CASE REPORT
A 69-year-old man presented to the emergency room with back pain and
uncontrollable shaking. His past medical history was significant for
metastatic renal cell carcinoma, a penicillin allergy, and surgical
history of small bowel obstruction two weeks after undergoing transverse
colostomy and one week post-renal biopsy. On physical exam, the patient
was confused and found tachycardic, tachypneic, hypotensive, and
febrile. Pertinent labs included lactate of 8mmol/L (0.5-2.2 mmol/L),
initial hemoglobin of 10g/dL that fell to 7.7g/dl (11.5 - 15.5 g/dL),
and a WBC count of 16,000/mL (4,500-11,000/mL). CT scan showed a left
necrotic, hemorrhagic renal mass invading the adjacent splenic flexure
of the colon. Invasion of the pancreatic tail and left adrenal gland
with distal splenic vessels coursing through the mass could also not be
excluded (Figure 1). The patient received one dose of aztreonam,
vancomycin, metronidazole, and levofloxacin in the emergency department.
Piperacillin/Tazobactam was not used given the patient’s history of
penicillin allergy.
After the patient was admitted to the intensive care unit for septic
shock, he was treated with an antibiotic regimen of vancomycin,
cefepime, and metronidazole. On day 2, the patient’s WBC count increased
to 49,000/mL (4,500-11,000/mL) and his procalcitonin was elevated to
>100ng/mL (<0.25 ng/ml). Blood cultures
identified Clostridium sordellii as the causative organism, and
vancomycin was switched for clindamycin while meropenem was continued.
Over the next week, subsequent blood cultures showed no growth and the
patient’s clinical status stabilized. The antibiotic regimen was
switched from meropenem to ertapenem for two weeks upon discharge,
followed by oral clindamycin to continue for chronic suppression of the
infection until resection of renal mass. Due to his cancer and dementia
progression, his family chose to pursue hospice care soon after the
hospital discharge.