Erysipelothrix rhusiopathiae is an omnipresent commensal in the environment, studied for over a century. a patient who came to us with overt heart failure. The patient had no typical signs or symptoms suggestive of infective endocarditis but was ultimately found to have significant vegetations on echocardiography. In our report, we describe a rare case of Erysipelothrix rhusiopathiae in a patient with endocarditis and atypical involvement of the tricuspid valve. Case presentation A 47-year-old man with a Rabbit Polyclonal to GABBR2 past medical history of hypertension and alcohol dependence and with a four-week history of progressive bilateral lower extremity edema presented. The patient is a lumberjack?and was gradually developing difficulty working long hours. His swelling?progressively extended to his knees, prompting a visit to his primary care physician. He underwent a lower extremity duplex in the outpatient setting, which was negative for deep vein thrombosis. The patient was started on oral furosemide but mentioned it did not improve his lower extremity swelling. After undergoing routine lab work with his primary care doctor, the patient was found to have abnormal kidney function and was admitted to the hospital for further evaluation.? On admission, the patient’s vital signs were as follows: temperature of 36.7oC, blood pressure of 148/91 mm Hg, heart rate of 72 beats/minute, and respiratory rate of 16/min. Clinically, the patient was volume overloaded with bibasilar lung crackles and 3+ pitting edema in bilateral lower extremities. His laboratory findings Buserelin Acetate were notable for a white count of 26,000 (elevated in part due to patient’s oral steroids for unknown reason), anemia, thrombocytopenia, blood urea nitrogen of 56, creatinine of 3.8 (baseline creatinine levels 0.5), hyponatremia, and an N-terminal pro B-type natriuretic peptide (NT-pro-BNP) level of 29,959. Urine studies revealed microscopic hematuria without proteinuria. Electrocardiogram revealed normal sinus rhythm with no acute ST-T wave changes. Further imaging included computed tomography (CT) of the chest, which revealed mild interlobular septal thickening in bilateral lung bases, suggestive of pulmonary edema. CT of the abdomen revealed diffuse gallbladder wall thickening without gallstones with no evidence of ascites.? At this stage, our preliminary diagnosis was cardio-renal syndrome due to an unknown etiology. The patient was started on intravenous diuretic therapy and oral beta-blockers in light of his acute decompensated heart failure. Additional blood work revealed low complement levels along with elevated cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) levels. Antinuclear antibodies, creatine kinase, and anti-streptolysin antibodies were negative. After 48 hours, the patient’s blood cultures were positive for gram-positive rods. He was started on empiric treatment with intravenous vancomycin. Since the patient did not have a baseline heart evaluation on file, a transthoracic?echocardiogram was ordered, which revealed a normal ejection fraction with severe tricuspid regurgitation, pulmonary hypertension, and multiple tricuspid valve vegetations (Figure ?(Figure11). Open in a separate window Figure 1 A 2-D echocardiography image of the tricuspid valve showing significant vegetations The Buserelin Acetate most significant vegetation was noted to be 2.6 cm x 1.6 cm in size. At this point, our working diagnosis was acute renal failure, with gram-positive bacteremia Buserelin Acetate secondary to tricuspid valve infective endocarditis. After six days, repeat blood cultures showed gram-positive rods with sensitivities revealing?Erysipelothrix rhusiopathiae?as the causative agent, resistant to vancomycin and sensitive to Penicillin G and ceftriaxone. The patient’s antibiotic regimen was converted to intravenous Penicillin G. Given that he was not a candidate for cardiac surgery, the decision was made to treat him on an outpatient basis with long-term intravenous antibiotics. Discussion Erysipelothrix rhusiopathiae is a.