Case 2, presented by Alana B. Levine, MD, describes a 70-year-old woman who was referred to the HSS Division of Rheumatology for a second opinion regarding polymyalgia rheumatica (PMR). One month prior to presentation at HSS, the patient developed a new non-painful, non-pruritic leg rash. Skin biopsy revealed leukocytoclastic vasculitis. At the time she was taking prednisone 5 mg daily which was increased to 40 mg daily, and the rash resolved. On presentation to HSS the patient complained of severe fatigue, nocturnal fevers to 101°F, night sweats, and anorexia with a 20 pound weight loss. The patient’s past medical history was significant for mitral valve prolapse and osteopenia. Her medications included methylprednisolone 4 mg daily, rabeprazole 20 mg daily, and calcium supplementation. After examination, the differential diagnosis at that time included systemic vasculitis, malignancy, and endocarditis. The patient was admitted for evaluation of acute renal failure. After multiple sets of blood cultures, the patient was started on broad spectrum antibiotics. A transthoracic echocardiogram showed severe mitral regurgitation with a 1.9 x 1.8 cm vegetation on the posterior mitral leaflet. Blood cultures grew gram-variable rods which were later speciated as Suttonella indologenes. Suttonella indologenes is a gram-negative rod-shaped bacteria found in normal respiratory tract flora but it has been known to cause endocarditis. Due to the size of the vegetation and severe mitral regurgitation, the patient was recommended for mitral valve replacement surgery.
Read full case details in Volume 5, Issue 2 of Grand Rounds - Complex Cases.
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