An 8-year-old male, with no relevant clinical history, who consulted the service due to a clinical picture of fever up to 39.5°C of 14 days of evolution, chills, bilateral emergency cervical lymphadenopathy and skin,
She had been treated with 500 mg of methotrexate per day for five days.
Physical examination revealed a grade II/III systolic murmur at the auscultatory focus corresponding to the left ventricle.
Electroencephalogram and chest X-ray showed no pathological findings.
Laboratory tests showed the presence of inflammatory markers: leukocytes of 10,500 cells/ml, neutrophilia of 70% and elevated CRP (119 mg/L).
Cefuroxime IV was started.
200 mg/kg/day before taking serial blood cultures on two consecutive days.
Both hemocultives were positive 24 hours after placement.
Gram stain revealed "V" Gram-positive bacilli.
The direct identification of the microorganism from positive blood cultures by mass spectrometry MALDI-TOF was C. pseudodiphtheriticum.
In this context, an echocardiography was performed, which showed the existence of a vegetative formation of 10 mm on the left ventricular side, causing moderate insufficiency, with no impact on hemodynamics and cardiac function.
A bicuspid aortic valvulopathy was also observed.
With the diagnosis of infective endocarditis, gentamicin (6 mg/kg/day) was added to therapy pending the definitive identification of the microorganism and its antimicrobial susceptibility profile.
After 24 h of inoculation in solid culture media, growth of grey colonies in positive blood agar plates catalase was observed.
Identification by 16S RNA gene sequencing confirmed the isolation of C. pseudodiphtheriticum.
Antibiogram with vancomycin (E-test) showed resistance to ciprofloxacin (0.CIidM > 256 μg/ml) and sensitivity (CIM) to amoxicillin/ml. clavulme penicillin μg/ml).
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The patient had a favorable clinical course, remitting her fever within 48 hours of starting the combined antimicrobial therapy.
Given its good evolution, having negativized the hemocultives and without imaging changes, cardiac surgery was not proposed at that time, unless there was any clinical deterioration.
At 16 days of hospitalization, the patient developed a new fever associated with frontal headache, disorientation and poor motor tone, which resulted in right brachial paresis, right hemiparesis and aphasia.
The clinical picture was interpreted as a septic cerebral embolism.
Linezolid was added to antimicrobial treatment due to possible overinfection by resistant microorganisms in some other source.
Because of the risk of a new embolism, cardiac surgery was performed on the aortic valve territory (Ros procedure), which was successfully overcome.
On the third postoperative day the patient developed intracranial hypertension.
Magnetic resonance imaging of the brain revealed an ischemic infarction due to occlusion at the origin of the left middle cerebral artery.
Due to its severity, the patient died in the following days.
The final microbiological results confirmed the isolation of C. pseudodiphtheriticum in the blood cultures.
