A 37-year-old woman with increasing confusion, shortness of breath, fever and chills.

The patient had a history of intravenous drug use complicated by tricuspid valve endocarditis due to methicilin-sensitive Staphylococcus aureus (MSSA) two years prior to admission.

In 02/1/03, she was again diagnosed with endocarditis at an outside hospital. Nafcillin and gentamicin were started. A cardiac catheterization revealed 70% occlusion in her distal left anterior descending coronary artery. Her hospital course was further complicated by an inferior wall myocardial infarction, aortic valve vegetation and septic emboli to spleen, lung and brain. She was then discharged home on intravenous antibiotics via a long-term peripheral intravenous line. On 02/28/03, she presented to the emergency room at The Johns Hopkins Hospital with complaints of shortness of breath, fevers and chills along with increasing confusion.

Hepatitis C
Gonorrheal cervicitis
Menometrorrhagia
Benign breast mass
Low back pain secondary to T7 and T8 disc herniation

None

Noncontributory

She is single. She has a history of 20-pack-year smoking. She drinks three beers a day. She injects heroin and cocaine.

Nafcillin
Hydralazine
Nitroglycerin
Lasix
Haldol
Epogen
Sliding Scale Insulin
Omeprazole

NKDA

Non-contributory

* General: in mild respiratory distress
* Vital signs: T 38.5, BP 85/40, HR 124, RR 22, 96% oxygen saturation on 2 L O2.
* HEENT: WNL except poor dentition
* Heart: Jugular veins visible to the jaw with a prominent ‘v’ wave, regular rate, PMI displaced laterally, 2/6 holosystolic and 3/6 diastolic decrescendo murmur (best heard at the apex). Pulses thready
* Lung: bilateral rhonchi, decreased breath sounds at both bases
* Abdomen: Bowel sounds positive, soft without masses, no enlargement of liver or spleen
* Extremities: 2+ edema to her thigh bilaterally
* Neurological: oriented to person, but confused. Unable to fully cooperate with detailed examination, intact strength grossly, symmetrical reflexes and cranial nerves

* WBC 9560, Hgb 11, Hematocrit 32%, Platelets 318
* Blood potassium 5.0 meq/L, Na 135 meq/L, Cl 100 meq/L, HCO3 12 meq/L.
* Serum creatinine 1.5 mg/dl, BUN 26 mg/dl, glucose 44 mg/dl
* Blood ammonia 99 umol/L (0-32), lactic acid 16.9 mmol/L (0.5-2.2),
* Lipase (11 U/L on 02/28/03, 428 U/L on 03/01/03)
* APTT 50.6-61.3 S, PT 25.2 S, D-dimer 46.81 mg/L, fibrinogen 165 mg/dl
* Urine protein semiquantitation: > 3+
* Blood culture: pending

The patient had multifocal peripheral inflammatory nodules with cavitation in her lungs on her prior chest CT of 12/00 (Image 1). Chest CT on 3/1/03 showed multiple inflammatory nodules in both lungs with evidence of cavitation (Image 2a and 2b), similar in character to those seen in 12/00 (Image 1) but differing in size and site. There now were also bilateral pleural effusions. Brain MRI on 03/06/03 showed multifocal ring-enhancing lesions at the gray- white junction distributed both supra- and infra-tentorially (Image 3).

On admission the intravenous line was removed and she was started on broad spectrum antibiotics. She improved clinically until 03/16/03 when she suffered a pulseless electric activity cardiac arrest after complaining of worsening shortness of breath that came on suddenly. She was resuscitated with fluids and epinephrine and transferred to the intensive care unit. Due to her dismal prognosis, her family requested a DNR order. She expired one day later.