on broad spectrum antibiotics after blood cultures were obtained which rapidly revealed methicillin- resistant staphylococcus aureus (MRSA). Despite the initiation of broad-spectrum antibiotics, the patient's blood cultures remained positive for MRSA after two days. Transthoracic and transesophageal echocardiography were performed and did not show vegetations. Without source control for four days on the proper antibiotic regimen, further imaging with computed tomography (CT) of the chest, abdomen, and pelvis was performed. These CT studies failed to identify an obvious source of infection. However, CT of the cervical spine revealed an inflammatory process in the left sternoclavicular joint, along with joint effusion and periarticular soft tissue swelling. Magnetic resonance imaging was ordered to further assess which revealed septic arthritis of the left
sternoclavicular joint with clavicular and manubrial osteomyelitis. The cardiothoracic surgery team was consulted for potential debridement of clavicular and manubrial osteomyelitis. Blood cultures were collected again and showed no growth. Following extensive discussion with the patient and surgical team, a conservative treatment plan including IV antibiotics and close follow-up was chosen. Discussion: Patients with PSO often present with non-specific symptoms such as chest pain, fever, tenderness, or erythema which can be diagnostically challenging for clinicians. Although these patients are typically treated with either culture guided antibiotic therapy alone or antibiotics with debridement and closure, there is no standard of care due to scarcity of the literature.
THE ELUSIVE DIAGNOSIS OF SYSTEMIC LUPUS ERYTHEMATOSUS Samuel Maltby MD, Fernanda Correa MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Systemic Lupus Erythematosus (SLE) is an autoimmune disease characterized by autoantibody formation and immune complexes that can affect all systems of the body. Initial clinical presentation can vary and present with nonspecific symptoms. As a result, diagnosis can be missed when presenting without classical symptoms or in a population with lower prevalence of disease. This case highlights the importance of keeping SLE on the differential when presenting with multiple system involvement through several admissions. Case: A 28-year-old male presented with fever and sharp, left-sided chest and flank pain. Chest x-ray revealed a moderate sized left sided pleural effusion. He also reported a bilateral lower extremity purpuric rash that had recurred and self- resolved multiple times over the past two months, arthralgias, and 15 pounds of weight loss in the past 6 months. Lab work revealed proteinuria, no leukocytosis, an elevated creatinine of 1.1, hyponatremia (131), and protein gap >4.0, also noted on a previous admission with a negative HIV, Hepatitis, and TSPOT. Pleural fluid studies revealed an exudative effusion with an elevated
LDH, and a WBC count of 36,457 cells/microliter with neutrophilic predominance. He had low C3 and C4 with a negative ANCA and cryoglobulin test and an ANA panel notably positive for anti-ds DNA, anti-SM, anti-SSA, anti-Ribosomal P, and anti- RNP. Based on EULAR and ACR criteria, a diagnosis of SLE was made. A kidney biopsy was obtained and revealed class V lupus nephritis. The patient was initiated on prednisone, hydroxychloroquine, and mycophenolate and discharged with follow up with nephrology and rheumatology. Discussion: The variability of clinical manifestations in SLE, overlapping characteristics with alternative disease processes, coupled with periods of remission and relapses can make SLE a difficult diagnosis. Since SLE can affect all organ systems of the body, prompt identification and initiation of treatment is imperative to prevent progression of organ damage. Most auto-antibodies lack sensitivity, but anti-ds DNA and anti-SM carry high levels of specificity for SLE and are part of the SLE diagnostic criteria. When there is multiple system involvement, constitutional symptoms, and at least one clinical manifestation of SLE, consider SLE as part of the differential.
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