1. EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION ONE ‘B’ is for ‘Bone’ A case of Clupea harengus var rubrum Author: Peter Cowling, North Lincolnshire & Goole Hospitals

2. Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the cost of developing and hosting this educational workshop series

3. Presentation 62 yr old female Emergency admission: Fever 38-39 o Rigors Vomiting Sudden onset Author: Peter Cowling, North Lincolnshire & Goole Hospitals

4. Past Medical History 1989 -Type 2 DM 2000 – Insulin dependent. HbA1C 14.5 PVD PN Charcot’s 3x4cm ulcer on sole L foot Retinopathy Author: Peter Cowling, North Lincolnshire & Goole Hospitals

5. Past Medical History 2006 - Sigmoidectomy for diverticular disease Anaemia 2 o vaginal polyps Bronchiectasis Hypertension Jun-Aug 2007 - Staph aureus paronychia Author: Peter Cowling, North Lincolnshire & Goole Hospitals

6. Examination Overweight. BMI = 38 Flushed, sweaty. Temp 37.8 o HR 110 bpm I + II + ASM BP 120/60 Chest clear Abdo NAD Diabetic feet as above Author: Peter Cowling, North Lincolnshire & Goole Hospitals

7. Investigations Hb 9.5 WCC 12.0 CRP 256 MSU - +ve dipstix, micro haematuria, pyuria + coliform Ulcer swab – mixed enteric flora swab in OPD 2/52 previously enteric flora + Staph aureus Blood cultures Author: Peter Cowling, North Lincolnshire & Goole Hospitals

8. Treatment Day 1 Trimethoprim for presumed UTI. Coliform sens to co- amox, trim, nitro. Resistant to amox. Trim continued after urine C&S result Author: Peter Cowling, North Lincolnshire & Goole Hospitals

9. Day 2 Blood culture positive for GPC ?strep Amoxicillin added to trimethoprim No specific treatment for ulcer Author: Peter Cowling, North Lincolnshire & Goole Hospitals

10. Day 3 Blood culture – Group B strep Sens pen, clari, clinda, synergistic genta, resistant to tetra Amoxicillin & trimethoprim continued Microbiologist advised investigations to exclude IE. Noted past GBS in abdo wound. TTE & TOE mild thickening of leaflets MV & TV. Otherwise normal. No vegetations Author: Peter Cowling, North Lincolnshire & Goole Hospitals

11. Day 7 Well, apyrexial, WCC 10.4, CRP 53 2 sets blood cultures negative Decision to stop antibiotics at 1/52 Discharged home Author: Peter Cowling, North Lincolnshire & Goole Hospitals

12. 1 week later Emergency admission Unwell, rigors, vomiting for 3/7. 1x diarrhoea Frequency + ‘smelly urine’ GP gave ciprofloxacin following +ve dipstix previous day Author: Peter Cowling, North Lincolnshire & Goole Hospitals

13. Examination Alert, orientated, sweaty T= 37.7 o HR 110, I + II + ?ASM BP 125/90 Chest + abdo clear O splinters / Janeway / Osler’s Author: Peter Cowling, North Lincolnshire & Goole Hospitals

14. Investigations Hb 8.7 WCC 13.0 CRP 410 +ve dipstix Author: Peter Cowling, North Lincolnshire & Goole Hospitals

15. Day 1 Called Microbiologist Advised IV co-amoxiclav Further blood cultures and further advice if not settling 2 sets blood cultures taken Author: Peter Cowling, North Lincolnshire & Goole Hospitals

16. Day 2 Blood cultures – GPC all bottles Apyrexial, o rigors HR 76, BP 120/60 Microbiologist advised continue co-amoxiclav Author: Peter Cowling, North Lincolnshire & Goole Hospitals

17. Day 3 Blood cultures – Group B strep Hb 7.5, WCC 8.5, CRP 378 Cardiologist referral ?IE Microbiologist advised MRI leg for ?OM and start genta as per IE Tx protocol Also advised ulcer swab Author: Peter Cowling, North Lincolnshire & Goole Hospitals

18. Day 4 Microbiologist advice – change co-amoxiclav to benzyl pen MRI reported possible OM cuboid + 5 th metatarsus T = 37.5 o, WCC 8.7, CRP 341 ECHO no evidence of IE Author: Peter Cowling, North Lincolnshire & Goole Hospitals

19. Day 6 Ulcer swab – heavy growth Staph aureus Afebrile, WCC 8.1, CRP 290 Orthopaedic referral re OM Microbiologist advised 6 weeks benpen/amox + clinda 300mg tds and D/W Cons Orthopaedics who felt amputation not indicated. Author: Peter Cowling, North Lincolnshire & Goole Hospitals

20. Days 8 -16 Day 8 T = 37.5 o, rigors, WCC 10.7, CRP 264 Feeling unwell and miserable Day 11 Apyrexial, WCC 14.8, CRP 323 Day 14 Apyrexial, WCC 13.5, CRP 265 Feeling well Day 16 Itchy rash over leg. Microbiologist advised continue antibiotics and repeat MRI. If bone destruction, Orthopaedic review. Author: Peter Cowling, North Lincolnshire & Goole Hospitals

21. Days 19 - 25 Day 19 rash all over body. Microbiologist advised stop benpen. Continue clinda. Day 20 T = 37.8 o, HR 120, BP 140/70, WCC 12.4, CRP 256 Day 25 MRI - ‘exuberant osteomyelitic changes with rapid progressive destruction …..fistula to palmar aspect of foot’ Author: Peter Cowling, North Lincolnshire & Goole Hospitals

23. Days 26 - 33 Day 26 Rash worsening. Microbiologist advised stop clinda and give co-amoxiclav pending surgery Day 28 Orthopaedic opinion. Gross destruction of mid foot extending to Os calci. No option but a BKA. Requested ESR. Day 33 BKA under cefuroxime prophylaxis Author: Peter Cowling, North Lincolnshire & Goole Hospitals

24. Day 35 Profuse diarrhoea………..but that’s for another time!!!!! Author: Peter Cowling, North Lincolnshire & Goole Hospitals

25. Day 42 Co-amoxiclav stopped Patient felt much better and less depressed Parameters tending to normal Discharged home Author: Peter Cowling, North Lincolnshire & Goole Hospitals

26. Learning Points Insidious infection Don’t get sidetracked Thorough investigations required Broad antibiotic cover required Surgery may be inevitable Multi-disciplinary approach ???anything else Author: Peter Cowling, North Lincolnshire & Goole Hospitals