A woman with fever, vesicular rash and hypoxemia

A 35 year old woman from West Bengal presented with fever and dry cough since 1 week. 1 month prior to presentation, she had developed a boil on the buttock that healed after treatment with oral amoxicillin-clavulanate. At presentation, the patient had tachycardia, a normal blood pressure, hypoxemia while breathing ambient air. Few vesicular lesions were found around the ankles and over the forearm. She was drowsy, however no focal neurologic deficits or signs of meningitis were present.

The complete blood count revealed leucocytosis and thrombocytopenia. Chest rediograph revealed bilateral illdefined pulmonary infiltrates. A CT scan of the chest revealed bilateral nodular consolidation and cavitation. Transesophageal echocardiography revealed a 16 mm vegetation over the tricuspid valve. Methicillin sensitive staphylococcus aureus was isolated from blood cultures drawn at admission.

Meropenem and vancomycin were administered initially with a switch to cloxacillin and clindamycin after culture results were known.

Hospital course was complicated by Acinetobacter ventilator associated pneumonia, Pseudomonas bacteremia and pulmonary hemorrhage. The patient died on D25 of ICU stay.

Fatal methicillin sensitive Staphylococcus aureus endocarditis of tricuspid valve