Table 1.
Summary of hospital course.
| Day | T max | WBC | SCr | Cultures | Antimicrobials | Imaging | Comments |
|---|---|---|---|---|---|---|---|
| ED | 40.5 | 8.0 | 5.10 | Bcx: 2/2 MSSA; TTP 8.3 hours | Vancomycin 1750 mg IV × 1 | X-ray R foot/ankle, X-ray chest per HPI | — |
| 1 | 37.9 | 8.1 | 4.44 | Bcx: 2/2 MSSA | Cefepime 2 g IV q24 h, linezolid 600 mg IV q12 h, remdesivir 200 mg IV × 1 | CT chest PE protocol: no PE, possible septic emboli and L IJ thrombophlebitis | Ortho attempted aspiration of R ankle—dry tap. Oxacillin 2 g IV q4 h started following detection of MSSA in ED blood cultures. |
| 2 | 37.3 | 8.7 | 4.19 | Bcx: 2/2 MSSA | Oxacillin 2 g IV q4 h | Panorex: periapical abscesses at #30. Duplex LEs: No DVTs. TTE: No vegetations | Remdesivir stopped by MICU due to AKI. ID consulted. |
| 3 | 37.3 | 7.6 | 2.53 | Ankle tissue culture: 5/5 MSSA; tracheal aspirate: MSSA | MRI R ankle (Figure 1): diffuse skin thickening and edema of foot and ankle w/o evidence of OM; large complex tibiotalar joint effusion w/synovitis and abscess along the FHL muscle | OR with ortho s/p R ankle I&D and arthrotomy; R leg FHL abscess I&D. Dental consulted. | |
| 4 | 38.5 | 5.3 | 2.12 | Bcx: 2/2 MSSA | X-ray chest: mild interval improvement in b/l interstitial airspace opacities c/w COVID-19 pneumonia, septic pulmonary emboli | Weaned off BiPAP; CPAP at night only. Tooth #30 extracted. | |
| 5 | 38.8 | 5.7 | 1.82 | Bcx: 2/2 MSSA | |||
| 6 | 38.9 | 6.2 | 1.57 | Bcx: 2/2 MSSA; COVID-19 RNA nasopharyngeal swab: positive | Oxacillin 2 g IV q4 h, ceftriaxone 2 g IV × 1 | CT CAP w/contrast: cavitating pulmonary septic emboli, fluid collection around L SC joint c/f early septic arthritis, phlegmon within R iliacus muscle. X-ray L knee/ankle: L knee medial osteoarthritis, L foot cellulitis, and acute on chronic achilles tendinopathy | Ceftriaxone added by ICU team for Gram-negative coverage given fever and tachycardia; X-rays looking for prior hardware; no surgical indication for SC joint per thoracic surgery. |
| 7 | 38.7 | 4.2 | 1.47 | Bcx: 2/2 MSSA | Oxacillin 2 g IV q4 h, ceftriaxone 1 g IV q24 h | Tee: no vegetations noted |
MSK IR consulted for iliacus muscle phlegmon. |
| 8 | 37.9 | 7.1 | 1.51 | Bcx: 1/1 MSSA | X-ray L shoulder/R knee: no evidence of OM or septic arthritis. MRI L knee/ankle/foot: severe L knee chondrosis, small L knee joint effusions, L ankle and foot cellulitis, small nonspecific collection extending dorsally from between the base of the L 3rd and 4th metatarsal, likely represents extension of adventitial bursitis. US lower back: loculated fluid collection deep and posterior in pelvis. MRI brain/spine (Figure 2): C3-C4 discitis/OM w/epidural abscess, no intracranial abnormality. CT spine: C3-C4 discitis/OM w/epidural abscess | Transferred to floor. | |
| 9 | 37.7 | — | — | Bcx: 1/1 MSSA; TTP = 13.6 hours | Ceftriaxone discontinued. ID recommend to change oxacillin to cefazolin plus ertapenem. Last dose dexamethasone given. Ortho spine consulted. | ||
| 10 | 37.2 | 7.1 | 1.39 | Bcx: 2/2 MSSA; TTP = 22.5 hrs; L foot aspiration: MSSA; cervical spine wound: MSSA | Cefazolin 2 g IV q8 h, ertapenem 1 g IV q24 h | ||
| 11 | 36.9 | 6.0 | 1.23 | Bcx: 2/2 no growth | L 3rd/4th metatarsal aspiration; OR for cervical fusion/epidural abscess drainage with ortho spine. | ||
| 12 | 37.2 | 4.1 | 1.10 | Bcx: 2/2 no growth | — | — |
Bcx, blood culture(s); TTP, time-to-positivity; FHL, flexor hallucis longus; SC, sternoclavicular; OM, osteomyelitis.