Female, 6 years old, 4 months old, eutrophic, living in extreme rural conditions, in the Peninsula Illahuape, Lago Ranco, Xa Region of Los Lagos
With no known morbid history, one month before his hospitalization he presented a high respiratory condition that was treated with symptomatic measures.
Ten days before admission she consulted in a rural clinic for fever, general malaise and abdominal pain of a week of evolution, where a urinary infection was diagnosed by dipstick oxazole starting treatment with cotrim.
Five days later she was evaluated in the outpatient clinic for fever and vomiting, changing her treatment to amoxicillin.
Sensing impairment, loss of language, paresthesia and decreased mobility of the right hemibody and sphincter incontinence were observed, and the patient was referred to the Hospital de Río Buenovia as an emergency.
She was admitted with severe, pale, poorly perfused, febrile T° ax 38.5°, pulse 120 x min, blood pressure 95/77, O2 saturation 96% (with oxygen supply 3 lts/min).
Neurological examination revealed impaired consciousness (Glasgow 10), psychomotor agitation, myotic pupils, neck stiffness, meningeal signs and right hemiparesis fascio-brachyo-crural.
Cardiac examination revealed a hyperdynamic beat visible throughout the precordial area and a 3/6 holosystolic murmur widely irradiated to the axilla and dorsum.
Lumbar puncture gave rise to opalescent CSF, whose cytochemical showed proteins 1g/lt, glucose 34 mg/dl, leukocytes 452/mm3 predominantly mononuclear, absence of bacteria in Gram stain and negative culture.
In two hemocultives S. pneumoniae was isolated whose susceptibility study by plate diffusion (Kirby Bauer) revealed resistance to penicillin.
The subsequent report of the ISP (National Indication of Drug Reaction) confirmed S. pneumoniae serotype 14 with intermediate resistance to penicillin (MIC 1 μg/ml) and susceptibility to third generation cephalosporins 0.5 μg.
The patient was managed in the ICU with volume support, ventilatory support, vasoactive amines and ceftriaxone ev (100 mg/kg/day) associated with vancomycin ev (60 mg/kg/day) from day 1.
The control CSF at 24 hours showed a negative x-ray appearance, with proteins 0.82 gr/lt, glucose 38 mg/dl, leukocytes 170/mm3 (35% PMN and 65% MN), and
Chest X-ray revealed mild cardiomegaly without consolidation image and brain CT ruled out collection, hydrocephalia and focal lesions.
Cardiological evaluation with 2D-echocardiography documented the presence of a vegetation of 1.5 x 2.0 cm in the posterior mitral leaflet, left ventricular dilation, mild periventricular defect, moderate mitral regurgitation echo.
Treatment with digoxin and furosemide was indicated.
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The control blood cultures obtained on the seventh day of treatment were negative.
The neurological outcome was favorable.
The patient presented an intense and generalized erythematous rash erythrodermy-type, associated with 34% hypereosinophilia (RAE = 10.166/mm3) that did not revert with the administration of corticosteroids and antihistamines.
Pathologists evaluated it as an adverse drug reaction, presumably secondary to the use of cephalosporins, and ceftriaxone was suspended on the tenth day of treatment.
Continued with vancomycin and rifampicin was added; coincident with this adjustment skin involvement was exacerbated, with rifampicin being withdrawn on the fourth day and adding amikacin.
She remained febrile for 23 days.
Serial echocardiographic control showed persistent vegetation, moderate dilation of left cavities and perforation of the posterior leaflet of the mitral valve.
The surgical resolution of endocarditis was then proposed, achieving control of the infectious process.
Elevated liver enzymes (ALT, AST, alkaline phosphatase)
On the 51 day of hospitalization, the patient presented pain in the left popliteal region with pulses diminished distally.
A Doppler ultrasound confirmed the existence of an obstruction of the left tibioperoneal trunk.
On the 56th day of evolution, 2D-echocardiography showed mild vegetation decrease, left ventricular dilatation with good contractility, significant mitral regurgitation and tricuspid regurgitation.
Brain CT scan was normal, while fibrinogen, D and CRP remained elevated.
Located to the Cardiology Center of Luis Calvo Mackenna Hospital to perform cardiosurgery, having completed 61 days with vancomycin and 10 days with amikacin.
The vegetation was resected and the posterior leaflet of the mitral valve was repaired with pericardial patch and the peripheral vascular clot was removed.
The residual mitral valve was successfully repaired, with minimal mitral insufficiency. Only one control was performed in our hospital after discharge.
