IM Board Review

Man’s best friend, fatal in the end

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A previously healthy 59-year-old woman with a remote history of splenectomy following a motor vehicle accident presented to the emergency department with a chief complaint of fever. She had been in her usual state of health until the day before, when she developed chills and fever, with temperatures as high as 39.4°C (102.9°F). She also began to have nausea, vomiting, and diffuse body weakness and had to be brought to the emergency department in a wheelchair. She denied upper-respiratory or urinary symptoms, headache, stiff neck, recent travel, or sick contacts.

She had sustained a minor dog bite on her right hand 2 days before, but she denied swelling, erythema, or exudate. The dog, a family pet, was up to date on all of its vaccinations, including rabies.

laceration (arrow) on patient’s right thumb from a dog bite
Figure 1. A 1-cm laceration (arrow) on patient’s right thumb from a dog bite 2 days before presentation.

Her temperature was 39.3°C (102.7°F), heart rate 121 beats per minute, and blood pressure 113/71 mm Hg. She had a clean, nonerythematous, healing, 1-cm laceration on her right thumb (Figure 1).

Initial laboratory values (Table 1) and a radiograph of her right thumb were unremarkable.


1. What is the appropriate next step in this patient’s management?

  • Discharge her from the emergency department and have her follow up with her primary care physician within 48 hours
  • Admit her for observation and defer antibiotic therapy
  • Admit her and start empiric antibiotic therapy
  • Admit but wait for culture results to come back before starting antibiotic therapy
The patient’s laboratory values on presentation

The patient’s history of splenectomy and presentation with fever raise the concern that she may be going into sepsis. In addition to fever, patients with sepsis may present with flulike symptoms such as myalgias, headache, vomiting, diarrhea, and abdominal pain.1

Sepsis in asplenic patients, also known as overwhelming postsplenectomy infection, can have a sudden onset and fulminant course, with a mortality rate as high as 50%.2 It is important to recognize those who are susceptible, including patients without a spleen from splenectomy or congenital asplenia, as well as those with functional asplenia from diseases such as sickle cell disease. Without the spleen, the immune system cannot clear immunoglobulin G-coated bacteria and encapsulated bacteria that are not opsonized by antibodies or complement.3

Any asplenic patient presenting with fever or other symptoms of systemic infection warrants immediate antibiotic treatment, without delay for cultures or further testing.1


With no clear source of infection, the patient’s clinical presentation was presumed to be due to a viral infection, and antibiotics were deferred. She was admitted to the hospital for observation.

The patient’s laboratory values during her hospital course

By the next morning, her mental status had declined. Her temperature at that time was 39.6°C (103.2°F), heart rate 115 per minute, and blood pressure 113/74 mm Hg. Her skin became mottled, and her lactate level increased from 1.9 mmol/L to 4.9 mmol/L (reference range 0.5–1.9 mmol/L) within 9 hours and continued to climb (Table 2).


2. Which first-line antibiotics should have been started on initial presentation?

  • Intravenous vancomycin and intravenous ceftriaxone
  • Intravenous vancomycin and intravenous metronidazole
  • Oral levofloxacin
  • Oral amoxicillin

At initial presentation to the hospital, the most appropriate regimen for this patient would have been vancomycin and ceftriaxone or cefepime in meningitis-level (ie, high) doses.2,4

Due to impaired immunity, asplenic patients are highly susceptible to encapsulated gram-positive organisms such as Streptococcus pneumoniae and gram-negative organisms such as Haemophilus influenzae, Neisseria meningitidis, and Capnocytophaga canimorsus. These organisms are all susceptible to ceftriaxone, with the exception of methicillin-resistant S pneumoniae, which is best covered with vancomycin.1 Patients with beta-lactam hypersensitivity can be treated with moxifloxacin instead.4,5

Vancomycin and metronidazole alone would not be adequate. Oral levofloxacin or amoxicillin would be appropriate initial treatment if the patient did not have access to a hospital within 2 hours. Ideally, the patient would have had one of these medications on hand and taken it at the first sign of fever.4

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When should brain imaging precede lumbar puncture in cases of suspected bacterial meningitis?

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