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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 163-165
 

Delayed recognition of complex staphylococcal infection in pyrexia of unknown origin


Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India

Date of Submission01-Mar-2020
Date of Decision09-Mar-2020
Date of Acceptance18-Mar-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Vanita Ahuja
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_19_20

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How to cite this article:
Ahuja V, Bhagwat KR, Kaur P, Gill K. Delayed recognition of complex staphylococcal infection in pyrexia of unknown origin. Indian Anaesth Forum 2020;21:163-5

How to cite this URL:
Ahuja V, Bhagwat KR, Kaur P, Gill K. Delayed recognition of complex staphylococcal infection in pyrexia of unknown origin. Indian Anaesth Forum [serial online] 2020 [cited 2020 Oct 31];21:163-5. Available from: http://www.theiaforum.org/text.asp?2020/21/2/163/295325




Sir,

Diagnosis of pyrexia of unknown origin (PUO) is challenging as the initial symptoms are weak until an overt complication is evident.[1],[2],[3] A 14-year-old male presented with severe pain abdomen, fever, and loss of appetite for few weeks. There was no history of cough with expectoration, neurological symptoms, bladder, or bowel complaints. There was no history of foreign travel, insect bite, drug intake, and any contact history. The patient was semiconscious with a heart rate of 140 beats per min, blood pressure of 90/50 mmHg, and oxygen saturation of 85% on room air. On chest auscultation, bilateral air entry was reduced with occasional rhonchi. Hematological investigations revealed leukocytosis, elevated C reactive protein level, and erythrocyte sedimentation rate. Chest radiograph showed bilateral diffuse infiltrates. Ultrasound abdomen showed hepatosplenomegaly with minimal free fluid in the bilateral iliac fossa. During exploratory laparotomy, there was no perforation, appendix was normal and enlarged mesenteric lymph nodes were sent for histopathology analysis. The patient was shifted to the intensive care unit (ICU) for supportive care management. The patient received intravenous (IV) Ceftriaxone 750 mg BD, IV metronidazole 500 mg thrice a day (TID) and antitubercular treatment (ATT) empirically. The patient continued to have high-grade fever, with nocturnal severity. Other cases of fever, i.e. tuberculosis, dengue, malaria, salmonella, Brucella, scrub typhus, viral infections, leukemia, connective tissue disorder, and juvenile idiopathic arthritis, were evaluated. Echocardiography revealed normal study. Anticipating a prolonged ICU stay, on day 9 open tracheostomy and on day 10, ultrasound-guided central venous cannulation was performed. Blood, tracheal, and urine culture were sterile. On day 12, the patient had unexplained spontaneous right-sided pneumothorax, which was managed with intercostal chest tube drainage (ICD). Another important finding was the gradual development of swelling of the right shoulder. Magnetic resonance imaging of the shoulder joint revealed osteomyelitis with multiple intramuscular and intraosseous collections. On ICU day 18, patients developed left lung side pneumothorax. A diagnostic aspirate of the right shoulder joint showed methicillin-resistant Staphylococcal aureus gram-positive stain. A high resonance computed tomography of the chest [Figure 1] showed left hydropneumothorax, cavitary nodules with thick-walled cystic lesions in bilateral lungs [Figure 1]. The histopathology report of lymph node biopsy revealed reactive lymphoid hyperplasia. ATT was stopped, and IV vancomycin 600 mg BD and ampicillin sulbactam 1.5 g TDS were started. The patient showed clinical improvement over 1 week period. Both ICD were sequentially removed over a period of a few days. The trachea was decannulated on ICU day 28, and the patient was discharged on ICU day 32.
Figure 1: Computed tomography with left moderate hydropneumothorax and bilateral subpleural cavitatory nodules

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In a developing country, tuberculosis is considered to be the most likely diagnosis in any patient with abdominal lymphadenopathy and clinical deterioration.

In the present case, due to the use of multiple antibiotics, there was inadequate suppression of Gram-positive staphylococcal infection and so was not diagnosed early. Such complex staphylococcal infections with Staphylococcus aureus are sometimes difficult to diagnose due to similarity in presentation with tuberculosis. S. aureus infection was the probable cause of mesenteric lymphadenopathy, septic arthritis, pulmonary changes of the infective cyst, cavitatory lesion, and spontaneous pneumothorax in the present case.[4],[5]

To conclude, atypical presentation of complex staphylococcal infection should be considered early in patient with PUO and treatment should be focused. A third-generation cephalosporin may be added for Gram-negative cover.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Dayal R, Agarwal D. Fever in children and fever of unknown origin. Indian J Pediatr 2016;83:38-43.  Back to cited text no. 1
    
2.
Rigante D, Esposito S. A roadmap for fever of unknown origin in children. Int J Immunopathol Pharmacol 2013;26:315-26.  Back to cited text no. 2
    
3.
Antoon JW, Potisek NM, Lohr JA. Pediatric fever of unknown origin. Pediatr Rev 2015;36:380-90.  Back to cited text no. 3
    
4.
Sikorska-Wiśniewska G, Liberek A, Góra-Gebka M, Bako W, Marek A, Szlagatys-Sidorkiewicz A, et al. Mesenteric lymphadenopathy – A valid health problem in children. Med Wieku Rozwoj 2006;10:453-62.  Back to cited text no. 4
    
5.
Munro APS, Blyth CC, Campbell AJ, Bowen AC. Infection characteristics and treatment of Staphylococcus aureus bacteraemia at a tertiary children's hospital. BMC Infect Dis 2018;18:387.  Back to cited text no. 5
    


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