CASE STUDY ANALYSIS

CASE STUDY ANALYSIS 1

Case Study Analysis: Acute Bacterial Prostatitis

(Author’s Name)

Advanced Pathophysiology

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Acute Bacterial Prostatitis

Scenario

42-year-old man presents to ED with 2-day history of dysuria, low back pain, inability to

fully empty his bladder, severe perineal pain along with fevers and chills. He says the pain is

worse when he stands up and is somewhat relieved when he lies down. Vital signs T 104.0 F,

pulse 138, respirations 24. PaO2 96% on room air. Digital rectal exam (DRE) reveals the prostate

to be enlarged, extremely tender, swollen, and warm to touch.

Prostatitis is a clinical condition that causes inflammation of a couple of excretory ducts

of the prostate glands. There are four variants of prostatitis syndrome namely, asymptomatic

inflammatory prostatitis, chronic pelvic pain syndrome (CPPS), chronic bacterial prostatitis

(CBP), and acute bacterial prostatitis. Enterococci species and gram-negative enterobacteriaceae

causes CBP and ABP. On numerous occasion, the E.coli is the major cause of the infections, with

gram-negative cultured microorganisms, such as P-euroginos, Klebseilla species, and Serratia

species as established by McCance and Huether (2018).

Most common tale for bacterial prostatitis is urinary tract infection. Its onset is associated

with low back perineal pain, elevated fever, and shiver. Most patients develop dysuria, which

cause urination altogether difficult, forcing to urinary retention, and nocturia. Occasionally,

patient’s symptoms include lower urinary tract obstruction characterized with constricted urinary

stream that may require medical attention (McCance and Huether, 2018). Normally, when the

patient stands up, the infection trigger prostatic pain due to muscle activity that cause pelvic floor

muscle to contract compressing the prostate gland. Certain patients, however, experience painful

ejaculation, low back pain, perineal or rectal pain. Palpation reveals the condition with an

engorged, and sore prostate that is hard, and warm when felt.

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The complication the patient develops, such as urinary retention can be managed with

antibiotic therapy preventing rupturing of the prostatic into the perineum, rectum, and urethra. It

also prevents septic shock, epididymitis, and bacteremia. Urinary retention is released suitably

with the suprapubic catheter. Acute infection is best managed with foley catheterization.

Pathophysiology

The E.coli variant that contributes to ABP normally gives rise to virulence factors, such

as cytotoxin necrotizing factor 1, alpha hemolysin, S fimbria, and P fimbria. The development of

acute bacterial prostatitis occur due to the following mechanism; upward spread of urethral

infection arising from meatus on numerous occasion during coitus, and outward flow of

infectious urine entering glandular prostatic tissue through prostatic and ejaculatory gland. It is

also associated with substantial amount of PMN’s within and atop acini related to intraductal

desquamation, cellular remains, and tissue attack by lymphocytes, macrophages, and plasma

cells. The symptoms of the disease can spread becoming more pronounced.

Factors that affect fertility (STDs)

ABP arises from either sexually transmitted diseases (STD) or urinary tract infection

(UTIs). Acute prostatitis occurs due to the inflammation of the prostate gland located beneath the

bladder of men. The function of the prostate gland is the sustenance of the sperms. It is a most

significant share of the semen. STDs, such as gonorrhea and chlamydia are known causative for

acute bacterial prostatitis. The fertility of an individual is affected with either chronic prostatitis

or asymptomatic inflammatory prostatitis that induces sperms to mix with the white blood cells

as explained by Dr. Shoske. However, it is not caused with chronic pelvic pain syndrome.

Research shows, when white blood cells is established in prostate secretions, it inhibits

the function of the sperm, subsequently, its quality making them sterile (Iliades et al., 2011). The

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mechanism of the effect is unknown by numerous physiologist, but association generally points

to reactive oxygen species. The previous molecules are constituents of the blood cells.

Researchers have found that semen of infertile men contains nearly 40 percent of the reactive

oxygen species.

Pelvic inflammatory disease (PID) is caused by gonorrhea and chlamydia when not

managed effectively. It also contributes to an infection in the fallopian tube and adjacent systems,

such as uterus, and tissue causing sterility. PID can also lead to complications, such as ectopic

pregnancies. Among the STD, HPV infection in women can lead to development of cervical

cancer. Pregnant women should or once planning to conceive should understand that STD can

contribute serious complication to their unborn child. Presently, routine prenatal care comprises

numerous screening tests for STDs.

Why inflammatory markers rise in STD/PID.

An abundance of C-reactive protein (CRP) in the blood is an indication of inflammation.

The condition has numerous etiology spreading from cancer to infection. Usually, the body

reacts to an injury or an infection in the body through inflammation. As the body responds to an

injury, the level of, pro- inflammatory, C-reactive protein (CRP), and cytokine increase intensely.

There are two test namely CRP test and erythrocyte sedimentation rate (ESR) used to determine

the amount of inflammatory protein produced in the blood. ESR test is an indirect assessment of

various proteins, while CRP the amount of C-reactive protein linked to inflammation.

According McCance and Huether (2018), CRP fixes itself both in macrophages as well as

bacteria triggering the complement system. The previous system is number of protein essential

for assisting macrophages expel invading microorganism, which are important in the initiation of

clotting process. They further points out that an infection triggers CRP to increase and

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diminishes with a proper management of the disease by using antibiotics. The test is vital for

observing the impact of an infection.

Factors that contribute to sexually transmitted infection (STI), especially mycoplasma

genitalium and chlamydia trachomatis contributes to chronic bacteria prostatitis. Magri et al.,

(2018) propose the use of molecular technique to establish STDs factors contribute infertility in

both the sexual partner and infected individual.

PID arising from chlamydia infection has known complications, such Fitz-Hugh-Curtis

disorder, tubal infertility, tubo-ovarian abscess (TOA), and ectopic pregnancy. The following

study was conducted among 497 women admitted with PID in a period of 9 year from 2002 to

2011. The study examined both PID case with chlamydia and without chlamydia, particularly by

assessing important factors, such inflammatory markers, lab finding, and clinical manifestation

of the PID.

Among the patient group that contained PID with chlamydia, it was established they have

alleviated levels of CA-125, CRP, and ESR that patient group that had not developed chlamydia.

High levels of CA-125 are an essential indicator for chlamydia infection, then ESR and CRP.

Therefore, according to Park et al. (2017), chlamydia infection associated with the development

of acute PID due to buildup of inflammatory markers.

Why prostatitis and infection happens. Also explain the causes of systemic reaction

Prostatitis arises from an infection originating from urethra or excretion of an infectious

urine toward the prostatic ducts. Similar bacteria that cause the urinary tract infection are also

associated with the development of prostatitis. The most common bacteria, however, is

established to be E.coli according to Perry & Langenstroer, (2007). Among other known variants,

include serratia, pseudomonas, Enterobacter, proteus, and Klebsiella. Gram-positive organism

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causal factor has not established. However, Enterococcus fecalis is the popular cause of chronic

bacterial prostatitis. The discharge of infectious urine is associated with the development non-

infectious prostatitis.

The bacterial infection from the urethra moving upwards as well as the discharge of

infectious urine causes an infection to the prostate gland. It can be managed through direct

inoculation of the bacteria using hematogenous seeding or biopsy needles. Chronic and acute

prostatitis is associated with Enterobacteriaceaes pathogen. Presently, the function of Enterococci

has been established in the development of the disease. These pathogens have the tendency of

forming biofilm capable of resisting various drugs.

The inflammation of prostatic is an essential element in the prostatic growth and is an

indication of an advancement prostatitis and benign prostatic hyperplasia (BPH). Lack of

management of the acute phase of the disease contributes to the neuro-inflammation/chronic

inflammation particularly the natural immune system affecting nerve system. Magri et al. (2018)

argues that, clinical evidence have shown that chronic inflammation is highly associated chronic

pelvic pain syndrome/chronic prostatitis (CPPS/CP) including BPH. Patient with a history of

clinical chronic prostatitis are predisposed to the development of prostate cancer.

There is dire need to establish cytological typing of immune cell to assist in the

classification of immune response to understand the development of the disease. Major causes of

prostatitis, particular the chronic prostatitis is not clearly established as established by Magri et

al. (2018). However, researchers have faith that the development of the disease arises from

individual immune system response to prior attacks of UTI. Another important explanation is the

immune system reaction to nerve damage, and microorganism that contribute to chronic

prostatitis.

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Why a patient would need a splenectomy after a diagnosis of ITP

Immune thrombocytopenia (ITP) is syndrome characterized with a abnormal bleeding

and bruising, which arises due abnormally low level of platelets (responsible for clotting of

blood). The disease was initially known as idiopathic thrombocytopenic purpura. ITP is

characterized with reddish-purple spots and purple bruises (Clinic, 2019). The disease occurs in

children after contracting a viral infection. It also disappears without needing treatment.

However, in adult the disease can persist for a long.

The pathophysiology of the disease is associated with antibodies that initiate the

obliteration are commonly glycoprotein IIb–IIIa or Ib–IX) on the membrane of the platelets, and

IgG class as established by McCance and Huether (2018). Besides, the disease can be managed

through splenectomy or dependent immune thrombocytopenia. It dislodges the main site of the

platelet clearance as well as autoantibody synthesis providing intensified response in contrast to

ITP therapies. Nevertheless, there are no dependable indicators of splenectomy reaction, and

long haul dangers of disease and cardiovascular difficulties must be view (Chaturvedi, Arnold, &

McCrae, 2018). Since the long term viability of various second-line clinical treatments for ITP

have not been legitimately compared, treatment choices must be made minus supportive proof.

Anemia and the different kinds of anemia (i.e., micro and macrocytic)

Anemia is associated with the reduced total amount of red blood cells circulating the

body. It can be stated as the reduction of the red cell or amount of hemoglobin in the blood.

Occasionally, it occurs due to loss of blood, enhanced destruction of erythrocyte, impaired

production of erythrocyte, and a combination of latter factors. The changes in plasma volume

due fluid retention an dehydration associates to total circulating red blood cell mass (McCance

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and Huether, 2018). For instance, diminished plasma volume from thirst (less water

consumption, delayed regurgitating, loose bowels, abnormal utilization of diuretics) with a

typical red platelet mass may demonstrate a relative polycythemia or unusually raised red cell as

a result of hemoconcentration. Serious lack of hydration can associate with expanded hematocrit

and hemoglobin levels.

Liquid maintenance is related with hemodilution as opposed to a genuine reduction in red

platelet mass. Blood LOSS upsets this equilibrium by making a demand for more iron, along

these lines exhausting the iron stores quickly to substitute the iron lost from blood loss/bleeding.

Iron likewise adds to immune role by directing immune effector systems (i.e., cytokine functions

[interferon-gamma (IFN-γ)], nitric oxide arrangement, and T-cell multiplication).

Conclusion

According to the symptoms presented with the 42-year old patient, his condition can be

diagnosed as acute bacterial prostatitis. Acute bacterial prostatitis (ABP) is an inflammation

excretory duct of the prostate glands. The disease is associated with urinary tract infection (UTI),

and characterized with constricted urinary stream. Patient diagnosed with the condition normally

show symptoms, such as elevated fever, shiver, low back perineal pain, and they develop dysuria.

The most common bacterial causing the disease is E.coli. ABP can be caused with STDs which

when not treated properly can contribute to infertility. The inflammatory markers that arise in

STD include elevated CA-125, ESR, and CRP, which are also critical PID associated with

chlamydia.

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References

Clinic, M. (2019, April 30). Immune thrombocytopenia (ITP). Retrieved from

https://www.mayoclinic.org/diseases-conditions/idiopathic-thrombocytopenic-

purpura/symptoms-causes/syc-20352325

Chaturvedi, S., Arnold, D. M., & McCrae, K. R. (2018). Splenectomy for immune

thrombocytopenia: down but not out. Blood, 131(11), 1172–1182.

https://doi.org/10.1182/blood-2017-09-742353

McCance, K. L., & Huether, S. E. (2018). Pathophysiology-E-book: the biologic basis for

disease in adults and children. Elsevier Health Sciences.

Iliades, B. C., Levine, B., Divina, D., Alkon, C., Dunleavy, B. P., & Robinson, K. (2011.).

Chronic Prostatitis and Fertility - Men's Health Center - Everyday Health. Retrieved from

https://www.everydayhealth.com/mens-health/chronic-prostatitis-and-fertility.aspx

Magri, V., Boltri, M., Cai, T., Colombo, R., Cuzzocrea, S., De Visschere, P., ... & Leli, C. (2018).

Multidisciplinary approach to prostatitis. Archivio Italiano di Urologia e

Andrologia, 90(4), 227-248.

Park, S. T., Lee, S. W., Kim, M. J., Kang, Y. M., Moon, H. M., & Rhim, C. C. (2017). Clinical

characteristics of genital chlamydia infection in pelvic inflammatory disease. BMC

women's health, 17(1), 5.

Perry, B., & Langenstroer, P. (2007). Benign prostatic hyperplasia.

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Sexually Transmitted Diseases. (2015). Retrieved from

https://labtestsonline.org/conditions/sexually-transmitted-diseases