A 76-year-old man was brought to the emergency department of Singapore General Hospital by his family for productive cough, dyspnea, fever, and increasing drowsiness over the past 4 days. Two days prior to presentation, he had been started on a course of amoxicillin. He had a background history of asthma, bicytopenia, and early Parkinsonism, for which he and his family had declined follow-up care. He was on continued care for pernicious anemia, hypothyroidism, and adrenal insufficiency, for which he had been on thyroxine and hydrocortisone replacement. He had suffered a femur fracture 1 year prior and had since been wheelchair and mostly home bound.
Initial blood investigations showed pancytopenia, raised inflammatory markers, and acute kidney injury. A chest X-ray demonstrated a right upper lobe consolidation consistent with an infective process. An aerobic blood culture (BD Bactec) drawn on admission became positive after 33 h of incubation. The initial Gram stain from the blood culture broth is shown in Fig. 1. Repeated Gram stain smears with concurrent Gram-positive and Gram-negative controls yielded similar results. The organism produced slightly mucoid off-white colonies on sheep blood agar after overnight incubation at 35°C. Growth on MacConkey agar yielded colonies of similar size and morphology. The organism was nonmotile, oxidase negative, and catalase positive. A sputum specimen collected 3 days after admission grew the same organism as the blood culture.
FIG 1.
Gram stain (oil immersion; magnification, ×1,000).
(For answer and discussion, see page 3108 in this issue [doi:10.1128/JCM.02552-13].)