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case_images: Clinical manifestations of the patient. (A). Day 1, Large purple patches presented on both lower limbs; (B). On day 8, direct bedside ultrasound suggested left intracervical thrombosis (red arrow); (C). MRI revealed patchy abnormal signal foci in the pons, suggesting central pons myelinolysis (red arrow); (D). On day 1, Chest CT showed multiple nodules and mass shadows in both lungs and pleural effusion on both sides; (E). On day 7, CT revealed multiple new cavitary lesions bilaterally, right hydropneumothorax, and left pleural effusion; (F). On day 26, the pulmonary infection was significantly reduced; (G). On day 26, the ecchymosis of lower limbs receded.
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case_images: Five days later, the patient's condition continued to worsen, with high fever (38.1-39.3 C), chest pain, shortness of breath, heavy sweating, yellow staining of skin and sclera, and large purple patches on both lower limbs (Figure 1). CT showed multiple nodules and mass shadows in both lungs and pleural effusion on both sides (Figure 1). Considering his pulmonary condition, bronchoscopy and closed thoracic drainage were performed, and both bronchoalveolar lavage fluid(BALF) and pleural drainage fluid were obtained. Day 7, repeat CT scan of the chest for follow-up revealed multiple new cavitary lesions bilaterally, right hydropneumothorax, and left pleural effusion (Figure 1). On day 8, direct bedside ultrasound suggested left internal jugular vein thrombosis (Figure 1). Magnetic resonance imaging (MRI) of the skull base suggested patchy abnormal signal foci in the pons, suggesting central pons myelinolysis (Figure 1), which was suspected to be a rare central nervous system damage (long-lasting cranial nerve palsy) caused by LS. Day 26, plasma mNGS testing was negative (Figure 2), the patient's circulatory condition stabilized, the pulmonary infection improved, and the ecchymosis of lower limbs receded (Figure 1).
case_images: The sequence characteristics of Fusobacterium necrophorum (Fn) detected by mNGS and the bacterial load changes during the treatment of the patient. (A). Changes of four infection related host response factors and the sequence number (RPM value) of Fn detected by plasma mNGS at different times. (B). On day 3, distribution of the sequences of Fn detected by plasma mNGS on the reference genome. (C). On day 3, distribution of the sequences of Fn detected by BALF mNGS on the reference genome.
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case_images: BALF mNGS testing, with the normalized reads per million reads (RPM) of 32,115 and 670,377, respectively (Figure 2). Based on clinical evaluation and the fact that Fusobacterium is an anaerobe, the antibiotic strategy was adjusted to metronidazole (500mg, Q6H), meropenem (1g, Q8H) and cefazolin (2g, Q8H). Fn was again detected in the plasma mNGS testing performed on the same day, with a decreased RPM value (RPM=312) compared to that of first test (RPM=32,115) (Figure 2). PCT and CRP) and bilirubin continued to decrease, the platelet counts increased and liver and kidney function gradually recovered. Plasma mNGS performed on that day showed that the RPM value (RPM=71) of Fn was significantly lower than before (Figure 2). Day 26, plasma mNGS testing was negative (Figure 2), the patient's circulatory condition stabilized, the pulmonary infection improved, and the ecchymosis of lower limbs receded (Figure 1).
case_images: Brief review of the clinical course of the patient.
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case_images: The patient's medical history is shown in Figure 3.