The patient was a 27-year-old male who had suffered a pneumonia while he was a child and was not a smoker, and did not have alcohol consumption.
He was diagnosed with extrinsic bronchial asthma and allergic rhinoconjunctivitis with hypersensitivity to grasses and olives.
Claiming treatment with inhaled corticosteroids
After a major physical effort (going from the shore in a procession during local holidays and sleeping very little) in the summer of 2003, he started with pain in the right upper limb irradiating to the right hemithorax.
Later he had fever and dysneic sensation, so he came to the hospital emergency department.
The clinical examination at admission revealed a poor general condition and a destructive stage lesion in the abdominal wall that could correspond to a furuncle.
The vesicular murmur was diminished at the right base.
Cardiac and neurological examinations were normal.
There were no organomegaly.
The patient presented leukocytosis (from 12,000 /mm cup to 18,700/mm guinea pig) with neutrophilia, and the rest of the symptomatology was within normal limits.
Jaundice
Creatinine increased during admission to 1.6 mg/dl and urea to 61 mg/dl Other biochemical values were: total bilirubin: 2.19 mg/dl, direct fraction: 1.33 mg/dl alkaline phosphatase: 687 IU/dl
The sedimentation rate was 71 mm in the first hour.
Serology for HIV and hepatitis B and C virus were negative.
Serial blood cultures were performed and tested positive for Staphylococcus aureus methicillin sensitive.
Transthoracic echocardiography showed normal images without pericardial effusion.
Ten days after the patient was admitted to the hospital, she had an erythematous, hot lesion in the right-hand culture, which disappeared into the digitopressure and was about 5 x 5 cm in size. Spiritis aureus was also positive.
Abdominal ultrasound was normal.
The chest CT scan showed a left pleural effusion with interstitial prominence.
Three small nodular images were observed in the right upper lobe, left upper lobe and another of subpleural location smaller than one centimeter compatible with small staphylococcal abscesses Fig.
Abdominal CT was normal, with no lymphadenopathy or fluid in the free cavity.
Bone scintigraphy showed intensely increased osteogenic activity at the level of the joint consistent with arthritis at this level.
A MRI of the sternum was performed.
There was gadolinium in the manubrium joint with the body extended to half of the manubrium and the proximal third of the body, as well as posterior captures, bl tissues and increases in size.
These findings were compatible with arthritis at this level and very suggestive of osteomyelitis.
There were no signs of bone destruction.
The clinical course was good with antibiotic treatment consisting of intravenous cloxacillin (IV) for 15 days at a dose of 2 g/ 6 hours and IV gentamicin for 7 days at a dose of 5 mg/kg/24 hours.
None of the patients required intensive care.
Subsequently, the patient was treated with oral rifampicin (doses of 600 mg/24 h) and levofloxacin (doses of 500 mg every 24 h) for two months.
The dermal lesion resolved five weeks later.
To rule out the existence of a primary immunodeficiency, a screening was performed with the following results: complement levels, lymphocyte subpopulations and markers, oxidative capacity of granulocyte expression and lymphocytic function markers.
Protective levels for specific IgG against tetanus toxoid, Haemophilus polysaccharide
Mildly elevated IgE and IgG4 levels were normal in the rest of immunoglobulins and IgG subunit levels (IgE = 170 IU/l, normal range: 0-100 IU/l; Ig normal G4 = 3.400 mg).
Isoglutinins titers could not be evaluated due to lack of samples.
This study was carried out with the patient being discharged and two months after the onset of the disease.
