Contributed by Ken Clark, MD and A William Pasculle, ScD.
Published on line in February, 2005
This is a 54-year-old female with a medical history of emphysema secondary to alpha-1 antitrypsin deficiency, status-post double lung transplant in January 2004. Her post-operative course was complicated by acute cellular rejection (grade 3), severe hemodynamic instability, pneumonia, and a sternal wound infection, requiring multiple, prolonged hospital admissions. During that time she was treated with a variety of immunosuppressants including azathioprine, cyclosporine, tacrolimus, and prednisone.
On July, 2004 she presented to an outside hospital with nausea, vomiting and dehydration. On admission, she had a fever of 101.3. All lab values on admission were within normal limits. A chest X-ray revealed a questionable pleural effusion and she was empirically started on levofloxacin, metronidazole, and piperacillin / tazobactam. On July 22, 2004 she was transferred to our medical center for further management. Testing for Clostridium difficile toxin on admission was negative. Chest X-rays and a CT-scan revealed pulmonary edema, bilateral pleural effusions, bilateral chronic bronchitis, and multiple bilateral opacities suggestive of pneumonia or rejection. Over the next several days her clinical condition remained unchanged. A bronchoalveolar lavage was performed on July 29. Cytologic examination of the lavage specimen showed fungal organisms and acute inflammation. Surgical pathology revealed mild lymphocytic bronchitis and acute purulent exudate. Cultures of the lavage specimen grew coagulase negative Staphylococcus and Streptococcus viridans. The following day her antibiotic regimen was changed to include vancomycin.
Since her transplant, 14 surveillance rectal swabs were all negative for Vancomycin Resistant Enterococci. A rectal swab performed after two days of vancomycin therapy was also negative for VRE. Culture plates of a follow-up rectal swab performed a week later are shown in the pictures below. Image 1 shows sparsely scattered colonies on a blood agar. Image 2 is a blood agar with a 30 microgram vancomycin disc. Scattered colonies are seen throughout the culture plate, in addition to heavy, confluent growth surrounding the vancomycin disc. Image 3 is a Mueller-hinton agar with a vancomycin E-test strip. The isolate shows increased density of growth with increasing concentrations of vancomycin. Biochemical analysis of the isolate showed it to be Enterococcus faecium.