Lactococcus Septicemia With Perihepatic Fluid Collection in End-Stage Renal Disease Patient

Abstract

A 38 year old African American male presented to the emergency room with complaints of having chills, fever, and shortness of breath. His past medical history was significant for sickle cell disease SS-type, end-stage renal disease dialysis dependent, diastolic congestive heart failure, and hemochromatosis. The patient stated that while receiving dialysis he started having the above symptoms. Blood cultures were taken at the dialysis center, and he was administered vancomycin and gentamicin. His temperature was recorded as 101.1, and he was hypotensive. The patient also admitted to gradual onset of abdominal pain, primarily on the right side and dull in nature;also, he had productive cough and rhinorrhea that started 3 to 4 days prior to admission. Of significance, this patient was in a hospital 2 weeks prior for symptomatic anemia and shortness of breath. He was admitted for severe sepsis perhaps secondary to healthcare-associated pneumonia and transaminitis possibly secondary to hemochromatosis vs hypoperfusion due to sepsis. He received hemodialysis, additional blood cultures were drawn, and placed on broad spectrum antibiotics, which included vancomycin, zosyn, and levofloxacin. Chest x-ray showed cardiomegaly and increased interstitial markings likely related to cardiac decompensation. CT abdomen and pelvis without contrast showed airspace opacity in the right lung base, enlarged liver with nodular contour compatible with cirrhosis, moderate amount of loculated perihepatic collection, and a calcified failed right sided kidney transplant. Laboratory data included a white blood cell count of 62,700, neutrophil percentage of 90.1%, and 14% bands on manual differential. Lactic acid 4.3 mm/l, procalcitonin 91.46 ng/ml, ammonia 64 μM/l. The patient's hepatic panel showed an albumin of 2.7 gm/dl, alkaline phosphatase 193 mu/ml, alanine transaminase 98 mu/ml, aspartate transaminase 242 mu/ml, direct bilirubin 5.9 mg/dl, and total bilirubin 10.9 mg/dl. The patient had a CT-guided drainage of the inferior perihepatic fluid collection. Approximately 200cc of amber colored fluid was removed and a drainage bag was placed. Fluid analysis and chemistries were consistent with exudative process. Infectious diseases was consulted for documented blood culture positivity for Lactococcus and Escherichia coli, with recommendation to continue vancomycin and zosyn, discontinue levofloxacin, and send perihepatic fluid for gram stain, culture, and cytology. The patient's fevers resolved and his white blood cell count continued to trend downwards from a peak of 62, 700. He was transferred from the medical intensive care unit to the medical floor for further management.