Case Presentation: A 30 year old male with no past medical history presented with progressive shortness of breath and chest pain. He stated that two weeks ago, he removed a wooden splinter from his left finger. The finger then developed swelling and erythema that progressed to painful drainage in association with worsening of presenting symptoms. Initial workup was notable for a CT chest demonstrating septic emboli in the left lung and a CT of the left hand showing cellulitis with superficial abscess formation in the 2nd finger. The patient underwent a distal phalanx amputation of the finger and was admitted to the medicine service for sepsis due to cellulitis. Initial blood cultures grew methicillin susceptible staph aureus (MSSA) and antibiotics were narrowed to cefazolin. On the second day of admission, the patient developed pericarditis evident on repeat EKG. Ibuprofen and colchicine were started. On the third day of admission, the patient decompensated, experiencing worsening chest pain and shortness of breath associated with persistent fever and tachycardia. Repeat CT of the chest with and without contrast showed the interval development of moderate to large bilateral loculated pleural effusions and the spread of previously noted septic emboli to the right upper, middle, and lower lobes. The patient improved with bilateral chest tube placement and antibiotic treatment with cefazolin. All repeat blood cultures were negative and workup for autoimmune or immunocompromising conditions was negative.
Discussion: Despite novel antibiotics and evolved source control methods, the mortality of the Staph Aureus (SA) bacteremia can surpass that of acute myocardial infarction(1). These metastatic infections classically affect the elderly or those with underlying immunocompromising risk factors such as dialysis dependency, intravenous drug use history, or history of endocarditis (2,3). Our patient demonstrated none of these qualities, neither prior to admission nor upon further work-up. In addition, after adequate source control and documented clearance of bacteremia on repeat blood cultures, the patient developed atypical complications. He developed multiple septic emboli to the lungs in the absence of endocarditis on both TTE and TEE. Though septic emboli are classically associated with endocarditis, they can also occur with soft tissue infections (4). The patient’s development of pericarditis and empyema without associated pneumonia was atypical as well. A study looking at the manifestations of complicated MSSA bacteremia found that out of the 282 complications identified in the study, only three and five were pericarditis and empyema, respectively (5). Clinical characteristics that might have predicted the above hospital course include the community acquired source of infection and the persistent fever after 72 hours of broad antibiotic coverage, both of which have been noted to herald complicated SA infections (5).
Conclusions: This case demonstrates that the management of MSSA bacteremia requires an attentive approach by the provider. Not only because of the disease’s high mortality rate, but also because of its propensity to spiral into an array of complications in both immunocompetent and immunocompromised individuals.
