Case 22--Persistent Septic Arthritis and New Pulmonary Opacities in an Intravenous Drug User

Clinical summary: A 66-year-old, emaciated man was admitted 6/19 from a nursing facility for 2 days of increasing confusion. He had been under continuous medical care since 4/98 when he was admitted for a complaint of "feeling bad." There was a history of intravenous drug use (heroin), smoking crack cocaine, and hepatitis C, but he was HIV negative. He was afebrile. The white blood cell count was 8.3 k/µl. End-stage renal disease (membranoproliferative glomerulonephritis thought to be secondary to hepatitis C) requiring hemodialysis, R knee and L wrist septic arthritis (S aureus and S pneumoniae), and anemia (hct 28%) were diagnosed. Blood cultures were also positive for S aureus, and he was treated with nafcillin and gentamicin. The course was complicated by recurrent line infections and fasciitis. A transesophageal echocardiogram showed no vegetations. In mid May, he was transferred to a nursing home for continued care. On admission from the nursing home, he had T 98.9°, HR 80/min, RR 26/min, BP 144/83, and O2 saturation of 96% on room air. Lungs were clear. No cardiac murmurs were heard. The R knee and L wrist were again swollen. Laboratory values were: WBC 18 k/µl, hct 30%, and plt 187 k/µl. A blood culture yielded methicillin-resistant S aureus. Vancomycin was begun. A transesophageal echocardiogram was performed, and a chest radiograph was taken. Bacteremia persisted, thrombocytopenia developed, and he remained confused. He was found dead on 6/30. An autopsy was performed.

Echocardiogram | Radiograph | Image 1 | Image 2 | Image 3 | Image 4 | Discussion

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