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 x10/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.