A 49 year old Afro-Cuban male with a history of chronic alcoholism and hypertension presented with a three day history of fever (106   F), change in mental status, and body aches in August, 2016. On admission, he was febrile 103.1   F, with a heart rate of 137 beats per minutes, blood pressure of 156/79 mm of Hg, and respiration rate of 32 breaths per minute. The patient's laboratory results on admission included white cell count 9.2 x 103/microL, platelets 71 x 103/microL, PT 28 s, PTT 43 s, INR 2.62, albumin 3.1, Tblb (total bilirubin) 13.6 mg/dl, AST (aspartate transaminase) 133, and ALT (alanine transaminase) 56. Lactic acid was 6.2 mmol/L, and blood alcohol level checked the next day was less than 10 mg/dl. In addition, he showed left lower extremity cellulitis, left great toe ulceration, and 2nd right toe dark discoloration. Five days prior to admission, the patient ruptured a lesion on his left great toe which caused blistering and limping when he walked. Two days later, he walked outside without footwear in soil contaminated by chickens and hens. The animals are unrestrained in the yard, and the patient's spouse reports that the area is not cleaned or sanitized. It happened as well that his backyard was flooded earlier that week, after a recent hurricane hit this area.
The patient has a history of poor hygiene and self-care, and was only brought to the hospital by insistence of the spouse.
During the first day of his hospital stay, the patient went into septic shock and intravenous vancomycin and piperacillin/tazobactam were started empirically. Blood cultures were collected and sent to the microbiology laboratory. Head CT showed no abnormalities and chest X-ray showed no cardiopulmonary disease. Ultrasound of the lower extremities showed indurations at the left pretibial regions about 4 cm-5 cm. X-ray of the left foot showed soft tissue swelling over the dorsum of the foot without osseous or joint pathology. The next day preliminary blood culture results revealed gram positive rods. Given patient's critical condition and encephalopathic state, the piperacillin/tazobactam treatment was changed to meropenem out of concern of central nervous system infection - mainly listeria given newly diagnosed liver cirrhosis this admission. However, on the third hospital day blood cultures grew the more infrequently seen Erysipelothrix Rhusiopathiae. The patient was evaluated by cardiology and a 2D transthoracic echocardiogram was negative for endocarditis. Susceptibility testing was done so that the antibiotic coverage could be adjusted for the most effective treatment (Table 1). The susceptibility profile showed susceptibility to ceftriaxone but resistance to penicillin. Ceftriaxone was then added to the patient's regimen at 2 g intravenously daily. Patient's clinical condition dramatically improved on day two antibiotics, and his repeat blood cultures on day two of antibiotics were negative. Patient completed four weeks of intravenous ceftriaxone. He was evaluated by our team two months later for extended spectrum E. coli urinary tract infection, and his blood cultures were negative.