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Rapid Progressive Seeding of a Community Acquired Pathogen in an Immune-Competent Host: End Organ Damage from Head to Bone.

Torres-Miranda D, Al-Saffar F, Ibrahim S, Diaz-Font S - Infect Dis Rep (2015)

Bottom Line: A 64-year-old male presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home.Hospital course demonstrated MSSA bacteremia, of questionable source, that resulted in endocarditis affecting right and left heart in a patient with no history of intravenous drug use.Our case, also presented with an uncommon manifestation of persistent infection dissemination despite adequate antibiotic treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, UF Health Jacksonville , FL, USA.

ABSTRACT
Methicillin-sensitive Staphylococcus aureus (MSSA) meningitis is a rare disease when not related to neurosurgery: there are only few reported cases in the literature to date. We describe a case that highlights not only meningeal but also diffuse and rapidly progressive systemic involvement with multi-organ failure. A 64-year-old male presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home. Hospital course demonstrated MSSA bacteremia, of questionable source, that resulted in endocarditis affecting right and left heart in a patient with no history of intravenous drug use. The case was complicated by septic emboli to systemic circulation involving the kidneys, vertebral spine, lungs and brain with consequent meningitis and stroke, even when treated empirically with vancomycin and then switched to nafcillin as indicated. Even though MSSA infections are well known, there are very few case reports describing such an acute-simultaneous-manifestation of multi-end-organ failure, including meningitis and stroke. Our case, also presented with an uncommon manifestation of persistent infection dissemination despite adequate antibiotic treatment.

No MeSH data available.


Related in: MedlinePlus

A) Axial diffusion weighted image shows multifocal intra-parenchymal hyper-intensities in a non-vascular pattern with (B) corresponding hypo-intense apparent diffusion coefficient findings. C) and D) right occipital restricted diffusion. Findings are compatible with acute multifocal ischemia secondary to septic embolisms.
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fig001: A) Axial diffusion weighted image shows multifocal intra-parenchymal hyper-intensities in a non-vascular pattern with (B) corresponding hypo-intense apparent diffusion coefficient findings. C) and D) right occipital restricted diffusion. Findings are compatible with acute multifocal ischemia secondary to septic embolisms.

Mentions: The patient was started empirically on vancomycin 15 mg/kg IV q 12h, while waiting for sensitivities. The TTE performed after bacteremia diagnosis showed an ejection fraction of 65% with normal valves and no vegetations. On day two of hospitalization the clinical picture worsened as the patient suddenly developed an altered mental status and nuchal rigidity. Lumbar puncture confirmed meningitis with a cerebrospinal fluid leukocytosis of 1157 (neutrophil 95%) and culture positive for S. aureus. Testing for HIV, Herpes Simplex Virus (HSV) and Tuberculin skin test (PPD) were all negative. Spine magnetic resonance imaging (MRI) showed osteomyelitis at T12-L1 and previously seen (in CT scan) renal infarcts. The patient continued to be febrile despite pathogen susceptible to vancomycin with MIC <2 mg/mL, trough previous to 4th dose 11, repeated trough 18.4, repeat blood cultures at 48 and 96 hours remained negative. Six days later he had clinical deterioration with tachypnea, hypoxia, new systolic 2/6 murmur, louder over cardiac apex area, and bilateral respiratory crackles. He also developed new right hemiparesis with upgoing babinski reflex of the right side. At this point, the patient was switched to nafcillin 2 g IV q 4h when blood culture results confirmed methicillin susceptibility on day 3 of admission. Head MRI showed multiple infarcts in a non-vascular pattern secondary to septic embolisms (Figure 1). The TEE showed severe mitral and tricuspid regurgitations, with 1.5 cm mobile vegetation on the posterior leaflet of the mitral valve. The patient was transferred to the intensive care unit due to the complicated picture of MSSA bacteremia, IE, osteomyelitis, meningitis, ischemic stroke, renal and pulmonary infarcts secondary to septic emboli. Nafcillin was continued with appropriate resolution of leukocytosis and fever. Patient’s mental status slowly improved and returned to baseline. There were indications for emergent mitral valve replacement, however given his recent finding of embolic stroke; this was not feasible due to high mortality risk. Follow up TTE showed worsening mitral and tricuspid valve involvement, therefore mitral and tricuspid valve replacements were performed, four weeks from IE diagnosis. He completed 8 weeks of nafcillin (given his vertebral involvement and unknown source). After 2 months of hospitalization, patient was discharged home with a dual-chamber pacemaker due to persistent 3rd degree atrio-ventricular block, post surgery.


Rapid Progressive Seeding of a Community Acquired Pathogen in an Immune-Competent Host: End Organ Damage from Head to Bone.

Torres-Miranda D, Al-Saffar F, Ibrahim S, Diaz-Font S - Infect Dis Rep (2015)

A) Axial diffusion weighted image shows multifocal intra-parenchymal hyper-intensities in a non-vascular pattern with (B) corresponding hypo-intense apparent diffusion coefficient findings. C) and D) right occipital restricted diffusion. Findings are compatible with acute multifocal ischemia secondary to septic embolisms.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4508536&req=5

fig001: A) Axial diffusion weighted image shows multifocal intra-parenchymal hyper-intensities in a non-vascular pattern with (B) corresponding hypo-intense apparent diffusion coefficient findings. C) and D) right occipital restricted diffusion. Findings are compatible with acute multifocal ischemia secondary to septic embolisms.
Mentions: The patient was started empirically on vancomycin 15 mg/kg IV q 12h, while waiting for sensitivities. The TTE performed after bacteremia diagnosis showed an ejection fraction of 65% with normal valves and no vegetations. On day two of hospitalization the clinical picture worsened as the patient suddenly developed an altered mental status and nuchal rigidity. Lumbar puncture confirmed meningitis with a cerebrospinal fluid leukocytosis of 1157 (neutrophil 95%) and culture positive for S. aureus. Testing for HIV, Herpes Simplex Virus (HSV) and Tuberculin skin test (PPD) were all negative. Spine magnetic resonance imaging (MRI) showed osteomyelitis at T12-L1 and previously seen (in CT scan) renal infarcts. The patient continued to be febrile despite pathogen susceptible to vancomycin with MIC <2 mg/mL, trough previous to 4th dose 11, repeated trough 18.4, repeat blood cultures at 48 and 96 hours remained negative. Six days later he had clinical deterioration with tachypnea, hypoxia, new systolic 2/6 murmur, louder over cardiac apex area, and bilateral respiratory crackles. He also developed new right hemiparesis with upgoing babinski reflex of the right side. At this point, the patient was switched to nafcillin 2 g IV q 4h when blood culture results confirmed methicillin susceptibility on day 3 of admission. Head MRI showed multiple infarcts in a non-vascular pattern secondary to septic embolisms (Figure 1). The TEE showed severe mitral and tricuspid regurgitations, with 1.5 cm mobile vegetation on the posterior leaflet of the mitral valve. The patient was transferred to the intensive care unit due to the complicated picture of MSSA bacteremia, IE, osteomyelitis, meningitis, ischemic stroke, renal and pulmonary infarcts secondary to septic emboli. Nafcillin was continued with appropriate resolution of leukocytosis and fever. Patient’s mental status slowly improved and returned to baseline. There were indications for emergent mitral valve replacement, however given his recent finding of embolic stroke; this was not feasible due to high mortality risk. Follow up TTE showed worsening mitral and tricuspid valve involvement, therefore mitral and tricuspid valve replacements were performed, four weeks from IE diagnosis. He completed 8 weeks of nafcillin (given his vertebral involvement and unknown source). After 2 months of hospitalization, patient was discharged home with a dual-chamber pacemaker due to persistent 3rd degree atrio-ventricular block, post surgery.

Bottom Line: A 64-year-old male presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home.Hospital course demonstrated MSSA bacteremia, of questionable source, that resulted in endocarditis affecting right and left heart in a patient with no history of intravenous drug use.Our case, also presented with an uncommon manifestation of persistent infection dissemination despite adequate antibiotic treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, UF Health Jacksonville , FL, USA.

ABSTRACT
Methicillin-sensitive Staphylococcus aureus (MSSA) meningitis is a rare disease when not related to neurosurgery: there are only few reported cases in the literature to date. We describe a case that highlights not only meningeal but also diffuse and rapidly progressive systemic involvement with multi-organ failure. A 64-year-old male presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home. Hospital course demonstrated MSSA bacteremia, of questionable source, that resulted in endocarditis affecting right and left heart in a patient with no history of intravenous drug use. The case was complicated by septic emboli to systemic circulation involving the kidneys, vertebral spine, lungs and brain with consequent meningitis and stroke, even when treated empirically with vancomycin and then switched to nafcillin as indicated. Even though MSSA infections are well known, there are very few case reports describing such an acute-simultaneous-manifestation of multi-end-organ failure, including meningitis and stroke. Our case, also presented with an uncommon manifestation of persistent infection dissemination despite adequate antibiotic treatment.

No MeSH data available.


Related in: MedlinePlus