I wish when I had started out in medicine all those years ago I had kept a record of all the outliers I have seen. Lowest sodium, highest WBC, etc. I have seen a lot of amazing pathology over the years, but just try and remember it. I have easily consulted on 15,000 patients and ten times that number of curbsides and phone calls. But I no longer remember the cases from last week, much less from a decade or two ago

This blog has been a record of the amazing diseases I have seen over the last nine years, but try finding anything on a blog, much less using it as a reference source. And when I read an old post, I’ll be damned if I can remember actually writing it.

There is no doubt that Google and PubMed are a great support for the aging brain.

The patient was successfully treated for MSSA endocarditis two months ago, and then, unfortunately, relapsed his iv drug habit. I have enough trouble resisting donuts and ice cream, I can’t imagine the siren call of heroin or cigarettes.

He presented to the ER with fevers and blood cultures were positive.

For 4 organisms.

S. mitis, S. sanguis, S. gordonnii and Gamella haemolysans.

That is a personal record for polymicrobial endocarditis, my prior being three (S. viridins, S. aureus and coagulase negative Staphylococcus) in all the blood cultures. Or so I remember it.

In the prior case there was a vegetation on the MV,AV and TV; in this case just the TV.

Not only polymicrobial, it is a post-endocarditis endocarditis. Most of the cases I have taken care of have seeded when an IVDA continues to use their line, a non-nosocomial healthcare-associated infective endocarditis.

…vascular manipulation was the leading source of bacteraemia causing HAIE.



Leave that line alone. The literature suggests S. aureus as the most common cause, although my unreliable memory suggests I have seen, or at least remember, more cases due to Candida.

A vegetation is fertile soil for bacterial growth, so it is no surprise the clot will become infected with new organisms, especially if the needle is licked. I am surprised it is rare as it is.

I could also swear there is an article on post-endocarditis endocarditis with fresh, as opposed to old, clot, but my Google-Fu must be off as I can't find it.

Penicillin G is the treatment for all 4, gotta kill them all.

Rationalization

Medicine (Baltimore). 2015 Dec;94(49):e2000. doi: 10.1097/MD.0000000000002000. Polymicrobial Infective Endocarditis: Clinical Features and Prognosis. http://www.ncbi.nlm.nih.gov/pubmed/26656328

Non-nosocomial healthcare-associated infective endocarditis in Taiwan: an underrecognized disease with poor outcome. http://bmcinfectdis.biomedcentral.com/articles/10.1186/1471–2334–11–221

Healthcare-associated infective endocarditis: an undesirable effect of healthcare universalization.