Case Presentation:
A 64‐year‐old retired shrimper with hypertension, hyperlipidemia, gout, and nonalcoholic steatohepatitis (NASH) with stage 3 fibrosis, presented to the emergency department with fever and vomiting. He had spent the day on his boat and had eaten shrimp for dinner prior to developing nausea, vomiting, shaking chills, and fever. He denied diarrhea, abdominal pain, dysuria, cough, chest pain, and dyspnea. On examination, he appeared dehydrated, had a temperature of 104.2°F, blood pressure of 145/73 mm Hg, and pulse of 114 bpm. His abdomen, head, neck, heart, and lungs were unremarkable. On the right index finger was a healing laceration without erythema or drainage. There was no rash or edema. His white blood cell count and the results of urinalysis and a chest radiograph were normal.
He defervesced with antipyretic therapy and remained afebrile. He was asymptomatic after only fluid resuscitation and bowel rest. He felt well and was eager to go home 36 hours after admission. Then initial blood cultures grew gram‐positive rods. The discharge process was postponed. Empiric therapy with vancomycin and meropenem was started. Repeated blood cultures grew the same organism, Erysipelo‐thrix rhusiopathiae. A transesophageal echocardiogram showed no evidence of endocarditis.
Discussion:
E. rhusiopathiae is a pathogenic gram‐positive rod that infects a wide variety of vertebrates and invertebrates worldwide. Swine are the primary reservoir, but fish and aquatic animals are major sources of infection in humans. E. rhusiopathiae usually enters through breaks in the skin. The most common form is a localized cutaneous eruption on the hand after exposure to infected animals. A second type is a generalized cutaneous form with diffuse macular rash and systemic symptoms. The third form, a sometimes fatal septicemia, is typically associated with endocarditis. Disseminated cases commonly involve a history of alcoholism. Most strains are susceptible to penicillin and cephalosporin. Resistance to vancomycin is notable because this antibiotic is often used in empiric therapy for endocarditis.
We describe an unusual case of E. rhusiopathiae bacteremia without endocarditis, rash, or localized infection in a patient with NASH, possibly a risk factor for dissemination, as is alcohol abuse. His rapid recovery with supportive care and a benign physical examination almost led to his discharge from the hospital prior to discovery of his unforeseen E. rhusiopathiae infection. In busy hospitals, stable patients are frequently discharged as soon as possible in order to have beds available for the more acutely ill. As this case suggests, patients may be discharged with significant abnormalities unreported.
Conclusions:
Hospitalists need to be aware that septicemia may present as a benign viral syndrome or gastroenteritis. Hospitals need to have reliable systems in place to follow up on test results reported after patients are discharged.
Author Disclosure:
R. Y. Meadows, None; S. B. Deitelzweig, None.