A 74-year-old retired man born in South Asia who moved to Sweden in his early twenties, presented to the ER with increasing dyspnea and retrosternal pain. Two days prior to admission the patient began experiencing generalized muscle pain, a headache, and mild retrosternal pain. The day before admission he developed a slight increase in his retrosternal chest pain and experienced dyspnea while walking. On the day of admission, the patient had dyspnea at rest and a retrosternal pain that led him to seek emergency care. The patient denied any fever, vomiting, coughing, diarrhea, or changes to micturition and no one in his environment was ill at the time.
The patient lived a healthy life with daily exercise, a healthy diet, and no current diagnosis or treatment. The patient had been treated and cured of tuberculosis at the age of 23 in his home country. He was a non-smoker and besides consuming 4 centiliters of whiskey to dinner every evening, he consumed a small amount of the Swedish tobacco of the mouth called "snus". He had no family history of cardiovascular events and his vaccination status was unknown.
The patient arrived at the ER and was evaluated according to ABCDE (Table 1). The patient's breathing rate was slightly increased and his blood pressure was low. The blood tests at admission were strongly suggestive of an infection and incipient sepsis: Creatinine: 220 mumol/L (ref<100), CRP: 435 mg/L (ref<5), leukocytes: 14.5 109/L (ref:3.5-5.5), troponin T: 172 ng/L (ref<5), lactate: 5 mmol/L (ref<2.3). This prompted bacterial cultures which later grew Neisseria meningitidis with a time to detection of 11.2 h (Table 2). Due to the retrosternal chest pain, an EKG was performed in the ER which showed generalized ST-elevations as well as a right bundle branch block (Fig. 1). The patient was rushed for a coronary angiography in order to rule out myocardial infarction (Fig. 2). A computed tomography scan was performed and showed no signs of lung embolus, pneumonia or damage indicative of his history of tuberculosis. There was however a small level of bilateral pleural effusion measuring 1.5 cm.
After the initial coronary angiography showed free flow and the laboratory values indicated an infection, the patient was placed on broad-spectrum antibiotics: piperacillin and tazobactam. When the blood cultures showed gram-negative cocci, the antibiotics were switched to cefotaxime for better coverage. When the resistance pattern arrived, the patient was switched to benzyl-penicillin.
The patient also exhibited signs of heart failure, such as pulmonary congestion and pitting edema of the legs, and thus received furosemide. Due to an increasing pericardial effusion causing early signs of cardiac tamponade (Fig. 3), the patient received a pericardiocentesis. The pericardial fluid was sent for PCR which was positive for meningococcus DNA. Cortisone and a proton pump inhibitor were administered to reduce complications of inflammation. The following day the patient developed abdominal pain. A CT-scan showed signs of intestinal perforation and the patient was switched to meropenem antibiotics and brought down for emergency surgery. The explorative surgery found a 2.5 cm large perforation by the duodenal bulb. The patient received stitches, an Omentpatch, and drainage. He was empirically placed on helicobacter pylori eradication therapy. Fig. 4 illustrates how c-reactive protein (CRP), leukocytes and Troponin T varied over the course of the hospital stay.
At three-month follow-up, the patient had just finished his colchicine therapy. The transthoracic ultrasound showed a slight dilatation of the ascending aorta, a slight insufficiency of the tricuspid and mitral valves, but was otherwise normal. The patient had to a large extent recovered from his illness.