EDUCATIONAL WORKSHOPS 2009
CASE PRESENTATION ONE
‘B’ is for ‘Bone’
A case of Clupea harengus var rubrum
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Sponsored through an unrestricted educational grant
from Novartis Pharmaceutical Ltd to help support the
cost of developing and hosting this educational
workshop series
Presentation
 62 yr old female
 Emergency admission:
Fever 38-39o
Rigors
Vomiting
Sudden onset
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Past Medical History
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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
Past Medical History
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2006 - Sigmoidectomy for diverticular disease
Anaemia 2o vaginal polyps
Bronchiectasis
Hypertension
Jun-Aug 2007 - Staph aureus paronychia
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Examination
 Overweight. BMI = 38
 Flushed, sweaty. Temp 37.8o
 HR 110 bpm I + II + ASM
 BP 120/60
 Chest clear
 Abdo NAD
 Diabetic feet as above
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
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
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
Day 2
 Blood culture positive for GPC ?strep
 Amoxicillin added to trimethoprim
 No specific treatment for ulcer
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
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
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
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
Examination
 Alert, orientated, sweaty
 T= 37.7o
 HR 110, I + II + ?ASM
 BP 125/90
 Chest + abdo clear
 Osplinters / Janeway / Osler’s
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Investigations
 Hb 8.7
 WCC 13.0
 CRP 410
 +ve dipstix
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
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
Day 2
 Blood cultures – GPC all bottles
 Apyrexial, origors
 HR 76, BP 120/60
 Microbiologist advised continue co-amoxiclav
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
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
Day 4
 Microbiologist advice – change co-amoxiclav to benzyl
pen
 MRI reported possible OM cuboid + 5th metatarsus
 T = 37.5o, WCC 8.7, CRP 341
 ECHO no evidence of IE
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
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
Days 8 -16
 Day 8 T = 37.5o, 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
Days 19 - 25
 Day 19 rash all over body. Microbiologist advised stop
benpen. Continue clinda.
 Day 20 T = 37.8o, 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
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
Day 35
 Profuse diarrhoea………..but that’s for another time!!!!!
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
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
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