What is the diagnosis and treatment plan for a patient with elevated lactic acid, urinary tract infection with Escherichia coli (E. coli), and acute kidney injury (AKI) with incidental findings of a left thyroid nodule and left adrenal adenoma?

From the Research

The patient should follow up with endocrinology for assessment of the thyroid nodule, which may require fine needle aspiration given its size (>1.5 cm), and for monitoring of the adrenal adenoma, which is likely benign but should be followed according to standard protocols. The patient presented with a urinary tract infection (UTI) caused by pansensitive E. coli, which was also found in blood cultures, indicating urosepsis. The patient had an elevated lactic acid of 2.0 but was not hypotensive or clinically septic. Initial treatment included ceftriaxone, followed by a 2-week course of levofloxacin upon discharge. The patient developed acute kidney injury (AKI) with a creatinine of 1.54 on admission, which resolved with IV fluid administration to 1.13 at discharge, suggesting a prerenal etiology. Incidental findings on imaging included a 1.9 cm left thyroid nodule (confirmed by ultrasound) and a 1.2 cm left adrenal adenoma seen on CT. Thyroid function was normal with a TSH of 2.01. Given the patient's family history of cancer and the size of the thyroid nodule, further evaluation of these incidental findings is recommended in the outpatient setting, as suggested by recent guidelines 1.

Key Points for Follow-Up

• The patient's thyroid nodule is significant in size (>1.5 cm) and may require fine needle aspiration for cytological evaluation, as recommended by guidelines for the management of thyroid nodules 1.
• The adrenal adenoma, although likely benign, should be monitored according to standard protocols to assess for any changes in size or function.
• The patient's family history of cancer increases the concern for malignancy, thus warranting a thorough evaluation of the thyroid nodule.
• Ultrasonography should be used in a targeted and standardized fashion (TIRADS classifications) for the evaluation of thyroid nodules, as it helps in assessing the risk of malignancy and guides the need for fine needle aspiration biopsy 1.

Recommendations for Management

• Follow-up with endocrinology for the assessment and management of the thyroid nodule and adrenal adenoma.
• Consider fine needle aspiration biopsy of the thyroid nodule based on its size and the patient's risk factors for malignancy.
• Regular monitoring of the adrenal adenoma with imaging studies as per standard protocols.