A 65-year-old male with a history of stage III a squamous cell carcinoma of the lung undergoing induction chemotherapy (carboplatin, paclitaxel and concurrent pulmonary radiotherapy).
She was admitted fifteen days after the last chemotherapy session for fever of 39°C associated with bilateral thigh pain.
Ultrasound and computerized axial tomography (CAT) of both hips were performed with contrast agent and a discrete pinching of both hips was performed with consolidation of the articular fluid and soft tissues.
An increase in acute phase reactants was observed in the laboratory: CRP: 331 mg/L (reference value up to 5 mg/L) and ESR: 100 mm (reference value up to 10 mm).
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With these clinical, imaging and laboratory findings, septic arthritis of the hip was diagnosed.
Puncture and drainage of joint fluid was performed with samples sent to culture and empirical antimicrobial treatment with piperacillin-tazodone was initiated at usual doses.
A gram-negative bacillus identified by mass spectrometry (MALDI-TOF) as Salmonella spp. was developed in the hemocultives and in the sample of joint fluid.
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According to the microbiological result, treatment was adjusted to cotrimoxazole 800/160 mg IV every 12 h associated with amikacin 500 mg IV.
The antimicrobial susceptibility study by diffusion method was sensitive to penicillins, ampicillin, cotrimoxazole, piperacillin-amika, ceficoxime-sulphate resistant, ampicillin.
Serotyping was performed in the Service of Malbrán Institute according to the Kauffman-White scheme, identifying the extended spectrum CTMrium genotype, with production of βMido-White (SE-14X).
The patient was implanted with persistent positive hemocultives after five days of antimicrobial treatment and the venous catheter was removed.
Antibacterial treatment was adjusted to monotherapy and intravenous administration.
A transesophageal echocardiogram confirmed a cottony image on the ventricular face of the coronary valve in the aortic valve without signs of valve insufficiency, which was interpreted as infectious endocarditis.
Due to persistent pain and increased joint fluid, a new surgical drainage of both hips was performed, which resulted in seropurulent material.
A drainage catheter was placed and analgesia with nonsteroidal anti-inflammatory drugs and corticosteroids was optimized.
Clinically stable, with a decrease in acute phase reactants (CRP: 48 mg/L) and clearance of bacteremia.
The patient was managed conservatively with an indication of completing six weeks of treatment with prednisone at home.
Ten days later the patient was re-operated due to fever, joint pain, increased CRP: 108 mg/L and leukopenia (1,950 cells/mm3; 52% neutrophils).
Neutropenia was interpreted as secondary to medullary toxicity due to myeloids, which had been suspended from the antibiotic.
Ultrasound of both hips showed increased joint fluid, so a new surgical drainage was performed.
Due to the persistence of Salmonella spp. in the culture of joint fluid, continue treatment with prednisone.
A control transesophageal echocardiogram showed no valvular dysfunction or other cardiac complications.
Ambulatory treatment continued, with maximum duration of treatment due to a history of relapse.
After six weeks of daily i.v. treatment at maximum dose, good adherence, and with joint fluid culture without bacterial development, she was treated with supresor plus tapering three weeks later.
During outpatient follow-up, the patient developed pneumonia associated with health care, without bacteriological isolation and acute respiratory distress syndrome, which led to his death.
