ACTINOMYCES EMPYEMA IN AN IMMUNOCOMPETENT HOST WITH DENTAL CARIES Margaret Conrad 1 , Alex Frangenberg 1 , Hope Oddo Moise MD 2 , Laura Hutchins MD 2 , Hai Tran MD 2 , Judd Shellito MD 2 , Victoria Burke MD 2 , Daniel Holmes MD 2 ; LSU School of Medicine 1 , Department of Medicine 2 , LSU Health New Orleans, New Orleans, LA.
Introduction: Actinomyces odontolyticus is a slow-growing, filamentous, anaerobic gram- positive bacteria that is part of normal oral, gastrointestinal, and vaginal flora. It is often found in cultures accompanying Streptococcus species. Case: A 68-year-old man with hypertension, systolic heart failure, COPD, polysubstance use disorder (tobacco, ETOH, cocaine, fentanyl) was admitted as trauma activation following a motorcycle accident resulting in pneumothorax requiring left chest tube insertion, multiple bony fractures, delirium, and agitation. The patient was discharged after refusing short-term placement. One month later, the patient was re-admitted after two weeks of progressive dyspnea with minimal exertion, anorexia, cough productive of purulent sputum, and hypoxic respiratory failure due to right middle and lower lobe necrotizing pneumonia with empyema. The patient complained of constant oral pain and was noted to have poor dentition. The initial chest tube drained over one liter of purulence with the administration of lytic therapy. Cultures grew Streptococcus anginosus,
Actinomyces odontolyticus, and Prevotella. The first chest tube was dislodged and replaced, however, the former site continued to have large amount of thick tan output with imaging concerning for bronchopleural fistula. CT surgery evaluated the patient for VATS but ultimately declined given the patient’s severe chronic lung disease, so a second round of lytics was done. The suspected source of the polymicrobial infection was chronic aspiration. Given the presence of thoracic Actinomyces, the patient was discharged with four weeks of IV ampicillin-sulbactam followed by 6-12 months of amoxicillin-clavulanate after repeat imaging. Discussion: Actinomyces is a difficult-to-isolate pathogen that often co-exists with streptococcal species. This co-aggregation is more resistant to destruction by neutrophils and phagocytosis, which leads to a higher percentage of abscess formation than either bacteria alone. Our case describes an atypical presentation of A. odontolyticus with co-aggregate S. Anginosus as an empyema with a possible oral source due to aspiration risk.
THE PERFECT STORM: A RARE CASE OF THYROTOXICOSIS INCITING DIABETIC KETOACIDOSIS Kaleb Derouen, Lydia Rewerts, Salim C. Lutfallah, Hannah Tonry Zulli MD, Briggs Welch MD, Michael Modica MD; Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA.
Introduction: Diabetic ketoacidosis (DKA) and thyroid toxicosis are two well-recognized endocrine emergencies that can be triggered by a variety of underlying conditions. However, these conditions have rarely been reported to occur together. This case report presents an unusual occurrence of new-onset Grave’s Disease presenting as thyroid toxicosis inciting DKA. Case: A 52-year-old female with a history of late autoimmune diabetes of adulthood requiring insulin presented with intractable nausea and vomiting, headache, body aches, acute encephalopathy, and hoarseness for one day. She and her partner confirmed adherence to the patient’s insulin regimen and denied recent illnesses. The patient did have a history of recent travel to Denver, CO, and Austin, Texas. On evaluation, she was tachycardic
to 150s, tachypneic to 35 bpm, and found to be in diabetic ketoacidosis (DKA) with lactic acidosis (5.0), blood glucose of 798, anion gap of 29, beta- hydroxybutyrate of 104ng/dl, procalcitonin of 13.82, and an arterial blood gas with a pH 6.93 and a pCO2 of 14. She was started on an insulin drip and broad-spectrum antibiotics. Infectious and ischemic work-ups were unremarkable. Despite aggressive IV fluid resuscitation, the patient was persistently tachycardic to the 150s, and the etiology of DKA remained unclear. Computed Tomography Angiogram was negative for a pulmonary embolism. Eventually, a TSH resulted <0.008 with a free T4 of 2.16 raising suspicion for thyroid toxicosis. After obtaining further history, the patient reported no history or symptoms of thyroid disease; however, her mother had a history of Grave’s Disease. The patient was placed on intraveonous propranolol 0.5mg 49
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