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A Cat-and-Mouse Game? Multiple Abscesses Due to Staphylococcus aureus Bacteremia

Published:November 24, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.10.027
      A 52-year-old woman with a history of atopic dermatitis presented at the hospital after experiencing back pain for 5 days and fever with shaking and chills for 1 day. She was distressed and disoriented upon examination. She also had a fever, tachypnea, tachycardia, and decreased oxygen saturation. There was tenderness in her posterior neck, mid lumbar region, and left shoulder. Laboratory tests revealed a significantly elevated C-reactive protein (CRP) level. A computed tomography (CT) of the chest and abdomen without contrast revealed bilateral iliopsoas abscesses (Figure 1A). Furthermore, magnetic resonance imaging (MRI) of the spine showed lumbar spondylodiscitis (L3/4/5/S1). She was initially treated with antibiotics alone without drainage, based on a discussion with the radiology and orthopedics team. Methicillin-sensitive Staphylococcus aureus was subsequently detected in the blood cultures. There were no septic emboli, heart murmurs, or vegetation on echocardiography. Positive blood culture and fever persisted despite treatment. A CT scan of the neck, chest, and abdomen was performed on day 5, which revealed new abscesses in the bilateral cervical long muscles and right scalene muscles (Figure 1B). However, these abscesses were not considered an indication for surgery. The abscess around the intervertebral space between L4 and L5 was drained percutaneously on day 6. Nevertheless, blood cultures were repeatedly positive until day 14. Furthermore, she had a persistent low-grade fever and left shoulder pain, with CRP higher than 15 mg/dL during the 2 weeks following day 14. New abscesses in the left supraspinatus muscle, left infraspinatus muscle, and left teres major muscle were found on imaging, including CT and MRI, performed on day 26 (Figures 1C and D). On day 29, she underwent drainage of the left subdeltoid abscess. Subsequently, her fever subsided, her CRP levels gradually decreased, and she was successfully discharged.
      Figure
      FigureMultiple muscular abscesses (arrows) were observed at different times during the clinical course of Staphylococcus aureus bacteremia. (A) Plain computed tomography (CT) scan on the day of admission showing bilateral iliopsoas abscesses. (B) New abscesses were observed in the bilateral cervical long muscle and right scalene muscles on day 5. (C and D) Other abscesses were observed in the muscles around the left scapula and head of the left humerus, on day 26.
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