nutrition by mouth to support nutritional needs.
 Medical Nutrition Therapy cont.
• Plan to d/c with TPN home care visits as an outpt. Etiology of
ascites likely 2/2 to severe malnutrition/hypoalbuminemia.
• TPN should help address malnutrition until she is able to meet her
nutritional requirements by mouth. TPN resumed 3/13 with full
diet.
• E.C. admitted on 4/1/18 with post prandial vomiting for over 1-2
weeks with every meal in the setting of anorexia. She was
evaluated by GI - had multiple studies which ruled out any acute
process. She was transitioned to oral Reglan for presumed
gastroparesis which was effective.
• PTA on 4/15/18, patient was receiving TPN from 2100 to 0900 d/t
malnutrition and inability to tolerate any other form of nutrition.
Tube feeds to begin 4/17/18 after consult with GI. 4/19/18 patient
continued to demonstrate significant high residuals, proximally
800 mL, nasogastric tube switched to low intermittent suction d/t
concerns of aspiration.
• 4/23/18 TPN infusing at goal rate via right femoral CVC. Peptamen
infusing at 10ml/hr with attempt to titrate again today. Residuals
have been between 10ml-100 ml.
 Medical Nutrition Therapy cont.
• The calculated needs for E.C. were as follows:
• Estimated Nutrition Needs: Using ABW= 49.5 kg
(2/1/18)
1485-1980 kcal/d Based on: 30-40 kcal/kg (promote wt gain)
79-89 g pro/d Based 1.6-1.8 g/kg (repletion, promote wt gain)
on:
1238-1485 ml fluid/d Based 25-30 ml/kg (hydration)
on:
• E.C. was initially prescribed multiple nutritional
supplements to improve po intake and to prevent
weight loss as able, but would eventually not be
able to tolerate most real foods, and would quickly
become dependent on EN and TPN to meet a
majority of her energy needs.
 Medical Nutrition Therapy cont.
• Some nutritional supplement recommendations are as
follows:
• - Gelatein Plus (cherry) BID @ 1000 and 1400
• - Carnation Breakfast essentials mixed in 2% milk TID @
1000, 1400, and HS
• - Culturelle one capsule BID - Recommend OTC
medication: daily probiotic to help replenish healthy GI
flora with hx of chronic diarrhea
• - Theragran daily & Vitamin D3 if depleted -
Recommend vitamin and mineral supplement therapy
given suspected micronutrient deficiencies
• First use of TPN on 2/2/18: Dietary consult received to
initiate TPN. Pt was found to have possible small bowel
obstruction vs. Ileus on Abdominal X-Ray. Pt is
currently NPO and NG was placed for suction.
 Medical Nutrition Therapy cont.
• Clinimix E 5/15 @ 65 ml/hr -- Start at 20 ml/hr x 6 hours. If tolerated,
increase by 15 ml/hr every 6 hours until goal rate is reached.
• 440 ml L20 every Monday, Wednesday, Friday
• Provides: ~1485 kcal (~30 kcal/kg); 78 g protein (~1.6 g/kg); 1560 ml fluid
(~31 ml/kg)
• Dex Load= 3.3 mg/kg/min
• Lipid Load= 0.08 g/kg/hr
• Estimated Nutrition Needs: wt=49.1kg (3/9/18)
1473-1964 kcal/d Based 30-40 kcal/kg, prevent wt loss
on:
73-88 g pro/d Based 1.5-1.8g/kg, repletion
on:
1227-1473 ml fluid/d 25-30ml/kcal, hydration
Based on:
 Medical Nutrition Therapy cont.
• E.C. energy needs differ substantially once being transferred to CCU
during 4/15/18 admission and meeting vent/CCU parameters.
• Estimated Nutrition Needs: No changes. 43.9kg (4/23/18)
880-1100 kcal/d Based 20-25/kg actual weight, vent/CCU
on: parameters, BMI 18
66-88 g pro/d Based 1.5-2/kg, repletion, vent parameters,
on: ,muscle wasting
965-1320 or per ml fluid/d 1ml/kcal Vs 25-30/kg hydration
MD Based on:
• E.C. does not completely adhere to a vegetarian diet or lifestyle, but
little research is available to show any clear evidence that a plant-
based lifestyle is beneficial in the treatment of Disseminated
Histoplasmosis. Below are some suggested supplements and herbal
remedies that may play a role in reducing symptoms r/t the fungal
infection Histoplasma.
 Medical Nutrition Therapy cont.
• Although no supplements cure histoplasmosis, a
few studies suggest that some supplements may
help reduce symptoms.8 Following these nutritional
tips may help reduce s/s:
• Eat bitter and spicy foods, such as those containing
turmeric (curries), cayenne peppers, green chilies,
olives, figs, garlic, and ginger.
• Drink warm teas which contain spices, such as
cardamom, clove, and cinnamon.9
• Eat antioxidant foods, including fruits (such as
blueberries, cherries, and tomatoes) and vegetables
(such as squash and bell peppers).9
• Drink 6 to 8 glasses of filtered water daily.
 Medical Nutrition Therapy cont.
• The following supplements may help reduce s/s, although
more scientific research needs to be performed to know for
sure:
• Vitamin C, 500 to 1,000 mg, 1 to 3 times daily. Vitamin C is an
antioxidant and may help strengthen the immune system.9
• Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5
to 10 drops (in favorite beverage) three times daily when
needed.9 Grapefruit seed may have antibacterial, antifungal,
and antiviral properties. It may also help strengthen the
immune system.
• Probiotic supplement (containing Lactobacillus acidophilus), 5
to 10 billion CFUs (colony forming units) a day, when needed
for maintenance of gastrointestinal and immune health.9
Refrigerate probiotic supplements for best results.
• Coenzyme Q10, 100 to 200 mg at bedtime, for antioxidant
and immune system support.9 Coenzyme Q 10 may interact
with blood thinners, such as warfarin (Coumadin), clopidogrel
(Plavix), or aspirin and make them less effective.
 Medical Nutrition Therapy cont.
• Herbs can strengthen and tone the body's systems (witch doctor therapy).
These herbs have not been studied specifically for histoplasmosis, but they
seem to stop the growth of some fungi:
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg TID, to reduce
inflammation and stop the growth of fungus.10 Cat’s claw may boost the
immune system, so people with autoimmune diseases (such as rheumatoid
arthritis or psoriasis) may want to avoid it.
• Garlic (Allium sativum), standardized extract, 400 mg, 2 to 3 times/day, to
kill fungus and boost the immune system.10 Garlic may increase the risk of
bleeding.
• Cranberry (Vaccinium macrocarpon), 300 to 1,800 mg, 2 times per day, to
fight fungus.10 Cranberry contains salicylic acid, the same ingredient in
aspirin.
• Reishi mushroom (Ganoderma lucidum), 150 to 300 mg, 2 to 3 times per
day, to reduce inflammation and strengthen the immune system.10 One may
also take a tincture of this mushroom extract, 30 to 60 drops, 2 to 3 times a
day. Reishi may interact with blood pressure medications and blood-
thinning medications.10
• Olive leaf (Olea europaea) standardized extract, 250 to 500 mg, 1 to 3 times
per day, for antifungal activity and immunity.10 One may also prepare teas
from the leaf of this herb. Olive leaf can lower both blood pressure and
blood sugar.10
 Prognosis
• Many people do not have serious complications, but rarely they may
include:
• Fibrous tissue in the lining of the chest wall cavity, which may squeeze the
esophagus, heart, or lungs, so they cannot work properly.8
• Meningitis
• Scar tissue in the lungs
• Blindness -- if infection spreads to the eyes
• Most cases of histoplasmosis are mild, and symptoms go away in 10 days
without treatment. Sometimes symptoms may last for several weeks. In the
most severe cases, particularly when the infection spreads throughout the
body, a person may need to take antifungal medications for a long time.8 If
left untreated, severe cases can cause death. People in areas where the
fungus is common may get a second infection, even after treatment. But
the second one is usually milder than the first.
• It remains unclear of whether or not E.C. will manage to make a healthy
recovery or not. She has been vented, sedated, and bed-ridden for ~11 days
now, and continues to have high gastric residuals. Pt unable to tolerate any
form of po nutrition, including water, and will vomit. Pt may be dependent
on TPN for the rest of her life, or unless medically warranted. Per medical
disciplinary team, E.C. planned to have trach placement sometime this
week.
 Conclusion
Throughout this case study, I became more familiar with
Disseminated Histoplasmosis. I investigated treatment options,
typical diagnostic tests, and prescribed medications for said
condition. Furthermore, I gained an understanding of the relationship
between Histoplasma and its relation to other organ systems.
Granted this is not a minor case of Histoplasmosis (FAR FROM IT),
with many factors coming into play such as GI issues as well as severe
malnutrition, nonetheless, provided me with a greater understanding
of the disease, and how to be more prepared for future pts who deal
with the same condition. It was difficult at times speaking with the
family of E.C. as they were extremely caring, and spent many
countless hours at the bedside waiting for better news to arrive that
has yet to come. I'm glad I was able to capture some of their turmoil,
and present a topic that many are not entirely familiar with, as it is
quite an unusual condition in this area of the country. I would have
liked to retrieve more nutrition history from E.C. herself prior to
being mechanically ventilated and under more severe medical
supervision. Overall this was a rewarding experience, and I hope I can
share my knowledge of Histoplasmosis with interns of my own one
day, or with my co-workers.
 References
1. Azar MM, Hage CA. Clinical Perspectives in the Diagnosis and Management of
Histoplasmosis. Clinics in Chest Medicine. 2017;38(3):403-415. doi:10.1016/j.ccm.2017.04.004.
2. Zhu L-L, Wang J, Wang Z-J, Wang Y-P, Yang J-L. Intestinal histoplasmosis in immunocompetent
adults. World Journal of Gastroenterology. 2016;22(15):4027. doi:10.3748/wjg.v22.i15.4027.
3. Doleschal B, Rödhammer T, Tsybrovskyy O, Aichberger KJ, Lang F. Disseminated
Histoplasmosis: A Challenging Differential Diagnostic Consideration for Suspected Malignant
Lesions in the Digestive Tract. Case Reports in Gastroenterology. 2016;10(3):653-660.
doi:10.1159/000452203.
4. Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical Practice Guidelines for the Management of
Patients with Histoplasmosis: 2014 Update by the Infectious Diseases Society of America. Clinical
Infectious Diseases. 2014;45(7):807-825. doi:10.1086/521259.
5. Azar MM, Hage CA. Laboratory Diagnostics for Histoplasmosis. Journal of Clinical
Microbiology. 2017;55(6):1612-1620. doi:10.1128/jcm.02430-16.
6. Carod-Artal FJ. Fungal Infections of the Central Nervous System. CNS Infections. 2017:129-156.
doi:10.1007/978-3-319-70296-4_7.
7. Shaikh MS, Memon AM. Disseminated histoplasmosis in an immuno-competent young male:
Role of bone marrow examination in rapid diagnosis. Diagnostic Cytopathology. 2017;46(3):273-
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8. Lum J, Abidi MZ, Mccollister B, Henao-Martínez AF. Miliary Histoplasmosis in a Patient with
Rheumatoid Arthritis. Case Reports in Medicine. 2018;2018:1-6. doi:10.1155/2018/2723489.
9. Liu X, Ma Z, Zhang J, Yang L. Antifungal Compounds against Candida Infections from
Traditional Chinese Medicine. BioMed Research International. 2017;2017:1-12.
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Infective Drug Discovery. 2013;5(1):91-93. doi:10.2174/157489110790112536.
Comprehensive Metabolic Panel results as follows:
Lab values on admit 1/31/18 Lab values drawn
Reference ranges
2/19/18

Glucose Random 65 (L) 82 74 - 109 mg/dL

Blood Urea Nitrogen 18 20 6 - 20 mg/dL
Creatinine 0.4 (L) 0.7 0.5 - 1.0 mg/dL
BUN/Creatinine Ratio 45 (H) 29* 7 - 25
EGFR >60 >60 >60 mL/min
Sodium 131 (L) 133* 136 - 145 mmol/L
Potassium 4.2 3.5 3.5 - 5.1 mmol/L
Chloride 96 (L) 97* 98 - 107 mmol/L
CO2 25 24 22 - 29 mmol/L
Anion Gap 10 12 5 - 14 mmol/L
Total Calcium 8.5 (L) 9.1 8.6 - 10.0 mg/dL
Total Protein 6.7 6.7 6.4 - 8.3 g/dL
Albumin 2.3 (L) 2.4* 3.5 - 5.2 g/dL
Globulin 4.4 (H) 4.3* 2.3 - 3.9 g/dL
Albumin/Globulin Ratio 0.5 (L) 0.6* 1.2 - 2.2

AST 21 16 <33 U/L

ALT 12 17 <34 U/L
Alkaline Phosphatase 257 (H) 295* 35 - 104 U/L
Total Bilirubin 0.4 0.4 <1.3 mg/dL
Magnesium 2.0 1.8 1.7 - 2.4 mg/dL
Lipase 6 (L) --- 13 - 60 U/L
 E.C. Family history as follows:

Cancer Mother

Heart disease Father

Cancer Maternal Uncle

Cancer Paternal Aunt

High cholesterol Paternal Uncle

Cancer Maternal Grandfather

Heart disease Paternal Grandmother

High cholesterol Paternal Grandmother

Heart disease Paternal Grandfather

High cholesterol Paternal Grandfather