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.