Physical Examination and Workup
The patient's white blood cell count was 22,000 cells/μL, with 85% neutrophils. His liver function test results were mildly abnormal; the alkaline phosphatase level was 150 IU/L, the alanine aminotransferase level was 72 U/L, the aspartate aminotransferase level was 85 U/L, and bilirubin was 1.4 mg/dL. Blood urea nitrogen and creatinine levels were within the reference range.
Chest radiography revealed findings consistent with pulmonary emboli. Transesophageal echocardiography revealed vegetation 2.1 cm in diameter on the anterior cusp of the tricuspid valve. Empirical therapy was begun with vancomycin 15 mg/kg every 12 hours. Within 18 hours, both bottles of all three sets of blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA).
The patient steadily improved, with normalization of his fever and decrease in his white blood cell count. The vancomycin trough level 5 days into treatment was 18 μg/mL.
Because of the nature of his infectious organism, as well as the presence of septic emboli associated with large vegetation, intravenous treatment was indicated (Figures 1-3). Blood cultures were repeated 3 days into treatment; all findings were negative.
During the patient's hospitalization, he had a constant stream of visitors. In the early morning of his seventh hospital day, he developed shaking chills and fever, with a temperature of 104°F. A 3/6 diastolic murmur was observed in the aortic area. Blood cultures were obtained.
Transesophageal echocardiography revealed massive vegetation on the posterior leaflet of the aortic valve. The patient's creatinine level had increased to 1.6 mg/dL. His white blood cell count was 15,000 cells/μL, with 90% polymorphonuclear leukocytes.
In the early afternoon, the patient began to have severe left leg pain. Upon examination, his leg was pale and cool to the touch, with no pulses detectable below the iliacs. An emergency vascular surgery consultation recommended selective arteriography, which revealed a large clot in the left femoral artery. A thrombectomy was performed.
The next day, the patient experienced a massive cerebral embolus. He developed Cheyne-Stokes respiration and was placed on a ventilator. The following day, he was declared brain dead, and life support was discontinued in accordance with his stated wishes expressed and advance directives.
While the patient's belongings were being cleared out, drug injection paraphernalia was discovered, along with a supply of brown heroin. At this point, the pathology laboratory called with the results of the examination of the retrieved thrombus.
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