2009 december featured case and 2009 idsa fellows' day case presentation
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Case Presentation. 2009 December Featured Case and 2009 IDSA Fellows' Day Case Presentation. M Haghighi MD Shahid Beheshti univesity of medical science. This case was originally presented at the Annual Meeting of the Infectious Diseases Society of America 2009 (IDSA, 47th meeting). - PowerPoint PPT PresentationTRANSCRIPT
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M Haghighi MD
Shahid Beheshti univesity of medical science
2009 December Featured Case and 2009 IDSA Fellows' Day Case Presentation
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This case was originally presented at the Annual Meeting of the Infectious
Diseases Society of America 2009 (IDSA, 47th meeting)
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A man in his sixties was admitted to a hospital because of fevers, dysuria and dark urine.
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One week earlier, temperatures up to 103-104°F (39.4-40.0°C) had developed, associated with dysuria, urinary frequency and dark urine. On the 7th day, he saw his primary care provider.
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prostatitis was diagnosed and ciprofloxacin (250 mg twice daily) administered.
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The next day, pleuritic chest pain developed on the right side, associated with mild dyspnea.
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He was admitted to the hospital. There was no history of cough, sputum production, diarrhea, abdominal pain, or rash.
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He had benign prostate hypertrophy. The level of prostate specific antigen (PSA) had been normal during the previous 4 years, most recently 3 months earlier. He had no known drug allergies.
Past medical history /Allergies
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Medications included doxazosin and ciprofloxacin.
Medications
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He was married and had traveled extensively to South America, South Asia, Asia, Mexico, the Pacific Islands, and Australia.
Epidemiological History
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Physical Examination
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The patient appeared ill. The temperature was 102.4°F (39.1°C), pulse 85 beats per minute, blood pressure 128/82 mm Hg and oxygen saturation 98% while breathing ambient air.
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The mucous membranes were dry. The abdomen was soft, mildly tender in the right upper quadrant, with suprapubic discomfort to palpation.
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There was no costovertebral angle tenderness. The rectal exam revealed an enlarged and boggy prostate, which was soft and non-tender. The remainder of his examination was normal.
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Studies
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The white blood cell count was 17,700 per cubic millimeter (neutrophils 75%, lymphocytes 17% and monocytes 8%) and the hematocrit 34% (reference range 40.7-50.3% in men).
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The level of serum glucose was 134 mg/dL (ref 65-199), alkaline phosphatase 393 IU/L (ref 38-126 IU/L) and albumin of 3.1 g/dL (ref 3.6-5.0 g/dL). The levels of electrolytes, urea nitrogen, creatinine and other tests of liver function were normal.
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The urinalysis revealed pH 6.0, leukocyte esterase 3+, red cells 3 cells per high-powered field, white cells greater than 50 cells per high-powered field, bacteria 1+, and no nitrites.
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A radiograph of the chest showed multifocal irregular nodular opacities bilaterally as below:
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Vancomycin, ciprofloxacin and cefepime were administered, however, fevers persisted.
Clinical Course Prior to Diagnosis
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On the 4th day, tests revealed a persistent leukocytosis, alkaline phosphatase 487 IU/L, aspartate aminotransferase (AST) 83 IU/L (ref 11-47 IU/L), and alanine aminotransferase (ALT) 113 IU/L (ref 7-53 IU/L).
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Cultures of the blood demonstrated polymicrobial oral flora, which were thought to be contaminants, and culture of a urine specimen was sterile.
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Computed tomography (CT) of the chest, abdomen and pelvis showed multiple cavitary pulmonary nodules .
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and an irregular hypodense lesion on right liver lobe, associated with a thrombosed right hepatic vein tributary.
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Differential Diagnosis
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Amebic liver abscess
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Staphylococcus aureus bacteremia with pulmonary
emboli
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Mycobacterium tuberculosis
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Echinococcus granulosus
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Bacterial liver abscess and prostatitis
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Malignancy
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Disseminated fungal infection
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Diagnostic Procedures
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The patient underwent an ultrasound-guided aspiration of the liver abscess. Gram stain of the aspirate revealed a gram negative rod.
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Specimen grew heavily mucoid pink colonies on MacConkey agar.
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Hypermucoviscous colonies on MacConkey agar.
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The "string test", which demonstrates the hyperviscosity is positive.
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Final Diagnosis
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Liver abscess caused by hypermucoviscous Klebsiella pneumoniae, associated with prostatitis and pulmonary septic emboli.
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