A young woman with urinary symptoms, septicaemia and a pectoral muscle abscess.

Abstract

Apreviously healthy 18-year-old woman was admitted to a medical ward with a 5-day history of lower abdominal pain, dysuria and fever. She had no past history of urinary tract disease. Her GP sent a urine sample for analysis at the onset of symptoms. Urine microscopy showed pus cells and culture revealed a positive growth of coliforms (>105/ml), sensitive to penicillin. The patient was given oral amoxycillin but her symptoms worsened. Hospital admission was therefore arranged. On admission her temperature was 38.7°C and she was dehydrated with suprapubic tenderness. There was no lymphadenopathy and chest examination was normal. Her haemoglobin was 10.3 g/dl, white cell count 7.75x109/litre and platelet count 110×109/litre. Liver function tests revealed a bilirubin of 67μmol/litre (normal range 5–17μmol/litre), alkaline phosphatase 140 IU/litre (normal range 20–90 IU/litre), alanine aminotransferase 238 IU/litre (normal range 5–40 IU/litre) and gamma glutamyl-transferase 105 IU/litre (normal range 0–40 IU/litre). Electrolytes, urea and creatinine were normal. She was treated initially with intravenous cephradine. Repeat urine examination demonstrated a sterile pyuria: microscopy showed pus cells but urine culture was negative. Anaerobic blood culture was positive for gram-negative rods after 1 day. Chest X-ray revealed multiple soft shadows throughout both lung fields. Computed tomography scan of the chest and abdomen showed multiple cavitating nodules in both lung fields (Figure 1), and multiple gas bubbles in the left pectoral muscle consistent with abscess formation (Figure 2). The pectoral muscle abscess was drained under ultrasound guidance and gram-negative rods were cultured from pus. Cultures from blood and pus were subsequently identified as Fusobacterium necrophorum using a Biomerieux (Basingstoke, Hampshire) rapid ID 32A kit. The patient made a full recovery with 10 days of treatment with intravenous metronidazole, benzylpenicillin and meropenem. The presumed source of primary infection was the urinary tract with metastatic abscesses arising in the lungs and pectoral muscle.