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Infectious Diseases Intercity Conference January 11, 2005 Viorel Florea, MD

History of the Present Illness. . 49-year-old woman presented to the ER with left-sided chest pain and shortness of breath Sharp pain with radiation to the left side of the neckDifficulty taking deep breathsSymptoms started the night before admission and are getting worseNo cough, fevers, or chi

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Infectious Diseases Intercity Conference January 11, 2005 Viorel Florea, MD

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    1. Infectious Diseases Intercity Conference January 11, 2005 Viorel Florea, MD

    2. 49-year-old woman presented to the ER with left-sided chest pain and shortness of breath Sharp pain with radiation to the left side of the neck Difficulty taking deep breaths Symptoms started the night before admission and are getting worse No cough, fevers, or chills. No nausea, vomiting, or constipation. No trauma to the chest.

    3. End-stage liver disease due to hepatitis C and alcohol abuse Portal hypertension with esophageal and gastric varices, s/p TIPS Ascites requiring paracenthesis every 2-3 weeks Encephalopathy requiring Lactulose Chronic kidney disease with baseline Creatinine around 2.2 History of right hip and knee infections with MRSA in 2000 Recent Clostridium difficile colitis H/o low C3 complement levels in the past

    4. VS: T 96.7, R 26, Sat 97% on 2L, P 93, BP 131/73 Gen: Chronically ill-appearing woman in no apparent distress HEENT: Poor dentition, A white film on her tongue. Neck: Supple, no JVD, no lymphadenopathy Lungs: Shallow breathing, decreased breath sounds at both bases Heart: RRR, distant S1 & S2, 2/6 systolic murmur at the LSB, no rub Abd: Normoactive BS, soft, distended, nontender Ext: 2+ edema in the lower extremities bilaterally Skin: Mildly jaundiced. Petechiae on the lower extremities Neuro: Alert and oriented x3, no focal motor deficits

    5. CBC: WBC count 6.8, Hemoglobin 8, Platelets 98,000. Metabolic: Low albumin of 2.1, Elevated prothrombine time (INR 1.6) Elevated creatinine of 5.2 and a BUN of 53 Chest X-ray: Large heart shadow Bilateral pleural effusion ECG: Low voltage

    7. Echocardiography: Large pericardial effusion Pericardial Window and Drainage 600 ml of slightly cloudy fluid under moderate pressure was evacuated. The underlying surface of the heart had a granular inflamed appearance Pericardial Fluid and Tissue sent for microbiologic studies

    8. Pericardial Fluid and Tissue: Red cells 20,667 Nucleated cells 21,143 87% neutrophils Gram stain: Pleomorphic Gram-Positive Rods Blood Culture: No growth

    14. Nocardia Actinomycetes Listeria Corynebacterium

    15. Corynebacterium species

    16. Corynebacterium Striatum

    17. Corynebacterium Striatum Pericarditis

    20. Proposed in 1896 as bacteria morphologically resembling the diphtheria bacillus Have been known to cause: Bacteremia particularly in association with venous access devices Endocarditis on both prosthetic and native valves Meningitis Neurosurgical shunt infection Brain abscess Peritonitis Osteomyelitis Septic arthritis Pneumonia UTI

    22. Nonlipophilic, Fermentative Corynebacteria C. ulcerans C. pseudotuberculosis C. xerosis C. striatum C. minutissimum C. amycolatum C. glucuronolyticum C. argentoratense C. coyleae C. imitans C. matruchotii Nonlipophilic, Nonfermentative Corynebacteria C. auris C. pseudodiphthericum C. propinquum Lipophilic Corynebacteria C. jeikeium C. urealyticum C. afermentans subsp. lipophilum (ANF-1) C. accolens C. macginleyi CDC coryneform group G C. lipophiloflavum

    23. Has been reported to cause endocarditis on both prosthetic and native valves No reports found on Corynebacterium striatum as the cause of pericarditis

    24. Many of these organisms are components of the normal skin flora. Thus, they are frequently found as contaminants in blood cultures Serious diseases as septicemia and endocarditis, are seen with increasing frequency owing to the growing population of immunocompromized patients and large numbers of patients with catheters and prosthetic devices in vessels and in the central nervous system Neutropenia appears to be the most important predisposing factor for severe systemic disease Patients with breaks in the skin who have received prolonged courses of antibiotics are at increased risk for disease Vancomycin is the antibiotic of choice

    26. Medications: Lactulose Furosemide Vitamin K and Multivitamins Paroxetine and Trazodone Synthroid Allergies: Penicillin Clindamycin Codeine Social History: History of alcohol abuse, denies any use now Smokes about 2 cigarettes per day ROS: Positive for Fatigue, Anorexia, Easy bruising, Swelling, Loose stools due to lactulose Negative for Visual changes, Hearing changes, Nausea, Vomiting, Constipation, Dysuria, Weight change, Fevers, or Chills.

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