Case Presentation: A 35-year old male with a PMH of homelessness and methamphetamine use presented to the ED in October 2022 for “flu-like symptoms” including chills, headache, congestion, abdominal pain and nausea/vomiting. He tested positive for influenza B and was admitted for symptomatic treatment and disposition planning. In reviewing his chart, it was apparent that he presented to various ED’s three times with similar symptoms over the past year. Each time, he was discharged on the basis that he was stable and initial lab work was reassuring. During one presentation in December 2021, the patient was admitted for sepsis versus systemic inflammatory response syndrome. On presentation, he was febrile, tachycardic and tachypneic with a new murmur and diffuse erythematous papules across his chest/extremities. CBC and BMP were unremarkable. Blood cultures were collected but a TTE was negative for vegetations. Given the negative infectious workup, the patient’s presentation was attributed to sympathomimetic toxicity. He stabilized with symptomatic care and was discharged on hospital day 1. Exactly one month later, his blood cultures grew B. quintana. Multiple efforts were made to contact the patient regarding his positive cultures, but he was lost to follow-up. Between admissions in December 2021 and October 2022, the patient presented to two different ED’s complaining of fever/chills, headache, cough, congestion, nausea and epigastric pain. During one of these visits, he was discharged with an assessment of “viral syndrome, nausea and vomiting, and epigastric pain.” During the other visit, a history of B. quintana bacteremia was referenced in documentation and blood cultures were collected but no additional intervention was initiated, and he was discharged with an assessment of “fever and chills.” On arrival to the hospital in October 2022, he was febrile with all other vital signs stable. CBC was within normal limits, RVP was positive for flu B and chest x-ray showed no evidence of pneumonia. B. quintana antibodies, a TTE and blood cultures were ordered on admission but empiric treatment for B. quintana bacteremia was initiated prior to receiving these results. The patient received 2 weeks of treatment with gentamicin and doxycycline followed by 2 weeks of doxycycline monotherapy. In the interim, the TTE showed no evidence of vegetations and serology was negative for IgM antibodies (< 1:16) and positive for IgM antibodies (1:512). Blood cultures remain without growth 30 days after collection.

Discussion: B. quintana is a fastidious, gram-negative rod that manifests as bacteremia, endocarditis and/or bacillary angiomatosis. Risk factors for infection include a history of homelessness and alcoholism. Presentations can range from mild “flu-like” symptoms to severe disease. Symptoms are nonspecific and may consist of fever, malaise, headache, nausea and a macular rash. The definitive diagnosis is made from a culture, but because the organism is difficult to isolate, other clinical clues and supportive diagnostics such as serologic tests are crucial. PCR-based tests are also useful in supporting the diagnosis, but these are not widely available.

Conclusions: TThis case highlights that the diagnosis of B. quintana requires high clinical suspicion with careful consideration of PMH, epidemiological data, nonspecific clinical presentations and variable diagnostic results. Additionally, it illustrates the importance of thorough chart reviews in preventing premature closure and reducing healthcare utilization.