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A CT angiography (CT-A) of her thorax was then performed to determine the cause of her vocal cord palsy. An immediate cause of this vocal cord palsy was not apparent. A laryngoscopy confirmed left vocal cord palsy. Ten days after discharge, she presented with left facial pain, hoarseness and high-grade fevers. The patient improved clinically after a 7-day course of intravenous tazobactam and piperacillin, her CRP trending down to 17 mg/L. As a urinary tract and intra-abdominal source of bacteraemia were ruled out, the source of bacteraemia was presumed to be secondary to hospital-acquired pneumonia, which was in view of her most recent admission and the findings on her chest radiography. We attempted a pleural tap on the left small effusion, but were unsuccessful. Transthoracic echocardiography (TTE) did not show any obvious vegetations, but it showed mild overall systolic dysfunction with possible inferolateral hypokinesis. A CT scan of the abdomen and pelvis did not show any anatomical abnormalities of the urinary tract or an intra-abdominal pathology to explain the bacteraemia. Subsequent further investigations were undertaken to help identify the source of gram-negative bacteraemia. On review of past records, no urinalysis was done during her cardiology admission.
PROTEUS BACTERIA SKIN
mirabilis bacteraemia, focusing on the urinary tract, abdomen, skin and respiratory tract or any device-related infections, did not reveal a source of the infection. Further detailed history to elicit the primary source of P. mirabilis, and the patient was treated with tazobactam/piperacillin (Tazocin), to which the organism was sensitive. Chest radiography showed a small left pleural effusion with overlying consolidation, and her urinalysis showed only 1×10 6/L polymorphs. Her international normalised ratio (INR) was subtherapeutic at 1.3. Her systemic examination was otherwise unremarkable.īlood tests showed a haemoglobin of 113 g/L, a white cell count (WCC) of 12.7×10 cells/L, a platelet count of 340×109 cells/L and an elevated C reactive protein (CRP) of 280 mg/L. Auscultation of the precordium and lungs identified no murmurs, but there was reduced air entry on the left lung base.
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There was no history of thoracic trauma or having had an interventional procedure in the recent past. She did not have any peripheral stigmata of infective endocarditis. On examination, her temperature was 39.5☌. Her other significant medical history included coronary artery bypass graft, congestive cardiac failure, infrarenal fusiform abdominal aneurysm (3 cm), hypertension with stage 3 chronic kidney disease and a 40 pack/year history of smoking. She represented after 1 week with a 2-day history of fever with chills and rigours.
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The admission was complicated with new-onset atrial fibrillation, which necessitated the initiation of anticoagulation therapy, following which she was discharged. 11 Our patient was treated with intravenous antibiotics together with thoracic endovascular aortic repair (TEVAR) with stenting, due to her age and other comorbidities.Īn 81-year-old woman was initially admitted to cardiology unit for treatment of angina that was secondary to anaemia requiring blood transfusion. 9 10 A disadvantage of EVAR is that the infected aneurysm is left behind which could lead to recurrent infections warranting lifelong antibiotics and follow-up, and therefore this is considered a palliative approach. 1 Endovascular aneurysm repair (EVAR) is becoming popular, particularly in patients who have a high surgical risk with a reported 2-year survival rate of over 70% reported with this procedure. Surgical treatment with extensive local debridement and re-vascularisation is considered to be the preferred option however, this is associated with high morbidity and mortality. There are no standardised guidelines to treat infected aneurysms. 5–7 There was only one other case of thoracic-infected aneurysm due to Proteus bacteraemia reported in the literature. 3 4 Infected aneurysm involving the thoracic aorta is much less common and most published cases were due to non-typhoidal Salmonella species and Staphylococcus aureus. These infected aneurysms are more frequently seen in the femoral arteries and are commonly due to invasive procedures followed by mycotic aneurysms in the intra-abdominal region. 1 2 We present a very rare case of Proteus mirabilis bacteraemia thought to have originated from an intrathoracic mycotic aneurysm. Although only 1%–4% of all the arterial aneurysms are mycotic, they cause significant morbidity and mortality.