Diabetes, pleuritic chest pain and multiple cavitary lung no
The present case has been published in the journal CHEST. A 39-year-old male presented to the ED with a 2-day history of fever, nonbloody productive cough, and worsening right-sided pleuritic chest pain. He reported a 1-week history of left molar pain that began after he syphoned stagnant water with a straw from a refrigerator drip pan.

His lung examination showed dull note on the right lower lung fields on percussion. He had bilateral diffuse rhonchi with diminished lung sounds in the right lower lung fields, but no pleural rubs.

Tuberculin testing and HIV screening were negative. Normal deep vein scan of bilateral internal jugular veins. A transthoracic ECG was negative for vegetation with an ejection fraction of 55%.

CT scan of the neck showed a left upper lobe cavitary lung lesion and no filling defects in internal jugular veins or any cervical abnormalities. Blood cultures showed gram-negative bacillus in the aerobic bottle and no growth in the anaerobic bottle. Sputum sample cultures were negative for bacterial or fungal organism.

He was finally diagnosed with sphingomonas paucimobilis bacteremia with hematogenous spread to the lung.

The patient presented with clinical and imaging evidence of metastatic foci from a primary infection that proved to be due to S. paucimobilis bacteremia. The patient had no clinical evidence of other conditions, such as Lemierre syndrome or granulomatosis with polyangiitis, although his CT angiogram showed multiple cavitary nodular lesions, none had a feeding vessel, his ultrasound of the neck was normal, and his echocardiogram showed no vegetation; these items eliminated the differential diagnosis of Lemierre syndrome.

He most likely acquired his infection when he siphoned contaminated water from a refrigerator drip pan that allowed bacteria in his mouth to enter the bloodstream because of his poor dental health.

The patient was started on empiric therapy with IV moxifloxacin and vancomycin. Meropenem was added after blood culture identification of gram-negative bacterium. When S. paucimobilis was identified and shown to be susceptible to ciprofloxacin, his previous antibiotics were discontinued and he was treated with ciprofloxacin alone.

His symptoms of fever, chest pain, and cough improved over the course of 2 to 7 days and he was discharged on a 4-week course of oral ciprofloxacin. A follow-up CT scan after 6 weeks of therapy showed significant decrease in the size of the pulmonary nodules and masses with no evidence of pleural effusion.

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Dr. C●●●●●●●●●a K●●●i Internal Medicine
Very interesting clinical setting. Complements to your microbkiology lab for isolation..
Sep 15, 2018Like