Case of the Month - August 2010

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A previously healthy 27 year old man sustained a high spinal cord injury whilst diving into shallow water in a river in the Western Cape in late summer. He was found floating on the surface of the water after an unspecified time period, and taken to hospital. He required intubation and ventilation for respiratory support. Three days later he was transferred to a nearby tertiary hospital for specialist spinal surgery.

On arrival the patient appeared stable. However, about 24 hours later he deteriorated suddenly, becoming hypotensive, with respiratory distress, hypoxia and decreased level of consciousness. A pulmonary embolus was suspected. Despite resuscitation, his condition deteriorated and he died 24 hours later.

Laboratory results available about 12 hours after his sudden deterioration showed that his white cell count had risen sharply, from 4.1 x 109 /L the previous day, to 24 x 109/L. A blood culture taken at the time grew Gram-negative bacilli after 6 hours and the patient was started on ertapenem. Chest x-ray reported new, extensive bilateral changes.

Following his demise, the blood culture isolate was identified as Aeromonas hydrophilia, resistant to ampicillin and co-amoxiclav, but susceptible to cephalosporins, carbapenems, ciprofloxacin and aminoglycosides.

A tracheal aspirate taken 8 hours prior to his rapid deterioration showed 3+ WBCs on microscopy and cultured a scanty growth of Klebsiella pneumoniae, resistant to ampicillin only, as well as a scanty growth of a fully sensitive Haemophilus influenzae.

A second blood culture taken 20 hrs after starting ertapenem was negative. A forensic post-mortem confirmed the presence of bilateral pneumonia with associated pleuritis and small pleural effusions.

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