Case Presentation
A 47-year-old male presented with a 5-day history of nonproductive cough, fever, chills, shortness of breath, and pleuritic chest pain. He has a medical history of non-insulin-dependent diabetes mellitus type 2. He denied nausea, vomiting, diarrhea, abdominal pain, headache, recent travel, recent dental procedures, alcohol use, smoking, and recreational drug use. Vital signs were stable on admission. On a physical exam, he was ill appearing, diaphoretic, tachypnic, and in respiratory distress using accessory muscles. Laboratory values were significant for these elevated values: WBC 27,930 (reference range 4,800-10,800/mcL ), CRP 208 (reference range 0-5.0 mg/L), Procalcitonin 1.11 (reference range .02-0.10 ng/mL), Ferritin 2,568 (reference range 30-400 ng/mL). Initial chest x-ray revealed multilobar pneumonia and large right-sided pleural effusion (Image 1). Further investigation with a CT of chest/abdomen/pelvis with contrast revealed a large empyema and multiple hepatic abscesses (Image 2,3). Before starting broad-spectrum antibiotics the empyema and hepatic abscess were drained and cultures grew streptococcus intermedius and the patient continued on 2 g of IV ceftriaxone daily. On the day of discharge, the patient lost balance while walking and sustained a fall after which a non-contrast head CT was obtained and identified multiple basal ganglia and right occipital lesions, with a follow-up MRI brain that confirmed ring-enhancing lesions concerning brain abscesses (Image 4). These lesions were deemed inaccessible by neurosurgery and then treated as a hematogenous spread of streptococcus intermedius in the setting of recent bacteremia with 2 g of IV ceftriaxone twice a day, 500 mg of metronidazole every 8 hours, and 1000 mg of vancomycin twice a day. Follow-up imaging confirmed the lesions to have decreased in size before discharge after 8 weeks of antibiotics. He was discharged on 875 mg of Augmentin twice daily for two months.