A 57-year-old female of European descent presented to our hospital with fevers and feeling unwell for two days prior to admission on a background of extensive metastatic stage (IV B) non-small cell lung cancer. She was receiving palliative radiotherapy to brain, chest and neck and had completed 6 cycles of carboplatin and etoposide chemotherapy. On examination, her temperature was 37.90C, she had a Glasgow Coma Scale of 15/15, her vitals were stable. However, she was clinically dehydrated with loud upper airway sounds heard on chest auscultation. A PICC line was present in the right upper arm. Infection markers, biochemistry and blood culture were sent. Investigations revealed anaemia (Haemoglobin: 87 g/L, Haematocrit: 0.26) and elevated white cell count (16.6/nL). The neutrophils showed left shift with moderate toxic changes (14.7/nL). C-Reactive Protein (CRP) had raised to 394 mg/L (Normal: <5mg/L). Biochemistry revealed features of acute kidney injury [estimated Glomerular Filtration Rate (eGFR): 50mL/min/1.73m2 and serum creatinine: 106 micromol/L]. Polymerase chain reaction test for Coronavirus disease-19 (SARS-CoV-2) was negative. Chest X-Ray showed an ill-defined confluent right upper lobe consolidation with coarse reticular markings. There was no evidence of pulmonary embolus on computerised tomography pulmonary angiography (CTPA). However, new metastatic masses were noted along with superior vena caval occlusion and enlarged mediastinal and hilar lymph nodes. Suspecting right sided pneumonia, Piperacillin/Tazobactam was advised and started along with intravenous fluids and her regular medications.

She had a Medical Emergency Team (MET) call on the second day of admission for tachycardia (Heart rate: 140s). No other symptoms and signs were noted. Sinus tachycardia was observed on electrocardiogram. Vital parameters were stable. Blood investigations were repeated, and metoprolol was added. Initial blood culture did not show any growth. However, the subsequent blood culture revealed Stenotrophomonas maltophilia and R planticola (from anaerobic bottle), with both being sensitive to Cotrimoxazole. Clinically, the patient was improving apart from the cough with minimal sputum production. No visible signs of infection were noted at the PICC line site. Inflammatory markers including CRP were trending downwards.

The Infectious Disease (ID) team was consulted. Piperacillin/Tazobactam was changed to oral Cotrimoxazole. Repeat blood cultures from two different sites were ordered. Renal functions were monitored. PICC was removed and the tip was sent for culture and sensitivity. Repeated blood culture report showed growth of R planticola – from the PICC line. However, the tip of PICC line did not reveal any growth. The ID team advised to continue oral Cotrimoxazole for 4 weeks.

She responded to treatment with Cotrimoxazole. However, her overall condition declined due to metastatic disease. Her condition deteriorated gradually; palliative team was involved for end-of-life care. She passed away comfortably in hospital after 6 weeks of admission on account of metastatic disease.