NYU Medicine Grand Rounds Clinical Vignette

Keri Herzog, PGY 2

December 8, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 35 year old man who presented to an outside hospital with two days of severe frontal headache, nausea, vomiting, and chills.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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 Methicillin-resistant Staphylococcus aureus.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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.

History of Present Illness

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 Day 1:– The patient underwent craniotomy and

evacuation of the abscesses.– Multiple cultures were sent

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 2-5:

– Transesophageal echocardiogram was performed and the results were unremarkable

– A bone scan was negative for any evidence of osteomyelitis

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 6-13:– Serial blood cultures were performed and

showed no growth– The patient was discharged to Coler-

Goldwater to complete an 8 week course of vancomycin

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Brain abscess due to community-acquired, agr defective, Methicillin-resistant Staphylococcus aureus, likely secondary to hematogenous spread from leg ulcer.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS