A 49-year-old Saudi man, a known case of insulin-dependent diabetes mellitus (IDDM), hypertension and ischemic heart disease, presented to the emergency department with a three-day history of fever, chills and ankle pain after trauma to his left foot. He reported a nonhealing ulcer on his left heel following a hot surface injury 20 days prior to his presentation. On examination, our patient looked ill and septic, with minimal ambulation. His temperature was 38.9°C and his blood pressure and pulse were 140/90mmHg and 108 beats/minutes respectively. A lower limb examination revealed bilateral decrease of sensation and a foot ulcer on his left heel. Careful examination of his left foot showed a 7×5cm deep ulcer on the lateral side that looked badly infected with change of skin color and profuse pus discharge. Our patient was seen by the orthopedic surgeon and an urgent extensive wound debridement involving the bone was undertaken. Blood, pus and bone tissue specimens were collected and sent to the microbiology laboratory for culture and sensitivity testing. A laboratory examination showed a white cell count (WBC) of 29×109g/L with 90% neutrophils, hemoglobin of 6.9g/L, and an erythrocyte sedimentation rate (ESR) of 97mm/h. His serum creatinine was 123umol/L, and urea mmol/L 8.9. His liver function test results were within normal limits except for serum alkaline phosphatase (ALP), which was raised (785IU/L). A left foot X-ray revealed soft tissue swelling, gas formation and fracture of the calcaneus bone. A left foot magnetic resonance imaging (MRI) scan revealed a calcaneus fracture with high suspicion of calcaneus anterior fragment osteomyelitis (Figure \n). An MRI scan of his right foot revealed mild neuropathic arthropathy (Charcot joint) with no evidence of osteomyelitis. Our patient was started empirically on intravenous ciprofloxacin 400mg twice daily, and intravenous clindamycin 600mg eight hourly. During the first three days after starting treatment, our patient showed no clinical improvement and he continued to run a low-grade fever. A pus culture grew Escherichia coli sensitive to ciprofloxacin, imipenem, meropenem, gentamicin and Enterococcus avium sensitive to ampicillin. A bone and tissue biopsy grew Morganella morganii sensitive to gentamicin, imipenem and resistant to ciprofloxacin, ampicillin, amoxicillin-clavulanic acid, piperacillin/tazobactam and cotrimoxazole. No growth occurred on the anaerobic plates despite prolonged incubation. Based on culture results, the initial antibiotics were suspended and our patient was started on imipenem 500mg intravenously (IV) six hourly, vancomycin 1g IV 12 hourly, and colistin 2 million units IV eight hourly. The blood culture obtained before treatment initiation, which was inoculated in an anaerobic bottle (Bactec Lytic/10, Anaerobic/F, Beckton Dickinson, Franklin Lakes, NJ, USA) and processed by an automated blood culture system (Bactec FX, Beckton Dickinson), grew very scanty Gram-negative cocci within 18 hours shown on Gram stain. The blood then was subcultured on Trypticase soy agar with sheep blood (BBL Microbiology Systems, Cockeysville, MD, USA) and incubated at 35°C in 5% CO2, in an anaerobic GasPak™ jar (BBL Microbiology Systems). After 48 hours of anaerobic incubation, the blood agar grew slow-growing tiny colonies (Figure \n) that showed Gram-negative cocci on Gram stain (Figure \n). The organism was identified by the Vitek 2 automated system (bioMérieux, Marcy-l'Étoile, France), as Veillonella species with a 99% probability rate. It was sensitive to imipenem (1.5μg/ml), clindamycin (0.047μg/ml), ceftriaxone (8μg/ml) and colistin, and resistant to penicillin (>32μg/ml), vancomycin, erythromycin and metronidazole. Further identification to species level and genotyping was unable to be performed, as the subcultured isolates failed to grow and the significant time delay before attempting to reisolate the organisms from the blood culture bottle rendered them nonviable. Over the subsequent five days, our patient’s condition worsened with a high temperature (38.9°C), rigors, a high WBC and ESR count. The wound was reevaluated by the surgical team and a decision of above-knee amputation was taken. Colistin and vancomycin were discontinued and imipenem was continued for four weeks. On follow-up, our patient showed gradual improvement of his condition and was discharged.
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.