Title : Bacteremia from E.cloacae, E.faecalis,C.tropicalis, cardiac device related endocarditis and septic arthritis from C.tropicalis
Abstract:
A 71-year-old man was admitted to our Department due to hematuria. From his medical history he reported multiple ischemic strokes in the setting of atrial fibrillation, a pacemaker due to complete atrioventricular block and diabetes mellitus on insulin.
From the clinical examination the patient was febrile with no other clinical finding, while from the laboratory testing we noticed mild leukocytosis and elevated CRP of 6mg/dl. From the urine test the total hemoglobin and red blood cells was elevated. He was empirically treated on IV piperacilline /tazobactam for Urinary tract infection.
Blood cultures yielded C.tropicalis, E.faecium and E.cloacae, while urine cultures yielded E.cloacae and C.tropicalis. Following the antibiogram his treatment was adjusted to IV ceftriaxone, IV vancomycin and IV micafungin. While receiving appropriate antibiotic treatment and having negative blood cultures, he presented with a new fever accompanied by pain, swelling and redness of the right knee joint, with simultaneous recurrence of mycetemia as well as isolation of C.tropicalis from the synovial fluid culture.
Transthoracic and transoesophageal echocardiography showed vegetations of the pacemaker leads.The pacemaker was removed, an epicardial pacemaker was placed, and the leads were sent for culture and molecular testing for fungi and common microbes, from which C.tropicalis was eventually cultured, while the molecular testing was negative for other pathogens.
He completed six weeks of treatment for Fungal pacemaker lead related Endocarditis and Septic Arthritis with micafungin. The joint was surgically cleaned and serially punctured due to persistent symptoms, with C.tropicalis recurrently isolated. Based on cases in the international literature, it was decided to perform an intra-articular injection of amphotericin B, an intervention that ultimately helped sterilize the joint. Septic arthritis from C.tropicalis is a rare clinical manifestation, with few cases in the international literature, mainly involving immunosuppressed patients with hematological malignancy. To our knowledge this is the first case with C.tropicalis endocarditis having as immunosuppression the uncontrolled insulin dependent Diabetes Mellitus.
