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Title : A 43 year-old female w/ left flank pain and fever
Date : October 1, 2008
Contributed by

Soo Yeon Moon, MD & Doo Ryeon Chung, MD, PhD Samsung Medical Center, Seoul, Korea

Patient History
Age/Sex 43-year-old woman
Chief complaint Left flank pain, onset: 3 days ago
Present illness

• She had a back pain since a week ago.
• Three days ago left flank pain developed and she felt bulging of that area.
• Her pain was aggravated and she had fever and chills a day prior to visit.
• Dysuria (-) urinary frequency (-)

Past medical history

• Cervicalcancer (2.5 years ago)
- s/p Total abdominal hysterectomy with bilateral salphingo-oophorectomy
- s/p Radiation therapy
- s/p Double J stent insertion
• Chronic kidney disease d/tobstructive uropathy

Physical examination

• Vitalsign: 108/61 mmHg - 113/min - 20/min- 38°C
• Abdominaltenderness/rebound tenderness (-/-)
• Left CVA tenderness (+)

Initial laboratory findings

• CBC 34,410/mm3 - 6.6 g/dL - 526K/mm3 (seg 92%)
• AST/ALT 19/15 U/L BUN/Cr 48.4/3.31 mg/dL
• ESR120 mm/hr CRP 24.82 mg/dL
• Urinalysis: WBC numerous/HPF, RBC5-10/HPF

Radiologic findings

Perirenal abscess was found at CT

Hospital course

• Intravenous ceftriaxone was administered.
• At HD3, bullous erythematousswelling appeared on anterior abdominal wall.
• Bullous lesion enlarged rapidly and skin defect developed.
• Skin defect became enlarged with suspicious communication with deep space.
• CT was performed.
• Emergent fasciotomy of abdominal wall and perirenal abscess was surgically drained.

Abdominopelvic CT (Hospital day 3)

Question - ID Case of the Week ( October 1, 2008 )
What would be the etiologic agent of this infection?
Correct Answer

Streptococcus agalactiae ( Perinephric abscess )

(Two posts from Korea --> C. perfringens
One post from Korea --> S. aureus
One from Korea --> Actinomycosis) 

Hospial course of patient
Streptococcus agalactiae was cultured from the blood and perinephric abscess of the patient. The patient was treated with ampicillin-sulbactam for 2 months. After treatment for perinephric abscess, recurred cervical cancer with pulmonary metastatic nodule was diagnosed. She is receiving chemotherapy now.


Streptococcus agalactiae infection 

 - Neonatal sepsis and puerperal infection 
-  2-4 fold increase in the incidence of invasive GBS (group B streptococcus) disease 
    in non-pregnant adults during the past 2 decades 
- Known risk factors:
    1) > 65 years
    2) Cirrhosis, DM, stroke,breast ca, decubitus ulcer and neurogenic bladder
    3) Maliganacy : cervical cancer, head and neck cancer

-Pathogenesis :
   1) Physical factors and mechanical barriers
       : altered integrity of anatomical barriers
            --> elderly patients with DM complicated by peripheral neuropathy or
                  peripheral cascular disease
   2) Underlying medical conditions
       : DM - multiple abnormalities of phagocyte funtion
   3) Immune senescence
       : Aging - profound dysfunction in cell-mediated immunity, B-cell dysfunction and
                      poor neutrophil-medicated function
   4) Delay in diagnosis
       : muted inflammatory response in elderly patients 

-Clinical manifestations :
   1) UTI : indwelling urinary catheters, neurogenic bladder, urologic abnormalitues of
               urinary flow, kidney stones, chronic kidney disease and DM
   2) Pneumonia : older debilitated adults, aspiration
   3) Skin and soft-tissue infections : cellulitis, lymphedema, vascular insufficiency,
              chronic dermatitis, or radiation-induced cutaneous injury
   4) Primary bacteremia : defective reticuloendothelial clearance
                                    - chronic liver disease
   5) Arthritis : knee, shoulder and hip joints, prosthetic joints
         DM, amlignancy, chronic liver disease or cirrhosis
   6) Osteomyelitis
   7) Meninigits
   8) Endocarditis

-Antimicrobial therapy : Penicillin


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