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NYU Medicine Grand Rounds Clinical Vignette

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Title: Journal Club Author: Louis Miller Last modified by: mosesn01 Created Date: 11/29/2010 12:22:06 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: NYU Medicine Grand Rounds Clinical Vignette


1
NYU Medicine Grand Rounds Clinical Vignette
  • Keri Herzog, PGY 2
  • December 8, 2010

2
Chief Complaint
  • 35 year old man who presented to an outside
    hospital with two days of severe frontal
    headache, nausea, vomiting, and chills.

3
History of Present Illness
  • The patients 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/clavula
    nate.

4
History of Present Illness
  • 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.

5
History of Present Illness
  • 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.

6
History of Present Illness
  • 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.

7
History of Present Illness
  • 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.

8
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

9
Additional History
  • Family History
  • Mother- diabetes, alive
  • Father- prostate cancer, deceased
  • Allergies
  • No known drug allergies
  • Medications
  • Insulin (unknown type/dose)

10
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

11
Laboratory Findings
  • Complete Blood Count
  • Leukocytes 13, Neutrophils 84
  • Hemoglobin 12
  • Platelets 333
  • Basic Metabolic panel within normal limits
  • Hepatic panel within normal limits

12
Head CAT Scan With Contrast
13
Head CAT Scan With Contrast
14
Head CAT Scan With Contrast
15
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.

16
Hospital Course
  • Hospital Day 1
  • The patient underwent craniotomy and evacuation
    of the abscesses.
  • Multiple cultures were sent

17
Hospital Course
  • 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

18
Hospital Course
  • Hospital Day 2-5
  • Transesophageal echocardiogram was performed and
    the results were unremarkable
  • A bone scan was negative for any evidence of
    osteomyelitis

19
Hospital Course
  • 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

20
Final Diagnosis
  • Brain abscess due to community-acquired, agr
    defective, Methicillin-resistant Staphylococcus
    aureus, likely secondary to hematogenous spread
    from leg ulcer.
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