Photo Quiz: Nausea and Emesis in a Complicated Patient

A 47-year-old female presented with a 2-day history of nausea, emesis, increased fistula stool output, and subjective fever and chills. Her medical and surgical history included metastatic ovarian cancer, for which her status is postchemotherapy, and multiple surgeries, the most recent being an abdominal debulking procedure 4 months prior to this admission. She had been receiving total parenteral nutrition (TPN) via an indwelling port catheter since this procedure. Her multiple surgeries had left her with an enterocutaneous fistula. Other history included thromboembolic events and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia diagnosed 2 months prior to this hospitalization. Her admitting symptoms had begun around the time when she was starting to reintroduce soft foods into her diet. Blood cultures were drawn, and antibiotic therapy, which, because of her MRSA bacteremia history and increased fistula output, included vancomycin, metronidazole, and piperacillin-tazobactam, was initiated. Laboratory tests at admission showed a white blood cell (WBC) count of 7.2 × 10³ cells/mm³ (normal, 4.1 × 10³ to 10.8 × 10³ cells/mm³), with differentials of 77.3% granulocytes, 15.3% lymphocytes, 6.1% monocytes, 0.4% eosinophils, and 0.6% basophils, a hemoglobin level of 9.5 g/dl (normal, 11.2 to 15.7 g/dl), and a platelet count of 530 × 10³ cells/mm³ (normal, 140 × 10³ to 370 × 10³ cells/mm³). Results of routine chemistry tests were essentially normal, but alkaline phosphatase, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were elevated to 337 U/liter (normal, 38 to 128 U/liter), 101 U/liter (normal, 10 to 50 U/liter), and 104 U/liter (normal, 10 to 40 U/liter), respectively. Imaging of the abdomen failed to display any acute process.

Blood culture revealed growth of this organism (Fig. 1).

Fig 1.

(A) Top plate, growth on Emmons Sabouraud dextrose agar; bottom plate, growth on potato flake agar. (B) Low-power view of wet mount of potato flake colony. (C) High-power views of individual organisms seen in panel b.

(For answer and discussion, see page 3914 in this issue [doi:10.1128/JCM.02294-12].)