Case presentation:
A 77-year-old Caucasian male with no known past medical history except
for benign prostatic hypertrophy presented to the emergency department
with a one-week history of acute onset of progressive dyspnea and
generalized swelling. Approximately three weeks prior to this emergency
room visit, he had been admitted to the intensive care unit in our
hospital for an episode of septic shock secondary to K. oxytocabacteremia. 1 out of 2 sets of blood cultures were positive for K.
oxytoca . He was then diagnosed and treated for two weeks for a
complicated urinary tract infection. He was initially treated with
intravenous ceftriaxone but later switched to oral levofloxacin given
susceptibilities as reported below in figure 1a.
On initial evaluation in the emergency department, the patient appeared
in mild distress. He was placed on a low flow nasal cannula, with oxygen
saturation of 94 percent on 2 liters of supplemental oxygen. Initial
vital signs were recorded as follows: Blood pressure was 116/75 mm Hg,
pulse 96 beats per minute, axillary temperature 98.7 Fahrenheit and
respiration 24 per minute. Physical examination was remarkable for
bibasilar crackles on chest auscultation and grade 2+ pitting peripheral
edema in bilateral lower extremities. He also had a grade 3 systolic
murmur best heard in the 2nd left intercostal space, loudest on
expiration. Otherwise, he was awake, alert and oriented to time, place
and person. No Janeway lesions, no splinter hemorrhages, no Osler’s
nodes were noted on the rest of the clinical exam.
His laboratory studies were remarkable for leukocytosis, white blood
cell count on admission was 15.6 x 103 cells/uL.
(Reference range 4.4-11.0 x103 /uL). His aspartate
transaminase was 78 Unit/L (reference range: 6-42 U/L) and alanine
transaminase was 60 Unit/L (reference range: 0-55 U/L). C-reactive
protein was 2.5 mg/dL (reference range: Less than 0.3mg/dL). Chest
radiograph showed bilateral vascular congestion, bilateral pleural
effusions and enlarged cardiac silhouette as depicted in Figure
1b . Multiple sets of blood cultures were negative. Bartonella ,Brucella and Coxiella specific antibodies were negative.