ABSTRACT
Erythroderma is characterized by diffuse erythema and scale covering over 90% body surface area that can affect individuals with inflammatory dermatoses such as psoriasis. Complications of erythrodermic psoriasis include infection and cardiovascular compromise. Here we present a case of a 68 year-old man who was hospitalized for erythrodermic psoriasis refractory to multiple immunosuppressive and immunomodulatory therapies, ultimately developing sepsis due to bacteremia and fungemia complicated by infective endocarditis and a mycotic aneurysm. Although the widespread loss of epidermal function in erythroderma increases the risk of infection by opportunistic pathogens, water loss, and electrolyte imbalances, there are very few reported cases of psoriatic erythroderma complicated by fungemia and mycotic aneurysm. Given the high mortality associated with widespread epidermal dysfunction, there is a great need for evidence-based treatment guidelines for psoriatic erythroderma. J Drugs Dermatol. 2024;23(8): doi:10.36849/JDD.7751.
Subject(s)
Aneurysm, Infected , Dermatitis, Exfoliative , Psoriasis , Shock, Septic , Humans , Male , Psoriasis/complications , Psoriasis/drug therapy , Psoriasis/diagnosis , Aged , Dermatitis, Exfoliative/diagnosis , Dermatitis, Exfoliative/etiology , Dermatitis, Exfoliative/therapy , Dermatitis, Exfoliative/drug therapy , Shock, Septic/diagnosis , Shock, Septic/microbiology , Shock, Septic/therapy , Shock, Septic/etiology , Aneurysm, Infected/diagnosis , Aneurysm, Infected/therapy , Aneurysm, Infected/microbiology , Fatal Outcome , Fungemia/diagnosis , Fungemia/drug therapy , Fungemia/microbiology , Fungemia/complications , Practice Guidelines as Topic , Bacteremia/diagnosis , Bacteremia/drug therapy , Bacteremia/complications , Bacteremia/microbiologyABSTRACT
A man in his mid-70s with a complex medical history, including splenectomy, presented with fever and rigours. Workup revealed Salmonella enterica serotype typhimurium bacteraemia and right internal iliac artery endarteritis. Two weeks following a 6-week course of antibiotics, he had a recurrence of Salmonella bacteraemia requiring an extended course of treatment.
Subject(s)
Anti-Bacterial Agents , Bacteremia , Endarteritis , Iliac Artery , Salmonella Infections , Splenectomy , Humans , Male , Salmonella Infections/complications , Salmonella Infections/diagnosis , Salmonella Infections/drug therapy , Bacteremia/drug therapy , Bacteremia/complications , Bacteremia/microbiology , Iliac Artery/diagnostic imaging , Anti-Bacterial Agents/therapeutic use , Aged , Recurrence , Salmonella typhimurium/isolation & purificationABSTRACT
Pseudomonas putida (P. putida) is a rare pathogen that primarily causes nosocomial infection. It is usually seen in immune dysfunction or immunocompromised patients and patients with invasive medical devices. Here, we present a rare case of P. putida bacteremia in a patient with cirrhosis of the liver.
Subject(s)
Bacteremia , Liver Cirrhosis , Pseudomonas Infections , Pseudomonas putida , Humans , Bacteremia/microbiology , Bacteremia/complications , Bacteremia/diagnosis , Pseudomonas putida/isolation & purification , Liver Cirrhosis/complications , Pseudomonas Infections/diagnosis , Pseudomonas Infections/complications , Male , Anti-Bacterial Agents/therapeutic use , Middle AgedSubject(s)
Bacteremia , Flavobacteriaceae Infections , Pneumonia, Bacterial , Humans , Bacteremia/microbiology , Bacteremia/complications , Bacteremia/diagnosis , Bacteremia/drug therapy , Flavobacteriaceae Infections/diagnosis , Flavobacteriaceae Infections/drug therapy , Flavobacteriaceae Infections/microbiology , Flavobacteriaceae Infections/complications , Pneumonia, Bacterial/microbiology , Pneumonia, Bacterial/complications , Pneumonia, Bacterial/diagnosis , Pneumonia, Bacterial/drug therapy , Flavobacteriaceae/isolation & purification , Male , AgedABSTRACT
PURPOSE: S. aureus bacteremia (SAB) is a common and severe infection with high mortality and morbidity. The clinical relevance of the finding of concurrent S. aureus bacteriuria (SABU) is debated. The goal of this study was to analyze whether a concurrent SABU is associated with complicated SAB, infective endocarditis (IE) and mortality. METHODS: We conducted a retrospective cohort study, reviewing medical charts of all episodes of SAB in patients > 18 years in the region of Skåne, Sweden, between 1st of January and 31st of June 2020. Episodes where a concurrent urine culture was performed were included for analysis. An episode was considered as complicated SAB if there was either attributable mortality, recurrent infection, embolic stroke, or occurrence of a complicated focus of infection. RESULTS: During the study period, there were 279 episodes of SAB. 154 episodes met the eligibility criteria, of whom 37 (24%) had concurrent SABU. In 78 episodes (51%), the patients had a complicated SAB. There was a significantly lower proportion of complicated SAB for episodes with concurrent SABU (32%), compared to episodes without concurrent SABU (56%), p-value 0.014. Moreover, in the cohort there were 11 episodes (7.1%) of IE and a 30 days mortality rate of 16%, with no difference between the groups with or without SABU. CONCLUSIONS: There is an association between concurrent SABU and a decreased risk for complicated SAB among patients with SAB. This study found no significant association between SABU and neither IE nor mortality for patients with SAB.
Subject(s)
Bacteremia , Bacteriuria , Staphylococcal Infections , Staphylococcus aureus , Humans , Retrospective Studies , Staphylococcal Infections/mortality , Staphylococcal Infections/microbiology , Staphylococcal Infections/epidemiology , Staphylococcal Infections/complications , Male , Female , Bacteremia/microbiology , Bacteremia/mortality , Bacteremia/epidemiology , Bacteremia/complications , Aged , Middle Aged , Bacteriuria/microbiology , Bacteriuria/epidemiology , Bacteriuria/complications , Sweden/epidemiology , Risk Factors , Aged, 80 and over , Endocarditis/microbiology , Endocarditis/mortality , Endocarditis/complications , Endocarditis/epidemiology , Endocarditis, Bacterial/microbiology , Endocarditis, Bacterial/mortality , Endocarditis, Bacterial/epidemiology , Endocarditis, Bacterial/complications , AdultSubject(s)
Bacteremia , Humans , Bacteremia/microbiology , Bacteremia/complications , Bacteremia/drug therapy , Male , Female , Anti-Bacterial Agents/therapeutic use , Middle Aged , AgedABSTRACT
Background: Ochrobactrum anthropi spp. is a non-enteric, aerobic gram-negative bacillus that has been reported to cause sepsis and occasionally bacteremia in both immunocompetent and immunocompromised hosts. This bacterium is capable of surviving in various habitats, but due to its affinity for aqueous environments, O. anthropi is hypothesized to have an affinity for indwelling plastic devices and other foreign bodies.
Case Presentation: We report a case of a 66 y/o male with a history of polysubstance abuse disorder admitted for toxic metabolic encephalopathy and found to have bronchopneumonia and bacteremia secondary to O. anthropi infection resulting in sepsis and cardiopulmonary arrest.
Discussion: Ochrobactrum spp. is an unusual pathogen of low virulence and has been noted to cause bacteremia and occasionally sepsis in both immunocompetent and immunosuppressed patients. Isolation of this pathogen in the appropriate setting should be considered a true pathogen and treated as such to avoid sequela of this infection.
Conclusion: This case report and literature review suggest that Ochrobactrum anthropi appears more frequently as a pathogen in nosocomial infections than suggested in the literature.
.Subject(s)
Bacteremia , Gram-Negative Bacterial Infections , Ochrobactrum anthropi , Humans , Ochrobactrum anthropi/isolation & purification , Ochrobactrum anthropi/pathogenicity , Male , Bacteremia/microbiology , Bacteremia/drug therapy , Bacteremia/complications , Gram-Negative Bacterial Infections/microbiology , Gram-Negative Bacterial Infections/complications , Gram-Negative Bacterial Infections/drug therapy , Gram-Negative Bacterial Infections/diagnosis , Aged , Anti-Bacterial Agents/therapeutic use , Cross Infection/microbiology , Pneumonia/microbiologyABSTRACT
BACKGROUND: Infective endocarditis (IE) is a serious complication of bloodstream infections (BSIs) that occurs at variable rates depending on the pathogen and clinical setting. There is a paucity of data describing the risk of IE in patients with hematologic malignancy who develop bacteremia while neutropenic. METHODS: Adult patients on the hematology ward from January 2018 to December 2020 with hematologic malignancy and bacteremia were evaluated retrospectively for endocarditis by applying the 2023 Duke-ISCVID criteria. Charts of possible cases were evaluated 90 days after the initial BSI for new infectious complications that could indicate missed IE. Descriptive statistics compared patients admitted for hematopoietic stem cell transplantation (HSCT) to those admitted for alternative reasons (non-HSCT). RESULTS: Among the 1005 positive blood cultures initially identified, there were 66 episodes in 65 patients with hematologic malignancy and at least grade 3 neutropenia for a mean duration of 11.4 days during their admission. Transthoracic echocardiography (TTE) was performed in 34.8% of BSIs, and transesophageal echocardiography (TEE) in 6.1%. There were no new infectious complications in possible cases 90 days after their initial BSI. No cases of endocarditis were identified. CONCLUSIONS: Endocarditis is rare amongst patients with hematologic malignancy, bacteremia, and neutropenia, and no cases were identified in this cohort. The use of routine TTE in this setting seems unwarranted, and the addition of TEE is unlikely to improve patient-centered outcomes.
Subject(s)
Bacteremia , Hematologic Neoplasms , Hematopoietic Stem Cell Transplantation , Neutropenia , Humans , Neutropenia/complications , Male , Female , Middle Aged , Hematologic Neoplasms/complications , Retrospective Studies , Bacteremia/microbiology , Bacteremia/complications , Hematopoietic Stem Cell Transplantation/adverse effects , Adult , Endocarditis/microbiology , Endocarditis/complications , Aged , Echocardiography , Echocardiography, TransesophagealSubject(s)
Bacteremia , Pseudomonas Infections , Pseudomonas aeruginosa , Pulmonary Embolism , Humans , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/microbiology , Pseudomonas Infections/complications , Pseudomonas Infections/diagnosis , Bacteremia/complications , Bacteremia/microbiology , Bacteremia/drug therapy , Pseudomonas aeruginosa/isolation & purification , Male , Anti-Bacterial Agents/therapeutic use , Female , Middle Aged , Tomography, X-Ray ComputedABSTRACT
This case of Pleisimonas shigelloides bacteremia resulting after a catfish barb injury highlights an unusual presentation of a common condition that requires alternative therapy for successful treatment. An otherwise healthy male in his early 40s presented to the emergency department with sepsis and rapidly spreading cellulitis shortly after a catfish injury at a freshwater lake. His broad-spectrum antibiotics were narrowed to ciprofloxacin when P. shigelloides grew from his blood culture. The case presents a unique mode of bacteremia, as usually P. shigelloides bacteremia develops in immunocompromised hosts after bowel wall translocation. The venomous nature of catfish barbs also contributed to the severity and rapidity of his presentation secondary to the local tissue effects of envenomation. With proper antibiotics and supportive care, he made a full recovery.
Subject(s)
Bacteremia , Catfishes , Gram-Negative Bacterial Infections , Plesiomonas , Animals , Humans , Male , Gram-Negative Bacterial Infections/diagnosis , Gram-Negative Bacterial Infections/drug therapy , Gram-Negative Bacterial Infections/complications , Bacteremia/drug therapy , Bacteremia/complications , Anti-Bacterial Agents/therapeutic useABSTRACT
OBJECTIVE: We aimed to investigate the impact of preceding seasonal influenza on the clinical characteristics of adult patients with invasive pneumococcal disease (IPD) in Japan. METHODS: Data for 1722 adult patients with IPD were analyzed before (2017-2019) and during the COVID-19 pandemic (2020-2022). RESULTS: The seasonal influenza epidemic disappeared soon after the emergence of the pandemic. Compared with that before the pandemic (66.7%), we observed a lower bacteremic pneumonia proportion in patients with IPD during the pandemic (55.6%). The clinical presentations of IPD cases significantly differed between those with and without preceding influenza. The proportion of bacteremic pneumonia was higher in IPD patients with preceding influenza than in those without in both younger (44.9% vs 84.2%) and older adults (65.5% vs 87.0%) before the pandemic. The case fatality rate was significantly higher in IPD patients with preceding influenza (28.3%) than in those without (15.3%) in older adults before the pandemic (P = 0.020). Male and aging are high risk factors for death in older patients with IPD who had preceding influenza. CONCLUSION: Our study reveals that preceding seasonal influenza plays a role in the development of bacteremic pneumococcal pneumonia, increasing the risk of death in older adults.
Subject(s)
Bacteremia , COVID-19 , Influenza, Human , Pneumonia, Pneumococcal , Humans , Japan/epidemiology , Male , Influenza, Human/epidemiology , Influenza, Human/complications , Influenza, Human/mortality , Female , Aged , COVID-19/epidemiology , COVID-19/complications , COVID-19/mortality , Middle Aged , Pneumonia, Pneumococcal/epidemiology , Pneumonia, Pneumococcal/mortality , Pneumonia, Pneumococcal/complications , Bacteremia/epidemiology , Bacteremia/mortality , Bacteremia/complications , Aged, 80 and over , Adult , Risk Factors , Seasons , SARS-CoV-2 , Streptococcus pneumoniae , Pandemics , Age FactorsABSTRACT
We present the case of a male with end-stage diabetic nephropathy on haemodialysis who initially presented with acute-on-chronic digital ulceration. While awaiting vascular intervention, he became septic with abdominal pain and diarrhoea. Flexible sigmoidoscopy confirmed pseudomembranous colitis secondary to Clostridium difficile. Blood cultures grew Parabacteroides distasonis, a Gram-negative gut anaerobe. Enterobacter cloacae, another Gram-negative anaerobic gut bacilli, was grown in colonic cultures and swabs of the digital ulcers. We hypothesise that the pseudomembranous colitis increased gut translocation and thus led to the systemic spread of both gut anaerobes. This is the first reported case of Parabacteroides distasonis bacteraemia in the context of Clostridium difficile infection. Our patient recovered with antibiotics and went on to have vascular intervention for his digital ulceration.
Subject(s)
Bacteremia , Enterocolitis, Pseudomembranous , Humans , Male , Bacteremia/microbiology , Bacteremia/drug therapy , Bacteremia/diagnosis , Bacteremia/complications , Enterocolitis, Pseudomembranous/microbiology , Enterocolitis, Pseudomembranous/diagnosis , Anti-Bacterial Agents/therapeutic use , Bacteroidetes/isolation & purification , Diabetic Nephropathies/complications , Middle Aged , Enterobacteriaceae Infections/diagnosis , Enterobacteriaceae Infections/microbiology , Enterobacteriaceae Infections/drug therapy , Enterobacteriaceae Infections/complications , Enterobacter cloacae/isolation & purification , Clostridioides difficile/isolation & purification , Renal DialysisABSTRACT
Purpura fulminans (PF) is a life-threatening complication of septic shock that can occur due to disseminated infections with Streptococcus pneumoniae The spleen is an important organ in the immunisation process against encapsulated bacteria. Patients with asplenia, either functional or anatomical, are therefore at increased risk of developing serious infections and complications, such as PF, if infected with such bacteria.This case report presents a woman in her late 40s with unacknowledged functional asplenia who was admitted to the hospital with signs of an acute disseminated infection causing septic shock, signs of disseminated intravascular coagulation and infectious PF. A few days after admission, the blood cultures showed growth of S. pneumoniae With early sepsis treatment, the patient survived although with some complications. Clinical presentation, investigations, differential diagnosis, treatment and outcome are presented. Treatment and early recognition of PF are presented and discussed. Relevant recognition and preventative treatment strategies for patients with asplenia are also reviewed and discussed.This case demonstrates the importance of early recognition and treatment of PF in septic patients and the importance of preventive treatment strategies for patients with asplenia to avoid serious infections and complications.
Subject(s)
Bacteremia , Pneumococcal Infections , Purpura Fulminans , Sepsis , Shock, Septic , Splenic Diseases , Female , Humans , Purpura Fulminans/diagnosis , Shock, Septic/complications , Pneumococcal Infections/microbiology , Streptococcus pneumoniae , Sepsis/complications , Bacteremia/complications , Splenic Diseases/complicationsABSTRACT
Infectious aortitis is a rare disease process which can be of fungal, viral or bacterial aetiology. This disease process is often incidentally found during concomitant infectious processes, likely due to haematogenous spread. Common sources are from cardiac, genitourinary and gastroenterologic sources. CT imaging of the aorta is essential in identifying physiological changes-wall thickness changes, ectasia and stenosis. We present a case of a female in her early 60s with a medical history of cardiomyopathy with heart failure and reduced ejection fraction, who was initially admitted for acute cholecystitis complicated by the development of gallstone pancreatitis. Imaging evaluation incidentally noted findings consistent with aortitis with a penetrating ulcer, and blood cultures were positive for Staphylococcus aureus bacteraemia, confirming her diagnosis of infectious aortitis. She was started on intravenous antibiotics, required preoperative nutritional optimisation, and subsequently underwent an open aortic resection and aortoiliac reconstruction with rifampin-soaked Dacron graft.
Subject(s)
Aortitis , Bacteremia , Soft Tissue Infections , Staphylococcal Infections , United States , Humans , Female , Aortitis/diagnosis , Aortitis/therapy , Aortitis/complications , Bacteremia/complications , Hospitals, Military , Staphylococcal Infections/complications , Staphylococcus aureus , Soft Tissue Infections/complicationsABSTRACT
BACKGROUND: Ralstonia pickettii is a low virulent, gram-negative bacillus that is rarely associated with human infections and may cause bacteremia. Microbacterium species are gram-positive coryneforms that are generally considered as a contaminant in Gram staining of blood cultures, especially when the time to positivity is longer than 48 h. Both these bacterial species are emerging opportunistic pathogens that may occasionally cause serious infections and even life-threatening health conditions. CASE PRESENTATION: Here, we report the case of a patient with bacteremia caused by both R. pickettii and Microbacterium. We advocate for providers to order rapid antibiotic susceptibility testing, since our patient's suffered two kinds of rare pathogens with the opposite of drug sensitivity results to imipenem. CONCLUSIONS: Our case present a patient suffered septic shock caused by R. pickettii and Microbacterium. Improving the antibiotic management based on the result of antimicrobial susceptibility tests is the key of successful treatment.
Subject(s)
Bacteremia , Gram-Negative Bacterial Infections , Ralstonia pickettii , Humans , Microbacterium , Gram-Negative Bacterial Infections/diagnosis , Gram-Negative Bacterial Infections/drug therapy , Gram-Negative Bacterial Infections/etiology , Anti-Bacterial Agents/therapeutic use , Bacteremia/diagnosis , Bacteremia/drug therapy , Bacteremia/complicationsABSTRACT
Hungatella species, including Hungatella hathewayi and Hungatella effluvii, previously identified as part of the Clostridium genus, are anaerobic bacteria primarily residing in the gut microbiome, with infrequent implications in human infections. This article presents the case of an 87-year-old Asian male admitted for a hyperosmolar hyperglycemic state with septic shock secondary to Hungatella hathewayi bacteremia originating from acute appendicitis. Remarkably, the bacterium was detected in the blood 48 hours before the emergence of clinical and radiographic evidence of acute appendicitis. Additionally, we conducted a literature review to identify all documented human infections caused by Hungatella species. Timely microbial identification in such cases is essential for implementing targeted antibiotic therapy and optimizing clinical outcomes.
Subject(s)
Anti-Bacterial Agents , Appendicitis , Bacteremia , Humans , Appendicitis/microbiology , Appendicitis/complications , Appendicitis/diagnosis , Male , Bacteremia/microbiology , Bacteremia/diagnosis , Bacteremia/drug therapy , Bacteremia/complications , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Clostridiales/isolation & purification , Clostridiales/classification , Clostridiales/geneticsABSTRACT
PURPOSE: This study aimed to identify the patient characteristics of children with febrile neutropenia, the associated bacterial organisms, and their sensitivity patterns. MATERIALS AND METHODS: A descriptive cross-sectional study was conducted at the Moi Teaching and Referral Hospital (MTRH) pediatric oncology ward, from June 2021 to April 2022. A total of 110 children who developed fever and neutropenia during chemotherapy were enrolled. Blood samples for culture were collected aseptically. Patient characteristics were presented in frequency tables. Antimicrobial sensitivity patterns were plotted in tables against the bacterial isolates cultured. Chi-square/Fisher's exact test was used to determine any association between patient characteristics, bacterial growth, and antimicrobial sensitivity. RESULTS: The majority (n = 66; 60%) were males. The median age was 6.3 years (standard deviation, 3.7). The majority of patients 71 (64.5%) had hematologic malignancies, the most common being AML. There was a significant association between severity of neutropenia and hematologic malignancies (P = .028). In total, 31/110 (28.2%) blood cultures were positive for bacterial growth. Gram-positive bacteria were more frequent (n = 20; 58.1%). The most common organism was Escherichia coli (n = 6; 18.2%), followed by Staphylococcus aureus (n = 5; 15.2%). All the isolates were sensitive to linezolid and vancomycin and also showed good sensitivity toward meropenem (n = 10/11; 90.9%). High resistance to cephalosporins was noted with ceftriaxone (n = 5/6; 83.3%), cefepime (n = 4/7; 57.1%), and ceftazidime (n = 3/4; 75%). CONCLUSION: The most common malignancy associated with febrile neutropenia was AML. Gram-positive bacteria were the most common isolates. There was high resistance to cephalosporins.
Subject(s)
Bacteremia , Febrile Neutropenia , Hematologic Neoplasms , Leukemia, Myeloid, Acute , Male , Child , Humans , Female , Anti-Bacterial Agents/adverse effects , Tertiary Care Centers , Cross-Sectional Studies , Kenya , Bacteremia/complications , Bacteremia/drug therapy , Bacteremia/microbiology , Cephalosporins/adverse effects , Hematologic Neoplasms/complications , Hematologic Neoplasms/drug therapy , Hematologic Neoplasms/microbiology , Febrile Neutropenia/drug therapy , Febrile Neutropenia/epidemiology , Febrile Neutropenia/complications , Leukemia, Myeloid, Acute/complications , Leukemia, Myeloid, Acute/drug therapyABSTRACT
A 22-year-old male, with a history of recreational drug use, was admitted with a 24-hour history of sore throat, bilateral otalgia, fever, chills, sweats, and pain in the upper chest. The blood cultures were positive for Fusobacterium necrophorum. A thoracic and neck soft tissue computed tomography (CT) scan revealed an intratonsillar abscess and pulmonary septic emboli. Initial treatment with Piperacillin-tazobactam and Clindamycin was de-escalated after 5 days. The patient made a complete recovery after 22 days of antibiotic treatment.
Subject(s)
Bacteremia , Fusobacterium Infections , Substance-Related Disorders , Male , Humans , Young Adult , Adult , Fusobacterium necrophorum , Abscess , Fusobacterium Infections/complications , Fusobacterium Infections/diagnosis , Fusobacterium Infections/drug therapy , Bacteremia/complications , Bacteremia/diagnosis , Bacteremia/drug therapyABSTRACT
BACKGROUND: Fusobacterium nucleatum (F. nucleatum) belongs to the genus Fusobacterium, which is a gram-negative obligate anaerobic bacterium. Bacteremia associated with F. nucleatum is a serious complication, which is not common in clinic, especially when it is combined with other intracranial pathogenic microorganism infection. We reported for the first time a case of F. nucleatum bacteremia combined with intracranial Porphyromonas gingivalis (P. gingivalis) and herpes simplex virus type 1(HSV-1) infection. CASE PRESENTATION: A 60-year-old woman was admitted to our hospital with a headache for a week that worsened for 2 days. Combined with history, physical signs and examination, it was characterized as ischemic cerebrovascular disease (ICVD). F. nucleatum was detected in blood by matrix-assisted laser desorption/ionization time-offight mass spectrometry (MALDI-TOF-MS). Meanwhile, P. gingivalis and HSV-1 in cerebrospinal fluid (CSF) were identified by metagenome next generation sequencing (mNGS). After a quick diagnosis and a combination of antibiotics and antiviral treatment, the patient recovered and was discharged. CONCLUSION: To our knowledge, this is the first report of intracranial P. gingivalis and HSV-1 infection combined with F. nucleatum bacteremia.
Subject(s)
Bacteremia , Fusobacterium Infections , Herpes Simplex , Herpesvirus 1, Human , Female , Humans , Middle Aged , Porphyromonas gingivalis , Fusobacterium nucleatum , Herpesvirus 1, Human/genetics , Base Composition , Phylogeny , RNA, Ribosomal, 16S , Sequence Analysis, DNA , Herpes Simplex/complications , Herpes Simplex/diagnosis , Herpes Simplex/drug therapy , Bacteremia/complications , Bacteremia/diagnosis , Bacteremia/drug therapy , Fusobacterium Infections/complications , Fusobacterium Infections/diagnosis , Fusobacterium Infections/drug therapyABSTRACT
Introduction: Boerhaave's syndrome, or the spontaneous transmural perforation of the esophagus, is typically thought to be due to an increase in esophageal pressure such as that which occurs during vomiting or retching. Another common etiology of esophageal perforation is esophageal instrumentation, such as during esophagogastroduodenoscopy or transesophageal echocardiography. This life-threatening condition requires prompt diagnosis and treatment to prevent patient demise. While a history of vomiting can aid in diagnosis, this history can be difficult to elicit in an unconscious patient or may be altogether absent. Additionally, Boerhaave's syndrome can present similarly to more common upper gastrointestinal or cardiac conditions. Since mortality increases with delays in diagnosis and treatment, it is imperative that clinicians maintain a high level of suspicion for Boerhaave's syndrome and initiate treatment urgently. Case Description: This report presents a 76-year-old man who presented to the emergency department after a history of several syncopal episodes and was found to be in complete heart block. Two days later, he acutely developed abdominal distention and coffee ground emesis. As the medical team was able to gather more history from the patient and his family, it was revealed that he had associated vomiting with his episodes of syncope. CT scan of the abdomen and pelvis demonstrated pneumomediastinum concerning for esophageal perforation. His clinical status subsequently deteriorated. He was intubated and a temporary transvenous pacer was placed before being transferred to our facility for emergent surgery. Discussion: Complete heart block in the setting of Boerhaave's syndrome is exceptionally rare, with only 2 cases reported in the literature. The decision to place a pacemaker in the setting of esophageal perforation/sepsis is complicated and depends on the patient's bacteremia status related to noncardiac comorbidities. Clearly this case represents the need for excellent multidisciplinary decision-making processes with excellent communication between hospital staff and all caretakers. Expeditious diagnosis and treatment of esophageal perforation is essential to prevent leaking of gastric contents into the mediastinum and worsening of cardiac complications and sepsis. Additionally, critical timing of various surgical procedures, especially the need for a permanent pacemaker implant with bacteremia is a complicated process not well described in the surgical literature.