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Title : A 49 year-old male w/ Fever and abdominal pain
Date : December 7, 2010
Contributed by

Seung Soon Lee, MD,
Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine
Modified by Young Eun Ha, MD , Samsung Medical Center

Patient History
Age/Sex 49 yr old male
Chief complaint Fever and abdominal pain (onset : 5 days ago)
Present illness

He had eaten the sashimi at a sushi restaurant in Anyang-si before 5 days (2010.08). Fever with abdominal pain and diarrhea  was presented thereafter.  On the day , a small amount of hematemesis was developed.

Past medical history

He recalled that his liver enzymes had been elevated 15 years before but he didn’t have any further evaluation or treatment. He was a social drinker.

Physical examination

Review of System revealed fever, chill, dyspnea, abdominal pain, nausea, vomiting, diarrhea, melena, hematemesis and poor oral intake. On physical examinagion, vital signs were 80/40-118/min-24/min-37.3’C, abdomen was tender, and pretibial pitting edema with erythematous skin color changes were seen on both lower legs.

Initial laboratory findings

            WBC 18.3x10*3 /uL (Neutrophil 89%)
            Hb 13.5 g/dL
            PLT 55x10^3 /uL

PT/aPTT  19.0 sec (INR 1.61)/50.0 sec

            Glucose               95 mg/dL
            Na/K/Cl               135/3.9/101 mmol/L  
            BUN/Cr                            15.6/2.4 mg/dL
            Albumin               2.6  g/dL    
            Cholesterol                       138 mg/dL        
            AST/ALT/ALP     101/71/283 IU/L
            T.bil/D.bil                         1.6/0.8 mg/dl
            LD                                     572 IU/L
            CRP                                   67 mg/L
HBsAg (+)

Radiologic findings

Noncontrast abdomen CT and Lower extremity MRI

Hospital course

With a diagnosis of Septic shock with acute renal failure, antibiotics (ceftazidime + doxycycline + metronidazole) with inotropic agents were administered, and continuous renal replacement therapy was started.

On esophagogastroduodenoscopy, esophageal varix (Gr III), gastric ulcer (H1), and erosive gatritis was observed.

At HD #2, mental status became semicomatose, and hemorrhagic bullae was developed on both lower legs

Emergent fasciotomy of both lower legs was performed.

On HD #2, it was reported that gram negative bacilli are growing on 2 sets of blood culture.

Question - ID Case of the Week ( December 7, 2010 )
What would be the etiologic agent of this infection?
Please send us your answer to the following e-mail address ( nuove@ansorp.org ).
• Name
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• Answer
The true answer of this case and a brief review will be presented next week.
The names of the persons who gave us a right answer will be also announced.

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