A 50-year-old man presented to the emergency room with several months of intermittent fever and progressive lower back pain. He described a mechanical fall one week prior to this admission. He had a medical history of alcohol abuse, intravenous drug use, hepatitis C infection, and native tricuspid valve infective endocarditis secondary to methicillin-resistant Staphylococcus aureus (MRSA) five months prior to his current hospital admission. At that time, his transthoracic echocardiogram showed a tricuspid valve vegetation measuring 11 × 6 mm with severe tricuspid regurgitation. He was partially treated with intravenous vancomycin followed by daptomycin with serial negative blood cultures. Magnetic resonance imaging (MRI) of his spine at that time showed no evidence of vertebral osteomyelitis or epidural abscess.\nTwo months prior to the current hospital admission, he presented to the emergency room with back pain. At this time, his blood cultures were positive for the growth of V. dispar, which was identified by matrix-assisted laser desorption/ionization-time of flight mass spectrometry. A transthoracic echocardiogram was performed prior to him leaving the hospital against medical advice and showed that the tricuspid valve vegetation was now smaller in size, measuring 7 × 6 mm (Figure ). He received no antimicrobial treatment at this time.\nDuring his current hospital admission, he was visibly agitated on physical examination and described significant lower back pain. His initial vital signs included a temperature of 39.5 degrees Celsius, heart rate of 120 beats per minute, respiratory rate of 20 breaths per minute, oxygen saturation of 97% on ambient room air, and blood pressure of 106/68 mmHg. His neck was supple and his neurological examination demonstrated normal tone throughout his upper and lower extremities. Strength in his right lower extremity was 3/5 for ankle plantar flexion and dorsiflexion, 2/5 for knee extension and flexion, and 3/5 for hip extension and flexion. His strength was 4/5 throughout his left lower extremity. His sensation was normal apart from decreased light touch sensation to his medial right gastrocnemius region. He had spinal and paraspinal tenderness in his mid and lower back. His reflexes were 2+ in his knees and plantars were down-going bilaterally. He had a grade III/VI systolic murmur best heard at the left lower sternal border. Air entry was equal and clear bilaterally with fine crackles to his right lower lung zone. No other peripheral stigmata of infective endocarditis were present on examination. Examination of the oral cavity showed he was missing upper teeth with overall poor dentition. Initial laboratory investigations are summarized in Table .\nHis electrocardiogram was normal. During his hospital admission, two sets of blood cultures obtained 96 hours apart were again positive for the growth of V. dispar. Given his persistent bacteremia, a transthoracic echocardiogram was performed which showed growth in the size of the vegetation previously noted on his tricuspid valve, now measuring 11 × 7 mm. There were also signs of torrential tricuspid regurgitation including a vena contracta width greater than 0.7 cm, a central jet that was filling greater than 50% of the right atrium, and a triangular-shaped continuous-wave Doppler signal which was as dense as the inflow signal along with evidence of systolic hepatic vein flow reversal (Figures , ).\nAn MRI scan of the spine showed early discitis/osteomyelitis of L3-L4 with a right paravertebral and right paracentral anterior epidural phlegmon with no abscess (Figure ). The neurosurgical team assessed the patient and recommended conservative management with ongoing antimicrobial therapy and physiotherapy, and monitoring for any worsening neurological deficits. In addition, given his poor dentition, a computed tomography (CT) scan of the brain, head, and neck was arranged, which showed no obvious evidence of an abscess collection within the neck, oropharynx, or brain. Furthermore, no septic pulmonary emboli were seen on imaging.\nSusceptibility testing was performed on his V. dispar isolate using broth microdilution and showed susceptibility to penicillin (minimum inhibitory concentration [MIC] < 0.5), amoxicillin-clavulanate (MIC < 4/2), and metronidazole (MIC < 8) compared against breakpoints according to the Clinical and Laboratory Standards Institute. He was treated with intravenous ceftriaxone for six weeks with clinical improvement noted within a few days following his admission. The patient reported near-complete resolution of his back pain and his repeat C-reactive protein level toward the end of therapy was 3.8 mg/L (normal 0.0-7.0 mg/L). Subsequently, he developed a central-line-associated bloodstream infection secondary to Candida dubliniensis with no evidence of endophthalmitis, for which he received a two-week course of intravenous caspofungin.\nA repeat MRI was arranged after his therapy which showed resolution of the anterior epidural phlegmon but interval worsening of the L3-L4 discitis/osteomyelitis with a new enhancement of the L3 and L4 facets without effusion (Figure ). A subsequent CT-guided lumbar spine biopsy of the L3/L4 region was performed, and bacterial, fungal, and mycobacterial cultures were negative. A repeat transthoracic echocardiogram was planned to establish a new baseline for his valvular anatomy given his risk of recurrent endocarditis; however, the patient left against medical advice.
A 31-year-old male with a history of heavy alcohol use presented to our hospital with a 3-day history of lower extremity edema, abdominal swelling, and periumbilical pain. He reported use of 6 cans of beer daily, with the most recent use 3 days prior to admission. On presentation, the patient was alert and oriented only to person and self. His vital signs were a temperature of 38.5°C, heart rate 129 beats/minute, and blood pressure 132/74 mmHg. Physical exam was significant for scleral icterus, asterixis, systolic murmur, abdominal distention with caput medusae, palmar erythema, and spider angiomas on his chest.\nLaboratory tests revealed a white blood cell (WBC) count of 11.7 K/mm3 (with 78% neutrophils, absolute lymphocyte count 1.3 K/mm3, and absolute monocyte count 1.0 K/mm3), platelets 88 K/mm3, lactate 2.1 mmol/L, alkaline phosphatase (ALP) 503 U/L, aspartate aminotransferase (AST) 172 U/L, and alanine aminotransferase (ALT) 19 U/L. Maddrey's Discriminant Function score was 35.3 (Prothrombin time 19.2 seconds and total bilirubin 6.8 mg/dL). Ascitic fluid analysis after paracentesis was negative for spontaneous bacterial peritonitis, with a nucleated cell count of 79/cumm and 23% segmented neutrophils. Further hepatitis workup yielded antinuclear antibodies positive for nuclear, speckled pattern with 1 : 1280 titer, actin antibodies IgG 57 units, and negative viral hepatitis panel for hepatitis A, B, and C. Abdominal ultrasound showed cirrhosis with hepatosplenomegaly and trace abdominal ascites.\nTwo sets of blood cultures obtained on hospital day 0 were negative. Intravenous ceftriaxone was started after collection of the initial blood cultures. Two additional anaerobic blood culture bottles obtained on day 2 of hospital stay were positive for Veillonella atypica, identified using MALDI-TOF (). Repeat blood cultures after 2 days of intravenous ceftriaxone were negative. The infectious disease team recommended discontinuing IV ceftriaxone as repeat cultures were negative and the patient had completed a 7-day course of ceftriaxone. Transthoracic echocardiogram was negative for valvular lesions. Liver biopsy obtained on hospital day 8 demonstrated bridging fibrosis and was consistent with alcoholic hepatitis with cholestasis (Figures and ).\nHospital course was complicated by hemodynamic instability and acute encephalopathy on day 3 and 4, where patient was tachycardic to 120 beats per minute, tachypneic to 30 shallow breaths per second, and febrile to 38.3°C. The patient's mental status was waxing and waning; there was a concern for sepsis, grade II hepatic encephalopathy, and alcohol withdrawal. Hemodynamic instability and mental status improved with IV lorazepam and lactulose, and the patient was subsequently discharged on hospital day 9. After confirmation of alcoholic hepatitis on liver biopsy, the patient started prednisolone 40 mg oral daily on day 7 after hospital discharge due to difficulty obtaining the prescription.\nPatient was evaluated in outpatient hepatology clinic 7 days after prednisolone therapy (14 days after hospital discharge). Pertinent labs showed a white blood cell count of 23.9 K/mm3, sodium of 123 mmol/L, and potassium of 2.9 mmol/L. Prothrombin time and total bilirubin had increased to 23.4 sec and 20.2 mg/dL, respectively. Calculated Lille score on day 7 of treatment was 0.577 and suggestive of treatment failure of alcoholic hepatitis. The patient was sent to the emergency room after the clinic visit for tachycardia and concern for sepsis. He was then readmitted to the hospital for further management. Repeat blood cultures and ascitic fluid culture on admission were negative. The patient was deemed a poor transplant candidate due to continued alcohol use and non-United States citizen status. After appropriate counseling, he left the hospital against medical advice to be home with family.\nDuring a phone follow-up 3 months after discharge, the medical team was informed that the patient was deceased.