1. NYU Medicine Grand Rounds Clinical Vignette Keri Herzog, PGY 2 December 8, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 35 year old man who presented to an outside hospital with two days of severe frontal headache, nausea, vomiting, and chills. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient’s history begins in June 2009, when he injured his right lower extremity in a construction accident. He was admitted to Bellevue hospital at that time with cellulitis, and was treated with vancomycin and amoxicillin/clavulanate. He improved, and was discharged to a homeless shelter to complete 10 days of amoxicillin/clavulanate. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. He presented to Bellevue Hospital in September 2009, again with left lower extremity cellulitis after stepping on glass. He was given vancomycin for 7 days and amoxicillin/clavulanate for 12 days and was discharged to the shelter system. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. The patient presented again in June 2010 with a left axillary abscess for which he was given cephalexin and trimethoprim/sulfamethoxazole. He underwent incision and drainage of the abscess, with cultures later positive for Methicillin- resistant Staphylococcus aureus. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. The patient was well until October 4, 2010, when he presented to an outside hospital with headache, nausea, vomiting, and subjective fevers. A nasal swab on admission was positive for Methicillin-resistant Staphylococcus aureus. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Magnetic resonance imaging revealed a right posterior temporal brain abscess, and he was given vancomycin, ceftriaxone, and metronidazole. He was then transferred to Bellevue for further care. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Additional History Past Medical History: Diabetes Mellitus Type 2 (for 6 years, on insulin) Purified Protein Derivative test positive Past Surgical History: none Social History: From rural Puebla, Mexico and immigrated to the United States 3 years prior to presentation. Lives predominantly in the shelter system Works part time in construction Social drinker, quit smoking 2009 after 10 pack-year smoking history, denies intravenous drug use U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Additional History Family History: Mother- diabetes, alive Father- prostate cancer, deceased Allergies: No known drug allergies Medications: Insulin (unknown type/dose) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Physical Examination (on arrival to Bellevue Hospital) General: Patient appeared his stated age, in no acute distress. Vital Signs: T: 100.4 BP: 110/74 HR: 95 RR: 18 O2 sat: 100% on room air CV: tachycardic, regular rhythm Extremities: 5 x 5cm indurated, superficial ulcer on the left lateral calf, draining purulent material Remainder of the physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Laboratory Findings Complete Blood Count: Leukocytes 13, Neutrophils 84% Hemoglobin 12 Platelets 333 Basic Metabolic panel: within normal limits Hepatic panel: within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Head CAT Scan With Contrast U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Head CAT Scan With Contrast U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Head CAT Scan With Contrast U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Working Diagnosis Brain abscess in setting of nasal swab positive for Methicillin-resistant Staphylococcus aureus due to septic emboli from left calf ulcer, versus septic emboli from endocarditis, versus septic emboli from chronic osteomyelitis. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Hospital Day 1: –The patient underwent craniotomy and evacuation of the abscesses. –Multiple cultures were sent Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Hospital Day 2-5: –The cultures from the brain abscesses was positive for Methicillin-resistant Staphylococcus aureus and ceftriaxone and metronidazole were discontinued –Examination of the organism from the brain revealed a virulence (agr) defective phenotype Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

18. Hospital Day 2-5: –Transesophageal echocardiogram was performed and the results were unremarkable –A bone scan was negative for any evidence of osteomyelitis Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

19. Hospital Day 6-13: –Serial blood cultures were performed and showed no growth –The patient was discharged to Coler- Goldwater to complete an 8 week course of vancomycin Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

20. Brain abscess due to community-acquired, agr defective, Methicillin-resistant Staphylococcus aureus, likely secondary to hematogenous spread from leg ulcer. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS