EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION ONE ‘B’ is for ‘Bone’ A case of Clupea harengus var rubrum Author: Peter Cowling, North Lincolnshire & Goole

EDUCATIONAL WORKSHOPS 2009

CASE PRESENTATION ONECASE PRESENTATION ONE

‘B’ is for ‘Bone’A case of Clupea harengus var rubrum

Author: Peter Cowling, North Lincolnshire & Goole Hospitals

Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the

cost of developing and hosting this educational workshop series

Presentation62 yr old femaleEmergency admission: Fever 38-39o

Rigors Vomiting Sudden onset


Past Medical History1989 -Type 2 DM 2000 – Insulin dependent. HbA1C 14.5PVDPNCharcot’s3x4cm ulcer on sole L footRetinopathy


Past Medical History2006 - Sigmoidectomy for diverticular diseaseAnaemia 2o vaginal polypsBronchiectasisHypertensionJun-Aug 2007 - Staph aureus paronychia


ExaminationOverweight. BMI = 38Flushed, sweaty. Temp 37.8o

HR 110 bpm I + II + ASMBP 120/60Chest clearAbdo NADDiabetic feet as above


InvestigationsHb 9.5WCC 12.0CRP 256MSU - +ve dipstix, micro haematuria, pyuria + coliformUlcer swab – mixed enteric flora swab in OPD 2/52 previously enteric flora + Staph aureusBlood cultures


Treatment Day 1Trimethoprim for presumed UTI. Coliform sens to co-

amox, trim, nitro. Resistant to amox. Trim continued after urine C&S result


Day 2Blood culture positive for GPC ?strepAmoxicillin added to trimethoprimNo specific treatment for ulcer


Day 3Blood culture – Group B strepSens pen, clari, clinda, synergistic genta, resistant to tetraAmoxicillin & trimethoprim continuedMicrobiologist advised investigations to exclude IE.

Noted past GBS in abdo wound.TTE & TOE mild thickening of leaflets MV & TV.

Otherwise normal. No vegetations


Day 7Well, apyrexial, WCC 10.4, CRP 532 sets blood cultures negativeDecision to stop antibiotics at 1/52Discharged home


1 week laterEmergency admissionUnwell, rigors, vomiting for 3/7. 1x diarrhoeaFrequency + ‘smelly urine’GP gave ciprofloxacin following +ve dipstix previous day


ExaminationAlert, orientated, sweatyT= 37.7o

HR 110, I + II + ?ASMBP 125/90Chest + abdo clearOsplinters / Janeway / Osler’s


InvestigationsHb 8.7WCC 13.0CRP 410+ve dipstix


Day 1Called MicrobiologistAdvised IV co-amoxiclavFurther blood cultures and further advice if not settling2 sets blood cultures taken


Day 2Blood cultures – GPC all bottlesApyrexial, origorsHR 76, BP 120/60Microbiologist advised continue co-amoxiclav


Day 3Blood cultures – Group B strepHb 7.5, WCC 8.5, CRP 378Cardiologist referral ?IEMicrobiologist advised MRI leg for ?OM and start genta

as per IE Tx protocolAlso advised ulcer swab


Day 4Microbiologist advice – change co-amoxiclav to benzyl

penMRI reported possible OM cuboid + 5th metatarsusT = 37.5o, WCC 8.7, CRP 341ECHO no evidence of IE


Day 6Ulcer swab – heavy growth Staph aureusAfebrile, WCC 8.1, CRP 290Orthopaedic referral re OMMicrobiologist advised 6 weeks benpen/amox + clinda

300mg tds and D/W Cons Orthopaedics who felt amputation not indicated.


Days 8 -16Day 8 T = 37.5o, rigors, WCC 10.7, CRP 264 Feeling unwell

and miserableDay 11 Apyrexial, WCC 14.8, CRP 323Day 14 Apyrexial, WCC 13.5, CRP 265 Feeling wellDay 16 Itchy rash over leg. Microbiologist advised

continue antibiotics and repeat MRI. If bone destruction, Orthopaedic review.


Days 19 - 25Day 19 rash all over body. Microbiologist advised stop

benpen. Continue clinda.Day 20 T = 37.8o, HR 120, BP 140/70, WCC 12.4, CRP 256Day 25 MRI - ‘exuberant osteomyelitic changes with

rapid progressive destruction …..fistula to palmar aspect of foot’


Days 26 - 33Day 26 Rash worsening. Microbiologist advised stop

clinda and give co-amoxiclav pending surgeryDay 28 Orthopaedic opinion. Gross destruction of mid

foot extending to Os calci. No option but a BKA. Requested ESR.

Day 33 BKA under cefuroxime prophylaxis


Day 35

Profuse diarrhoea………..but that’s for another time!!!!!


Day 42Co-amoxiclav stoppedPatient felt much better and less depressedParameters tending to normalDischarged home


Learning PointsInsidious infectionDon’t get sidetrackedThorough investigations requiredBroad antibiotic cover requiredSurgery may be inevitableMulti-disciplinary approach???anything else


Documents

EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION ONE ‘B’ is for ‘Bone’ A case of Clupea harengus var rubrum Author: Peter Cowling, North Lincolnshire & Goole