Mr. S, a 74-year-old male with diabetes, hypertension, heart disease, and kidney failure, presented to the emergency room with a fever of 38.6°C for one day and neck pain radiating to his head for five days. Examination was unremarkable. Blood cultures grew methicillin-sensitive Staphylococcus aureus sensitive to cefazolin. A CT scan and MRI of the neck showed abnormalities. The plan is to remove the permacath catheter, perform an echocardiogram, continue IV antibiotics, correct hyperkalemia, and follow up with spine surgery. The diagnosis is bacteremia likely from the intravascular catheter.

1. Morning Report
Presenter : Dr.Abdullah Almazyad R1
Moderator : Dr.Muhannad Alassiri R3

2. Chief Complain
• Mr.S is a 74 years old presented to ER complaining
of Documented Spiking of 38.6 and Neck pain

3. History of Presenting Illness
• Mr.S is a 74 years old male KCO DM , HTN , IHD (PCI to LAD 2010 ) and recent
diagnosis of Unstable Angina , and ESRD on PermaCath since last 6 months
• He presented to our ER complaining of Documented spiking fever of 38.6
(highest) that started 1 day ago and , no diurnal variation , not associated with
weight loss or night sweats and Neck pain that is constant but radiates to the upper
shoulders and back of his head as a shock wave , started 5 days ago with no change
in course , no exacerbating or aggravating factors , pain is sever effecting pt sleep
• No Photophobia , no phonophobia , lasted more then 72 hours , never had
similar episodes , no lacrimation or rhinorea
• No Seasonal variation , doesn’t change with position , doesn’t have a stressful or
tense life , No Rash , no Hx of recent Travel outside Saudi Arabia

4. • Past Medical and surgical :
– Kco DM , HTN , IHD and ESRD
– Hernia Repair 30 years ago , and Cardiac Catheterization with PCI 10 years ago
– No Hx of blood Transfusion or Allergy
– He is using Aspirin , Clopidogrel , Bisoprolol , Isosorbide Dinitrate , Hydralazine , Amlodipine ,
Insulin NPH , and Sodium Bicarbonate
• Family Hx :
– His Mother was diagnosed with HTN
– His Father was diagnosed with DM
– No Family Hx of similar Episodes in the family
• Social Hx :
– he lives in Al-Biasha
– He is a retired
– He doesn’t smoke , and doesn’t exercise requlerly

5. Review of Systems
• Respiratory :
– No chough , no SOB , no hemoptysis
• Gastrointestinal :
– No abdominal pain , no dysphagia , no diarrhea
• Genitourinary :
– No dysuria , no flank pain , No Hesitancy
• Neurological :
– No weakness , no dizziness , Neck pain with radiation to upper shoulder and scalp
• Musculoskeletal :
– No joint pain , no muscle pain , no history of Trauma
• Hematology :
– No Bruising , no history of ease of bleeding, no history of Autoimmune disease
• Endocrine :
– No history of cold intolerance or Polyuria

6. General Examination :
Patient was Lying comfirtabilly on bed , with Peripheral IV line and PermaCath on the right
side , he looks in mild pain with acceptable body weight
Hand Examination :
-there was no rashes , ulcers , or discolorations
-No jenway lesions or Splinter Hemorrhage
-no joint pain , redness , tenderness , swelling , or change in temperature
-no limitation in range of motion
Head and Neck :
-no Malar rash , no Jaundice , no hair loss , no evidence of Annuler stomatitis , no Cyanosis
- JVP wasn’t raised
- No Generalized Lymphadenopathy
- Limited movement of the neck to the right side due to pain

7. CardioVasculer Exam
• Reguler pulse with rate of 78
• Inspection : no visible prominent veins , no visible pulsation , no
Scars , No discoloration , JVP wasn’t raised
• Palpation : no palpable thrills or Parasternal heaves , PMI was in
midclavicular line 5th intercostal space , No tenderness
• Auscultation : First and Second Heart sounds are audiable in all
auscultatory areas with no added sounds , no Murmurs
• No Basal Crackles , No lower limbs edema , no splenomegaly
• PermaCath looks clean , no redness surrounding it , no pus or
discharge

8. Respirstory Examination
• Inspection :
– Chest movement was symmetrical , RR : 18
• Palpation :
– Trachea was central ,equal chest expansion , no Subcutaneous
emphysema
– No palpable lymph nodes (anterior and posterior triangle ,
Supraclavicular , and axillary region)
• Percussion :
– Bilateral Resonant all over chest
• Auscultation :
– Vesicular Breathing equal bilaterally all over chest
– No Wheezing or crackles

9. Gastrointestinal Examination
• Inspection :
– Normal Abdominal Contour , symmetrical , Umbilicus is inverted
– No visible hernia , no visible dilated veins , no visible masses
• Palpation :
– Soft and lax , no tenderness , no palpable masses
– No Hepatomegaly or Splenomegaly
• Percussion :
– No shifting dullness
– Liver span is approximately 10 cm
• Auscultation :
– Audible bowel sounds , no renal bruit

10. Musculoskeletal Examination
• Joints :
– No visible joint or bone deformities
– No tenderness on movement or palpation , no swelling
, no difference in temperature
– No decreased ROM , swelling or erythema
• Muscle :
• No Proximal or Distal Weakness , no Tenderness

11. Neurological Examination
• GCS : 15/15
• Upper limbs :
– Sensory : intact for touch and pain
– Normal power , tone and reflexes
• Lower Limbs :
– Sensory : intact to touch and pian
– Normal power , tone and reflexes
• Limited movement of the neck to the right side due to pain
• Negative Brudzinksi and Kernigy’s sign

12. Summary
• Mr.S is a 74 years old male kco DM , HTN , IHD ,
and ESRD presented to ER complaining of Spiking
fever of 38.6 last 1 day and Hx of Neck pain with
radiation to scalp and upper shoulder since 5 days
• Examination was unremarkable

13. DDx?

14. Labs :
• CBC :

15. Electrolyte and Renal Profile

16. • Blood Culture :
– -Peripheral : +ve for MSSA in 20 hours Staphylococcus aureas sensitive to
Cefazolin
– -Central : +ve for MSSA in 17 hours Staphylococcus aureas sensitive to
Cefazolin
• Urine Exam :
– -WBC : 336
– RBC : 103
– Culture : <10000 of mixed gram positive flora
• CSF :
– -Coloreless , Clear , 1 WBC
– -no growth after 72 hours
– Glucose : 9.5 Protein : 0.24

17. Head and Neck CT

18. Cervical MRI

19. Plan :
• To Remove PermiCatheter (source of infection)
• Echo to rule Infective Endocarditis
• Repeat Blood Culture until negative
• Follow up with Spine Surgery
• IV ABX Cefazolin to be continued for 14 days from
last negative Blood culture
• Correct Hyperkalemia

20. Bactremia
• Primary Infection : due to direct inoculation of the blood ,
in pts on Intravasculer Catheter
• Secondary Infection : due to infection in another site
spreading to blood stream like due to UTI
• Common organisms : S.Aureus , Beta hemolytic strep ,
Enterococci , GNR
• Time To grow :
– High risk : <24 hours
– Low risk : >72 h unless slow growing organisms HACEK

21. Diagnosis
• Obtain Blood culture prior to abx if possible >2
sets (2 bottles in each set , each with 10 cc blood)
• If proven bactremia then daily surveillance cxs
until negative for 48 hours
• If S.Aureus obtain TEE or TTE

22. • Persistently positive culture ?
– D/C the lines
– Consider Metastetic infection
– Infected thrombosis
– Infected prosthetic material (joint , vascular graft ,
abscess)