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Title : A 56 year-old female w/ fever, chill, and altered mentality
Date : January 25, 2010
Contributed by

Cheol-In Kang, M.D. Samsung Medical Center, Seoul, South Korea

Patient History
Age/Sex 56-year-old woman
Chief complaint fever, chill, and altered mentality
Present illness

A 56-year-old woman presented to our Emergency Department (ED) with fever, chill, and altered mentality. She had been taking medications for partial seizure for 10 years. One day before admission to the ED, fever and chill developed. Subsequently, sleeping tendency developed and altered mentality was aggravated.

Past medical history

She had been taking medications for partial seizure for 10 years.

Physical examination

At ER, she had confused mentality and the CSF analysis was performed. The findings of CSF were as follows; WBC 2420/ul (poly 63%), protein 149.1 mg/dl, and glucose 39 mg/dl. Although brain MRI showed chronic ischemic changes in the both cerebral white matters, there was no evidence of acute infarction or hemorrhage in the brain MRI. Ceftriaxone, vancomycin, and ampicillin were administered as initial empirical antibiotics for the treatment of acute bacterial meningitis. Blood culture grew gram-positive bacilli, but the morphology of bacterial colonies was different from that of Listeria monocytogenes. No bacterial pathogen was cultured in the CSF sample. Cardiac echocardiography was performed to examine the presence of endocarditis, and moderate to severe mitral regurgitation with oscillating mass, compatible with infective endocarditis, was detected in the examination. From google images. http://bacterioweb.univ-fcomte.fr/photo2detail.php?id=169

Question - ID Case of the Week ( January 25, 2010 )
What could be a possible pathogen for this patient who presented with community-acquired meningitis and endocarditis?
Correct Answer

Erysipelothrix rhusiopathiae


Erysipelothrix rhusiopathiae bacteremia

1. Microbiology

- E. rhusiopathiae is a straight or slightly curved aerobic or facultatively anaerobic bacillary organism.

- It is gram-positive but may appear gram-negative because it decolorizes readily.


2. Clinical manifestations

- Systemic infection with E. rhusiopathiae is unusual and most cases were complicated by endocarditis.

- Although this organism has caused prosthetic valve endocarditis, most reported cases of endocarditis have involved native valves.

- There was a history of an antecedent or concurrent skin lesion of erysipeloid in 36% of patients.

- Complications of Erysipelothrix endocarditis include congestive heart failure, myocardial abscess, aortic valve perforation, meningitis, brain infarctions, glomerulonephritis, septic arthritis, and osteomyelitis.

- More than one third of the patients require valve replacement.

- Bacteremia without endocarditis has been reported with increasing frequency.


3. Treatment

- Most strains are highly susceptible to penicillins, cephalosporins, clindamycin, imipenem, and ciprofloxacin.

- Penicillin G is the drug of choice for serious infection. Ampicillin and ceftriaxone have also been used successfully.

- Most strains are resistant to vancomycin, sulfonamide, trimethoprim-sulfamethoxazole, teicoplanin, aminoglycoside.

- Resistance to vancomycin is important because this agent is often used empirically to treat bacteremia caused by gram-positive organisms



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