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Occult manifestations of bacteraemia in an 82 year old woman

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6807 (Published 24 November 2014) Cite this as: BMJ 2014;349:g6807
  1. Craig Gouldthorpe, fifth year medical student1,
  2. David Heseltine, consultant in elderly medicine2
  1. 1Hull York Medical School, University of York, York YO10 5DD, UK
  2. 2York District Hospital, York, UK
  1. Correspondence to: C Gouldthorpe hycg{at}hyms.ac.uk

An 82 year old woman presented with breathlessness, increasing confusion, and a feeling of being generally unwell for the past two weeks. As well as a cough—productive of clear sputum—and dysuria, she also reported pain in her right rib on admission.

Her medical history included hypertension, osteoarthritis, hypothyroidism, and polymyalgia rheumatica, for which she was taking 10 mg prednisolone a day. Two years earlier she had been treated for venous leg ulcers, which were positive for meticillin resistant Staphylococcus aureus (MRSA).

On examination she did not have a fever, appeared pale, and had dry mucous membranes. Her respiratory rate was 18 breaths/min with oxygen saturations of 96% on air. Both lung bases were dull to percussion and reduced breath sounds were noted. No additional heart sounds were noted and nor were there any signs of infective endocarditis. Furthermore, she had no ulcers on presentation.

Initial investigations showed a raised white cell count (17.1×109/L; reference range 4.0-11.0), raised urea mmol/L (9.5; 2.5-7.8), raised creatinine (142 µmol/L; 49-90), and raised C reactive protein (2657 nmol/L; 0-76.2). A midstream urine specimen was negative for micro-organisms. and chest radiography showed no focal consolidation. Subsequent blood cultures were positive for S aureus, sensitive to flucloxacillin and resistant to penicillin. Paraspinal abscesses were detected on magnetic resonance imaging (fig 1).

Questions

  • 1. What are the common sources of Staphylococcus aureus bacteraemia?

  • 2. What investigations would you consider in the management of this patient?

  • 3. What are the management options of S aureus bacteraemia?

Answers

1. What are the common sources of S aureus bacteraemia?

Short answer

S aureus bacteraemia commonly arises from skin and soft tissue infections and indwelling venous catheters. It can also arise from pneumonia, endocarditis, or deep seated foci.

Long answer

S aureus commonly colonises the skin and mucous membranes. Although it is usually harmless, it can result in bacteraemia.1 The organism is …

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