A 78-year-old male patient, diabetic in treatment with oral antidiabetics, with a history of recurrent renal lithiasis and nephritic colic, and with a malignant neoplasm of the neck treated by RT two months earlier, who presented with bladder dysuria.
Two days before he was in the emergency room where he was diagnosed with UTI, and antibiotic treatment with amoxicillin-clavulanic acid was started without improvement.
The physical examination showed an axillary temperature of 38.2o C. The rest of the examination was completely normal, including rectal examination that showed a prostate size III/IV, not indurated and slightly painful.
An important leukocytosis of 41800 with neutrophilia (93%), a glucose of 337 mg/dl, a platelet count of 394000, a fibrinogen index of 771 were noteworthy in the blood analysis performed.
Pyuria and microhematuria were observed in the urine sediment and no pathology appeared in the simple X-rays of thorax and abdomen practiced.
Abdominal ultrasound showed no pathology.
With the suspicion of UTI, she was admitted to the Urology Department and intravenous antibiotic treatment was instituted after obtaining an urinocultive.
The chosen regimen in this case was the combination of ceftriaxone 1 g plus tobramycin 100 mg every 12 hours.
On the third day of admission and due to the clinical and analytical improvement of the patient, it was decided to switch from intravenous to oral antibiotic therapy, continuing with cefuroxime-axilla.
On the seventh day, and coinciding with the arrival of the hemocultives and urinocultives enrolled at admission and who were informed as negative, the patient presented a fever peak of 39o C. and a new elevation of leukocytes.
We decided to restart the intravenous antibiotic therapy and perform a v-prostatic ultrasound in which the patient's great prostate (400 cc.) stood out.
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The suspicion that it could be an acute prostatitis in the context of a BPH was suspected. Intravenous antibiotic therapy was continued and a Millin type Adecision was scheduled when the infectious clinical symptoms disappeared.
Despite antibiotic therapy, the evolution continued to be unfavorable, the fever peaks persisted, so the treatment regimen was changed introducing levofloxacin i.v. culture instead of ceftria.
Despite the change in antibiotic treatment, the patient continued to present fever and worsening of the general condition so it was decided to perform a transrectal ultrasound to rule out the presence of any complication, in which there was a poorly defined area of abscess medial doechogenic.
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Pathological findings were established and a transrectal ultrasound guided puncture of the abscess was performed, obtaining about 20 ml of purulent material, which was sent to microbiology.
Prostate and pus exudate cultures were positive for E. coli.
Despite the puncture, the patient continued with septic symptoms and did not report any improvement. A CT was performed to confirm the diagnosis and rule out abscess complications.
CT showed an increase in the size of the prostatic gland with a multilayered liquid collection located caudally to the gland.
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Because CT findings failed transrectal puncture, a transvesical prostatectomy was performed.
After opening the capsule, we could appreciate the total destructuring of the gland, with the presence of multiloculation and purulent material inside, as well as extensive areas of apical prostatic necrosis that compromised the tissue urethra.
Pathology showed two small foci of microacific adenocarcinoma, very distant from the resection limits, with Gleason 2 + 3 and acute prostatitis and hyperplasia complicated with large nodular necrosis areas.
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The postoperative course was satisfactory, with a rapid clinical and laboratory improvement, progressing to hospital discharge 21 days after the intervention.
Fifteen days after discharge, the patient was seen in our outpatient clinic with stress urinary incontinence.
After six months of the intervention, the patient continues to have mild constipation and needs absorbents for daily hygiene.
