Case No 1

53-years old female morbidly obese patient with transversal spinal cord lesion and after amputation of both lower extremities was sent to the hospital for fever with infected decubitus in gluteal region

Medical History

Present Illness: Huge pelvic decubital ulcer troubled her for a very long time, it is treated by her friend. About a week ago worsened her local finding on the left hip. Second day is febrile, maximally 38.3 °C, pain not recorded, yesterday once vomited, other problems are denied. Today examined by GP, his record describes an extensive necrotic infected focus on the decubitus edge. That is why the patient was sent to traumatologic out-patient clinic. Blood sample was taken for blood count and basic biochemical tests. Lab test revealed leukocytosis with raised neutrophil count and highly elevated CRP. On agreement with the duty doctor she was sent to the ID Dept at the Bulovka Hospital.

FHx: Not relevant to the present status.
EHx: Denies contact with infection.
W/SHx: disability pension, disability pension, her financial situation is tight, not self-sufficient, she is completely dependent on care of her friend.
PMHx: common child diseases, arterial hypertension on therapy, chronic CAD, s/p NSTEMI front and lower wall, diabetes mellitus II type on PAD, probably badly controlled, mild dyslipidemia on therapy, morbid obesity, metabolic syndrome, COPD (chronic obstructive pulmonary disease), serious polyneuropathy combined etiology, s/p viral hepatitis A, chronic VHB and VHC by parere
PSHx: polytrauma 10 years ago, spinal cord injury with paraplegia, above-knee amputation of LLE, later after a fall from inavlid wheelchair she underwent below-knee amputation of RLE because fractures of the distal femur and lower leg were complicated by gangrene and phlebothrombosis, other complications: huge inoperable abdominal hernia, mixed post-traumatic incontinence, s/p appendectomy
GHx: Postmenopause
Allergies: pollen, NKDA
Medications: Baclofen 25 mg 1-0-1 tbl po, Berodual N inh as necessary, Cymbalta 60 mg 0-0-1 tbl po, Euphyllin CRN 300 1-1-1 tbl po, Helicid 20 mg 1-0-0 cps po, Kalium chloratum 500 mg 1-0-0 tbl po, Lyrica 150 mg 2-0-2 tbl po, Moduretic 1-0-0 tbl po, Motilium 1-0-1 tbl po, Pentomer Retard 400 mg 1-0-1 tbl po, Siofor 1000 mg 1-1-1 tbl po, Amaryl 3 mg 1-0-0 tbl po, Rilmenidin 1-0-0 tbl po, Telmisartan 80 mg 1-0-0 tbl po, Vasocardin 100 mg 1-0-1 tbl po, Warfarin 3 mg 1-0-0 tbl po, Doreta in pain as necessary (obtained from med list that patient brought in)
Abuse: The patient started smoking when she was 16 years and now smokes roughly 10 cigarettes daily, alcohol intake occasionally, she rejects illicit drugs.

Physical Examination

VS: T 36,3 °C, HR 87/min., BP 117/73, RR 14/min., SpO2 NA.
General: Morbidly obese woman lying in bed.
Psychiatry: Alert and oriented to person, place, and time, co-operating, psychomotor speed reduced.
Skin: Skin without icterus, cyanosis, exanthem, normal turgor. extensive pressure ulcer IIIrd-IVth stage localized on dorsal side of amputation stump. Defect of extensive range affecting also ilium. In gluteal region there is necrotic skin, no fluctuation. Intensive odour.
Head: NAD.
ENT: Nares without any discharge. Mucous membranes moist. Oropharynx without erythema or exudate. Tongue a little drier, with whitish coating.
Neck: Jugular vein filling not increased. Neck is supple, no masses, no thyroid enlargement.
Lymph Nodes: Not palpable.
Cardiovascular: RRR. Heart sounds, S1 and S2 normal, no m/g/r. Pulses 2+ equal on both sides.
Lungs: Breathing alveolar with numerous moist rales/crackles bilaterally. Good air movement.
Abdomen: Obese, scar after laparatomy, extreme abdominal hernia. Abdomen soft, difficult to palpate due to obesity. No rebound or guarding. Normoactive bowel sounds.
Rectal: Deferred.
Extremeties, MSK: LLE: above-knee amputation, RLE: below-knee amputation.
Neurological: Cranial nerves intact, motor skills of upper extremities are normal, paraplegia, DTR cannot be investigated because s/p amputation, complete loss of sensitivity of the lower body.


Case 1   Fig 1 S/p high femoral amputation of LLE, s/p operation of extensive pressure ulcer localized on dorsal side of amputation stub, after reamputation and necrectomia, defect of extensive range affecting also ilium


Laboratory Tests

Hematologic examination:

Biochemical tests:

Microbiologic examination:

Antibiotic [1][2][3][4][5]
oxacillin R
ampicillin C R R
amoxicillin/clavulanic acid C R R
ampicillin /sulbactam C R
piperacillin /tazobactam C R
cephalotin C R R
cefuroxime C R
cefotaxime C R
ceftazidime C R
cefepime C R
cefoperazone /sulbactam C R
imipenem C R
meropenem C R
co-trimoxazole C R R
tetracycline R R C
tigecycline R C C
erythromycin R R
clindamycin R
vancomycin C
teicoplanin C C
gentamicin C R R
amikacin C R R
ciprofloxacin C R R
chloramphenicol C R R
colistin R C
linezolid C
mupirocin C
rifampicin C
fluconazole C
itraconazole C
amphotericin B C
nystatin C
pimafucin C


Imaging and Other Paraclinical Examinations

Imaging studies:


CT pánve   Fig 2 CT scan: Topogram



CT scan   Fig 3 CT scan: axial view of the pelvis



CT   Fig 4 CT scan of the abdomen and pelvis: coronal image


Electrophysiologic examinations:



Diagnostic Conclusion

Describe all diagnoses what can be seen from patient history, physical examination and further examinations.


Suggest the combination of antibiotics and their dosing according to sensitivity of isolates.


12 Skin, soft tissue and wound infections
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