CASE PRESENTATION
A 63-year-old Caucasian female with past medical history of osteoporosis
on actonel and no prior hospitalizations, presented to the Emergency
Department (ED) on January 25, 2020 with complaints of fever of 101.1 F,
polyarthralgia, myalgia, and diffuse weakness. Patient admitted to
performing an intense cross fit workout four days prior, leading to
diffuse myalgias in upper and lower extremities associated with chills
and shaking at night. This ED visit was preceded by a visit to urgent
care, a day before for similar symptoms. Radiography of the right
shoulder was negative for fracture. She was prescribed toradol for the
diffuse myalgias and severe right shoulder pain. Since then the myalgias
had worsened with additional finding of decreased urine output causing
her to present to the ED. Associated symptoms included fever, chills,
decreased activity, weakness, decreased urine output, and dark colored
urine. She denied any prior instance of a similar episode. Patient also
denied any recent trauma, travel, any new exposures, or any sick
contacts. Patient is up to date on her vaccinations. Review of systems
was negative for rhinorrhea, chest pain, shortness of breath, nausea,
vomiting, abdominal pain, diarrhea, dysuria, swelling, numbness, and
tingling. No pertinent family history of arthritis or skin disease.
Patient is an elementary school teacher who participates in regimented
workout routines and exercise bootcamps. Patient reported allergy to
Penicillin. Vital signs were blood pressure of 99/55, heart rate of 89,
respiratory rate of 18, and temperature of 101.1 F. Physical exam on
admission revealed no rashes or skin lesions, muscle strength was 5/5
bilaterally in upper and lower extremities, sensation was intact
peripherally, and cranial nerves were grossly intact. Positive findings
included tenderness to palpation of the bilateral calves and upper
extremities. Patient also noted right posterolateral shoulder pain
radiating to the proximal arm, worse with overhead movement, abduction,
and external rotation with adduction. Pertinent labs showed no
leukocytosis. Hematocrit of 36.4% and mean corpuscular volume of 89 fl.
AST and ALT were elevated at 163 and 186 respectively. Lactic acid was
1.6 mmol/L, C-reactive protein was elevated at 22.5 mg/L and ESR was 35.
Elevated creatine kinase of 322 U/L. Normal magnesium of 1.7 mEq/L and
phosphorus of 2.2 mg/dL. Urine analysis (UA) showed pyuria of 12 white
blood cells with moderate blood. UA was negative for glucose, bilirubin,
ketones and nitrates. Chest radiograph showed no acute disease. X-ray of
the right shoulder showed mild degenerative changes of glenohumeral
joint. Transesophageal echocardiography was negative for vegetations,
electrocardiogram showed sinus tachycardia, and magnetic resonance
imaging showed no evidence of osteomyelitis. Tests for lyme disease, andInfluenza A&B showed negative findings. Blood culture
showed growth of gram-positive bacteremia in chains, later found to beGroup C Streptococcus .
The patient was admitted to inpatient services with a diagnosis of
sepsis secondary to gram positive bacteremia. On the day of admission,
her sequential organ failure assessment (SOFA) score was 3 with
thrombocytopenia and hyperbilirubinemia. On day 2 of hospitalization,
infectious disease favored the diagnosis of Right arm and forearm
cellulitis with gram positive bacteremia. Clinical exam showed edema,
erythema, and significant warmth in her right upper extremity.
Tenderness to palpation was also noted to the right lower extremity
below the knee. On day 3 of hospitalization, the general floor nurse
noted expansion of rash with a new cutaneous finding on the left arm and
left lower leg. Patient denied any pruritus of the new rash. Physical
exam revealed oval shaped macular rashes throughout arms and legs
bilaterally with warmth and tenderness to palpation (Figure 1 ).
Decreased active and passive range of motion was also noted bilaterally.
Patient was admitted to the intensive care unit (ICU) with concern of
necrotizing fasciitis. Further imaging revealed no emphysema tracking up
fascial planes or rim enhancing abscess and no crepitation on palpation
made necrotizing fasciitis unlikely.
The provisional diagnosis was Group C streptococcus bacteremia
associated with diffuse myalgias and cutaneous manifestations. Treatment
was initiated with vancomycin, flagyl and cefepime which was switched to
doxycycline and ceftriaxone due to suspicion for lyme disease and
positive growth for gram positive cocci in chains. With this course of
antibiotics patient’s clinical symptoms began to improve. Six days later
the rash started regressing and the patient reported subjective relief
of pain. On the day of discharge, the patient was afebrile and reported
almost complete resolution of pain and rash. No leukocytosis was found,
and repeat cultures were negative for growth. Transmitinits also
resolved. Patient was discharged from the hospital in stable, improved
condition. Patient was switched to oral ceftin to complete the
antibiotic course.