Question

Case Study #4

A 72-year old man has experienced mild fevers, decreased appetite, and night sweats for the past 4 months. His health has been otherwise good, except for the long-standing complaint of difficulty in urinating. He also awakens from sleep to urinate 3-4 times every night.

On physical examination his temperature is 101.5°F and the patient is found to have a new systolic ejection heart murmur. There are peripheral signs of endocarditis. An examination reveals a prostate gland that is twice the normal size. Two sets of blood cultures are collected into aerobic and anaerobic collection bottles containing SPS.

In order to further evaluate the enlarged prostate, his physician passes a catheter into the patient's bladder after he has voided completely. 500ml of urine are obtained (suggesting a chronic bladder outlet obstruction). A culture of the catheter urine is obtained, and the catheter is removed.

An echocardiogram (ultrasound of the heart) shows evidence of degenerative disease of the aortic valve and a 2cm vegetation on the coronary cusp of the valve.

After 24 hours, both of the blood and urine cultures grow Enterococcus faecalis. The patient is treated with intravenous ceftriaxone, but his symptoms do not improve.

Question:

a. Does this patient appear to have endocarditis? If so, what was the probable source? (2 points)

Question:

b. Enterococcus spp. are among the most common organisms to be isolated in blood cultures. What is the primary reason? (2 points)

Question:

c. What is the difference between bacteremia and septicemia? (2 points)

Question:

d. Explain why the patient did not improve with intravenous ceftriaxone? (2 points)

Answer 1

a. Does this patient appear to have endocarditis? If so, what was the probable source? (2 points)

Yes the patient appears to be having endocarditis.

Risk factors

• Prosthetic heart valves or structural cardiac defects (eg, valve disorders, hypertrophic cardiomyopathy [HCM]).
• Age: More common in older people, who are more likely to have degenerative or calcific valve lesions, reduced immunologic response to infection, and the metabolic alterations associated with aging.
• Intravenous (IV) drug use: There is a high incidence of staphylococcal endocarditis among IV drug users.
• Immunosuppression: Patients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis.

Signs and symptoms

• Primary presenting symptoms are fever and a heart murmur: Fever may be intermittent or absent, especially in elderly patients, patients receiving antibiotics or corticosteroids, or those who have heart failure or renal failure.
• Vague complaints of malaise, anorexia, weight loss, cough, and back and joint pain.
• A heart murmur may be absent initially but develops in almost all patients.

b. Enterococcus spp. are among the most common organisms to be isolated in blood cultures. What is the primary reason? (2 points)

Individuals in emergency clinic settings are especially defenseless against E. faecalis disease on the grounds that hospitalized patients will in general have decreased resistance. The basic utilization of intravascular and urinary catheter gadgets can likewise add to the spread of disease, as these instruments as often as possible harbor the E. faecalis microorganisms.

The microbes can cause disease in individuals when it enters wounds, blood, or pee. Individuals with debilitated insusceptible frameworks are especially in danger, for example, the individuals who:

•           have powerless invulnerability because of sickness or medical procedure

•           are experiencing malignant growth treatment

•           are on dialysis

•           are getting an organ transplant

•           have HIV or AIDS

•           have had a root channel

E. faecalis is accepted to be one of the best three driving reasons for clinic procured contamination.

c. What is the difference between bacteremia and septicemia? (2 points)

Sl.No	Bacteremia	Septicemia
1.	Presence of bacteria in blood is very simple and less in number	Presence of bacteria and multiplication of bacteria in blood
2.	This may be due to wound or infection, or through a surgical procedure or injection.	This may be due to infections throughout the body, including infections in the lungs, abdomen, and urinary tract.

d. Explain why the patient did not improve with intravenous ceftriaxone? (2 points)

Acute infective endocarditis is made when the onset of infection and resulting valvular destruction are rapid, occurring within days to weeks.

Objectives of treatment are to eradicate the invading organism through adequate doses of an appropriate antimicrobial agent (continuous IV infusion for 2 to 6 weeks at home).