meropenem and Cytomegalovirus-Infections

We report a case of a frail 82-year-old man with seronegative rheumatoid arthritis and a recent pacemaker insertion, admitted with pulmonary oedema and a symptomatic pericardial effusion. He was treated with diuretics and an urgent pericardiocentesis, a sample from which cultured Enterobacter cloacae. A subsequent abdominal CT scan revealed faecal loading, an abnormal anorectal canal and sigmoid colon and a bowel perforation. Endoscopy, biopsies and histopathology confirmed a diagnosis of cytomegalovirus (CMV) colitis with coexistent fungal infection. The E. cloacae infection was successfully treated with 6 weeks of intravenous meropenem, while the CMV and fungal infections were treated with a combination of valganciclovir and fluconazole. We postulate that the bowel perforation resulted from a combination of CMV colitis, faecal loading and steroid therapy and led to bacterial translocation of E. cloacae and the development of the pericardial effusion. This case represents an unusual pathophysiology for the development of an E. cloacae pericardial effusion.

Topics: Aged, 80 and over; Anti-Bacterial Agents; Arthritis, Rheumatoid; Colitis; Colon, Sigmoid; Cytomegalovirus Infections; Diuretics; Drug Therapy, Combination; Enterobacter cloacae; Enterobacteriaceae Infections; Frail Elderly; Humans; Intestinal Perforation; Male; Meropenem; Pacemaker, Artificial; Pericardial Effusion; Pericardiocentesis; Pulmonary Edema; Radiography; Rectum; Risk Factors; Thienamycins; Treatment Outcome

A 27-year-old woman was admitted to the emergency department with fever and a petechial rash on suspicion of meningitis. Shortly after arriving she developed cardiac arrest. Blood work up showed severe lactate acidosis, anaemia and thrombocytopenia. A focused assessment with sonography in trauma scan showed free intraperitoneal fluid and an emergency laparotomy revealed massive bleeding from a ruptured spleen. The patient was successfully resuscitated. She proved to be infected with cytomegalovirus causing idiopathic thrombocytopenic purpura, splenomegaly and splenic rupture. She was treated for 14 days with ganciclovir and meropenem and discharged on recovery. Atraumatic splenic rupture caused by viral infection is a rare condition although well described. In the case of our patient, thrombocytopenia added to the severity of the splenic rupture. A multidisciplinary team approach was essential for the management and the eventual recovery of the patient.

Topics: Adult; Antiviral Agents; Cytomegalovirus; Cytomegalovirus Infections; Emergencies; Female; Ganciclovir; Heart Arrest; Humans; Meropenem; Rupture, Spontaneous; Splenectomy; Splenic Rupture; Thienamycins; Thrombocytopenia; Treatment Outcome