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.