A 34-year-old African-American male with a history of uncontrolled diabetes mellitus type I and recurrent skin infections secondary to intravenous drug abuse was admitted with diabetic ketoacidosis (DKA) in September 2019 at Monmouth Medical Center, New Jersey, United States. His other history included but not limited to chronic pancreatitis, polysubstance abuse, multiple bacteremia episodes in past with MRSA,
Patient was initially treated with intravenous (I.V.) insulin along with I.V. fluid boluses as per DKA treatment protocol, and the later was started on subcutaneous insulin. Electrolytes were replete appropriately. On the third day of hospitalization, he was found to have a subcutaneous soft tissue abscess in the medial aspect of left antecubital fossa measuring 2.6 × 1 × 2.4 cm. The abscess was incised and drained. Since preliminary wound cultures were positive for Gram-positive cocci, the patient was started empirically on vancomycin. An initial set of blood cultures were negative. One week after admission, the patient started having chills followed by an increase in body temperature to 102 degrees Fahrenheit, not relieved with antipyretics. The wound was healing, without active infection. White blood count was within normal limits. Chest X-ray was negative for any infiltrates/pneumonia/pleural effusion. CT scan of the abdomen did not show any abdominal abscess or source of infection. It showed the possibility of gastroesophageal reflux disease and gastroparesis secondary to opioids and DM. Repeated blood cultures initially showed Gram-negative rods in both tubes with Gram-positive cocci in pairs and chains in one tube. With the thought that bacteria might be resistant to vancomycin, antibiotics were switched to broad-spectrum with daptomycin to cover Gram-positive bacteremia and meropenem to cover Gram-negative bacteremia empirically. Final blood cultures showed
Antibiotic susceptibility of cultured
The bacterial genus
Although bloodstream infections are often associated with contaminated intravascular products and medical equipment leading to an outbreak,
Bacterial endotoxin leads to cytokine production and is the responsible agent for infection. Signs and symptoms of bacteremia include but not limited to nonspecific pathophysiological reactions, such as gastrointestinal symptoms, fever, changes in white blood cell counts, anaemia, thrombocytopenia, disseminated intravascular coagulation, hypotension, and shock [
The possible cause in our patient might be wound superinfection. Another reason can be gastric mucosal injury leading to translocation of bacteria through the GI tract because of possible GERD, although the patient was not on antacids prior to bacteremia. The patient had DM-I and chronic untreated viral hepatitis which are associated with high rates of spontaneous bacteremia. The clinical course was mild and the patient recovered fully with effective antibiotic treatment without any complication.
The authors declare no conflicts of interest.
All authors contributed equally to this case report.