Case report:
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.