Case Report: 55 year old man with fever and pelvic pain

History of Presenting Illness:

55 year old man with insulin-requiring diabetes mellitus and diabetic polyneuropathy with right foot ulcer presents to the Emergency Department with pain in the suprapubic area radiating into the rectum and shaking chills.

  1. He went in a river to fish 4 weeks ago and developed a blister around his diabetic ulcer; it swelled up but there was no obvious purulence.

  2. About 4 weeks ago, he developed fever and chills and thought he was coming down with a cold; symptoms gradually subsided after 3 days.

  3. 4 days prior to presentation, he noted onset of fatigue.

  4. The next day, he noticed the onset of fever and chills.

  5. The day of admission, he developed fullness in the bladder and deep pelvis. He decided to go in, because he thought he might need antibiotics.

Review of Systems: Gen: +fevers, chills; GI: no nausea, vomiting or diarrhea Lungs; no cough or shortness of breath, 12 point other than above was negative

Past Medical History:

  1. Diabetes mellitus with polyneuropathy – prior surgery on left foot 2 years ago. Last A1c was 10.0 one month ago

  2. Hypertension

  3. Hyperlipidemia

  4. Recent admission for ulcer debridement in setting of acute cellulitis (right foot) – 2 months ago; Group B Strep grew on culture. He had prior exposure to keflex

  5. Rosacea, papulopustular – he mentions that 3 days before he became ill, he saw a pustule on his lid and expressed it. He uses clindagel and topical hydrocortisone

Social: No smoking or alcohol; he quit smoking after recent hospital visit

Fam HX: noncontributory

Meds:

  1. Lantus insulin 60 units daily

  2. Novolog 15 units pre meal with sliding scale adjustment

  3. Lisinopril 20mg daily

  4. Atorvastatin 20mg qhs

All: sulfa

Physical Examination

VS: T 102.3, HR 115, BP 100/50, Resp 16 bpm, Pulse ox 98% room air

Gen: Appears acutely ill, moderate distress from suprapubic and posterior pain

HEENT: No thrush or ulcers; Lymph: no axillary, cervical or supraclavicular LAD. Neck: Supple, nonrigid, trachea midline

Chest: Hs1s2, tachycardia, no murmur, click, rubs or gallops; Lungs: no wheezes, rales or rhonchi

Abd: suprapubic tenderness suggested, Rectal: Declined.

Extremities: Right foot: dry, calloused diabetic foot ulcer, slightly malodorous, no evidence of expressible fluctuance or erythema on examination.

Neuro: Cranial nerves 2-12 intact, non-focal

Laboratory and Radiographic Investigation:

  1. Wbc: 25,000, Neutrophils 85%, Lymphoctyes 10%

  2. H/H: 12/36, Platelet 95,000

  3. Chemistry: BUN 26, Creatinine 1.2

  4. LFT: AST 200, ALT 150, Alk phos 159

CT Abdomen and pelvis

Discussion Questions:

Question 1: What does this CT scan show?

Question 2: The patient was found to have 6/6 positive blood cultures for an organism that was also found in his urine culture (spoiler below). Given his particular presentation, which microorganism is likely to be the cause?

Question 3: The patient is hospitalized for this presentation. Which antibiotic(s) would be appropriate to start with?

You can find the answers here.