Fever and haemoptysis in an injecting drug user

A 24 year old man presented with a 10 day history of fever, night sweats, weight loss, and a productive cough with occasional haemoptysis. He had a history of injecting drug use. He was on a community methadone replacement programme for opiate dependency. On examination, he had a fever (39.4°C), hypotension, and tachycardia. He had a few needle track marks in both antecubital fossae. Coarse crackles were heard throughout both lung fields, although oxygen saturation was 97% on room air.

Blood tests showed: white cell count 19.8×10⁹/L (reference range 4-11), C reactive protein 186 mg/L (<10), urea 15.5 mmol/L (2.5-6.7), and creatinine 210 μmol/L (70-100). Urine dipstick was positive for blood.

Plain chest radiography showed multiple, round, ill defined areas of consolidation throughout both lung fields, with loss of the cardiac silhouette at both the right and left heart borders, as well as bilateral blunting of both costophrenic angles to the lower zones. No hilar or mediastinal lymphadenopathy was noted. He was started empirically on intravenous benzylpenicillin and oral clarithromycin for presumed severe community acquired pneumonia (as per local hospital guidance). His methadone prescription was confirmed with community drug services and the dose corrected for his renal function. Sputum culture was unremarkable and was negative for acid and alcohol fast bacilli. Serology for HIV and autoantibodies was negative. Two consecutive blood cultures grew Staphylococcus aureus.