A 78-year-old Man Presented with Knee Pain and Recurrent Fever

Abstract

<p>發燒為常見臨床症狀，本案例是一位78歲末期腎臟疾病接受長期血液透析治療男性，近一個月曾發生永久性透析導管感染合併金黃色葡萄球菌菌血症，此次因左膝關節疼痛就醫，理學檢查發現關節發熱腫脹，診斷感染性關節炎入院治療， 關節液及血液培養顯示金黃色葡萄球菌，在抗生素治療及行左膝切除關節成形術後仍反覆發燒， 經由專科護理師完整病史收集、全身理學檢查、實驗室檢驗結果，排除導管感染及心內膜炎等相關鑑別診斷，電腦斷層血管攝影顯示囊狀主動脈合併周圍積液確診為感染性動脈瘤。因年紀大合併多種慢性共病（塵肺症、慢性阻塞性肺病及末期腎臟疾病等），在家屬考量動脈瘤切除、結紮及血管重建手術利弊後決定採保守治療（6週Piperacillin-Tazobactam和Vancomycin抗生素靜脈注射療程），發燒及低血壓狀況改善，且血液培養亦未發現新的感染。臨床上，當病人主訴反覆發燒合併金黃色葡萄球菌菌血症時，根據我們的案例及文獻回顧，應強調以焦點式理學檢查積極探查可能的轉移性感染（包括：導管感染、軟組織感染、感染性關節炎、心內膜炎及感染性動脈瘤等），輔以影像學檢查。以此案例提升專科護理師於類似複雜案例時的照顧能力，利於醫療團隊即早確定診斷及介入治療，以降低延遲治療對於脆弱老年病人帶來負面影響。</p> <p> </p><p>Fever is a common symptom in clinical practice. A 78-year-old male with end-stage kidney disease (ESKD) who underwent hemodialysis was admitted due to left knee pain. Upon physical examination, there were signs of joint heat, swelling, and tenderness in addition to febrile state, suggesting a diag­nosis of septic arthritis. Staphylococcus aureus (SA) was later identified in both the synovial fluid and blood culture. However, the patient experienced recurrent fever despite receiving appropriate antimi­crobial treatment and undergoing left knee resectional arthroplasty. To rule out other potential diagno­ses related to SA bacteremia, a thorough evaluation involving medical history, physical examination, and laboratory tests was conducted. The computed tomography angiography revealed the presence of a saccular aortic aneurysm with perianeurysmal fluid collection, confirming a diagnosis of mycotic an­eurysm. The patient and his family carefully considered the advantages and disadvantages of surgical options, such as aneurysm excision, ligation, or vessel reconstruction. Under the considerations of the age and underlying comorbidities such as pneumoconiosis, chronic obstructive pulmonary disease, and ESKD, conservative treatment was performed (a 6-week course of intravenous piperacillin-tazobactam and vancomycin). The fever and hypotension gradually subsided, and there was no evidence of blood­stream infection. Based on our case and extensive literature reviews, it is crucial to actively evaluate metastatic complications, including infective endocarditis, catheter infection, septic arthritis, and my­cotic aneurysm, among patients who present with persistent fever and concurrent SA bacteremia. This case aims to enhance the abilities of nurse practitioners in conducting comprehensive assessments, providing vital information to the medical team, facilitating accurate diagnoses, timely interventions, and ultimately reducing the adverse impact of delayed treatment in vulnerable older adults.</p> <p> </p>