A 30 year old female with SLE presenting with tricuspid endocarditis

A 30 year female diagnosed with systemic lupus erythematosus and lupus nephritis presented with low grade fever and malaise since 1 month. A 2D echocardiogram showed multiple tricuspid valve vegetations. Erysipelothrix rhusiopathiae was isolated from three sets of blood cultures. The organism was sensitive to penicillin and to ceftriaxone. The patient was started on ceftriaxone 2g IV once daily for 4 weeks.

On retrospective questioning, the patient recalled a history of sustaining a cut injury while slicing fish 1 month prior to presentation.

Endocarditis of the tricuspid valve caused by Erysipelothrix rhusiopathiae

A 34 year old man with severe pneumonia after renal transplantation

A 34 year old man was transferred to the hospital after being treated for severe necrotising pneumonia for ~ 1 month in another hospital. The patient had a renal transplant 2.5 years prior to presentation. He had been treated with pulse corticosteroids for acute rejection at 6 and 12 months post transplant. He had developed chronic cellular rejection of the transplanted kidney. Immunosuppression at the start of his illness includes prednisolone 10 mg OD, cyclosporine and mycophenolate mofetil. He developed acute kidney injury during the current illness and was on alternate day hemodialysis.

The CT scan revealed multiple cavitary consolidation in both lungs. The sputum and bronchoscopic lavage samples in the other hospital had grown Carbapenemase producing Klebsiella pneumoniae. He had been treated with colistin 1 MU IV OD x 10 days and IV tigecycline since the past 2 days.

Differential diagnosis included necrotising pneumonia caused by multidrug resistant Klebsiella, tuberculosis and invasive fungal infections.

At presentation a large right pleural collection was identified on the chest radiograph. Pleural aspiration revealed hemorrhagic fluid. A bronchoscopic lavage performed after endotracheal intubation grew Carbapenemase producing Klebsiella pneumoniae.

The patient developed respiratory failure soon after admission. The trachea was intubated and mechanical ventilation was initiated. He died of severe pulmonary hemorrhage and asphyxia on D3 of hospital stay.

Severe necrotising pneumonia caused by multidrug resistant Klebsiella pneumoniae. Fatal.