Transcript Journal Club

NYU Medicine Grand Rounds
Clinical Vignette
Keri Herzog, PGY 2
December 8, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 35 year old man who presented to an
outside hospital with two days of severe
frontal headache, nausea, vomiting, and
chills.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient’s history begins in June 2009, when he
injured his right lower extremity in a construction
accident .
•He was admitted to Bellevue hospital at that time with
cellulitis, and was treated with vancomycin and
amoxicillin/clavulanate.
•He improved, and was discharged to a homeless
shelter to complete 10 days of amoxicillin/clavulanate.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•He presented to Bellevue Hospital in September
2009, again with left lower extremity cellulitis after
stepping on glass.
•He was given vancomycin for 7 days and
amoxicillin/clavulanate for 12 days and was
discharged to the shelter system.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient presented again in June 2010 with a
left axillary abscess for which he was given
cephalexin and trimethoprim/sulfamethoxazole.
•He underwent incision and drainage of the
abscess, with cultures later positive for Methicillinresistant Staphylococcus aureus.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient was well until October 4, 2010, when
he presented to an outside hospital with headache,
nausea, vomiting, and subjective fevers.
•A nasal swab on admission was positive for
Methicillin-resistant Staphylococcus aureus.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Magnetic resonance imaging revealed a right
posterior temporal brain abscess, and he was
given vancomycin, ceftriaxone, and metronidazole.
•He was then transferred to Bellevue for further
care.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Diabetes Mellitus Type 2 (for 6 years, on insulin)
•Purified Protein Derivative test positive
•Past Surgical History:
•none
•Social History:
•From rural Puebla, Mexico and immigrated to the United States 3
years prior to presentation.
•Lives predominantly in the shelter system
•Works part time in construction
•Social drinker, quit smoking 2009 after 10 pack-year smoking
history, denies intravenous drug use
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Family History:
•Mother- diabetes, alive
•Father- prostate cancer, deceased
•Allergies:
•No known drug allergies
•Medications:
•Insulin (unknown type/dose)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
(on arrival to Bellevue Hospital)
•General: Patient appeared his stated age, in no
acute distress.
•Vital Signs: T: 100.4 BP: 110/74 HR: 95 RR: 18
O2 sat: 100% on room air
•CV: tachycardic, regular rhythm
•Extremities: 5 x 5cm indurated, superficial ulcer
on the left lateral calf, draining purulent material
Remainder of the physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Complete Blood Count:
• Leukocytes 13, Neutrophils 84%
• Hemoglobin 12
• Platelets 333
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Head CAT Scan With Contrast
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Head CAT Scan With Contrast
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Head CAT Scan With Contrast
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
•Brain abscess in setting of nasal swab positive for
Methicillin-resistant Staphylococcus aureus due to
septic emboli from left calf ulcer, versus septic emboli
from endocarditis, versus septic emboli from chronic
osteomyelitis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient underwent craniotomy and
evacuation of the abscesses.
– Multiple cultures were sent
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2-5:
– The cultures from the brain abscesses was positive
for Methicillin-resistant Staphylococcus aureus and
ceftriaxone and metronidazole were discontinued
– Examination of the organism from the brain revealed
a virulence (agr) defective phenotype
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2-5:
– Transesophageal echocardiogram was performed
and the results were unremarkable
– A bone scan was negative for any evidence of
osteomyelitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 6-13:
– Serial blood cultures were performed and
showed no growth
– The patient was discharged to ColerGoldwater to complete an 8 week course of
vancomycin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Brain abscess due to community-acquired, agr
defective, Methicillin-resistant Staphylococcus
aureus, likely secondary to hematogenous spread
from leg ulcer.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS