Case Study

A 38 year old man presented to hospital with a 10 day history of bloody sputum, left sided chest pain aggravated by inspiration and movement, dyspnea, fatigue and pyrexia. He had been using intravenous heroin and crack cocaine for the past 10 years and was diagnosed to be infected with both the human immunodeficiency virus and hepatitis C virus 5 years ago, but he declined therapy for both infections. He had just finished a 6-month course of directly observed antituber-culous therapy. Hospital record from an admission 3 months previously disclosed that at that time he was colonized with methicillin resistant Staphylococcus aureus (MRSA) in his nostrils and throat.

On examination, he was cachectic and jaundiced. The blood pressure in the right arm was 110/35 mmHg, his heart rate 110 beats per minute and the respiratory rate 36 per minute. His oxygen saturation on room air was 94%. Old and fresh track marks were present in both arms. Evaluation of fundi revealed multiple hemorrhages. His jugular venous pressure was markedly elevated at 15 cm. In addition to S3 and S4 gallop, there were a 3/6 holosystolic murmur over the second intercostal space radiating to the neck, a 3/6 systolic ejection murmur over the right sternal border and a 2/6 diastolic murmur over the left second intercostal space. Dullness to percussion was appreciated in the right lower lung field with decreased breath sounds and bronchial breathing. Also present were hepatosplenomegaly, ascitis and ankle edema. The neurological examination was normal.

The chest radiograph showed consolidation and a cavity with an air fluid level in the right lower lung field. The electrocardiogram revealed second degree A-V block, left axis deviation and left ventricular hypertrophy.

The hemoglobin was 66 g/L with normal indices, the white blood cell count 32 x 109 cells/L with the majority being polymorphonuclear cells and the platelet count 850 x 109 cells/L. The INR is 3.2 with elevated liver enzymes. The viral load was > 100,000 copies/ml and the urine contained 100 red blood cells, 100 white blood cells and red blood cell casts.

A transthoracic echocardiogram showed two pedunculated vegetations about 2 cm in length on the anterior and posterior cusps of the aortic valve and an additional vegetation on the tricus-pid valve, associated with severe aortic and tri-cuspid insufficiency.

In light of the history of injection drug use and previous colonization with MRSA, decision was made to initiate empiric therapy with van-comycin and ciprofloxacin which was used instead of an aminoglycoside because of renal failure. Within 72 hours of their collection all 3 sets of blood cultures grew MRSA and Candida albicans was recovered from all blood cultures at 96 hours. Parenteral fluconazole was then added to his treatment. Unfortunately, he became progressively more dyspneic and hemodynamically unstable. Despite emergency valve replacement surgery 6 days after admission, profound hypotension, third degree heart block, ischemic bowel and coagulopathy ensued. He died 3 days after the emergency valve replacement surgery.

This case illustrates the challenges in the treatment of endocarditis in patients with complex concomitant illnesses.

All Natural Yeast Infection Treatment

All Natural Yeast Infection Treatment

Ever have a yeast infection? The raw, itchy and outright unbearable burning sensation that always comes with even the mildest infection can wreak such havoc on our daily lives.

Get My Free Ebook

Post a comment