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A 39 year old woman with fever and myalgia

Case Editor - Judd Flesch

Reviewed By Critical Care Assembly

Submitted by

Hugh Davis, M.D.


Department of Internal Medicine

Cedars Sinai Medical Center

Los Angeles, CA

Isabel Pedraza, M.D.

Director, Respiratory Intensive Care Unit

Division of Pulmonary/Critical Care Medicine

Women's Guild Lung Institute, Division of Pulmonary and Critical Care Medicine, Cedars Sinai Medical Center

Los Angeles, CA

Submit your comments to the author(s).


A 39-year-old Caucasian woman presents to the emergency department with a one-week history of fever and diffuse muscle aches.  She also reports a one-day history of pain and swelling in her left inguinal area in addition to diffuse pain throughout her right thigh with overlying erythematous skin changes.

One week prior to presentation, she was seen by her primary care physician with complaints of fevers, chills, and diffuse muscle aches.  She was noted to have marked pyuria on routine urinalysis, and was started on levofloxacin for suspected urinary tract infection.  She subsequently developed painful swelling of her left forearm that was believed to be flouroquinolone-induced tendonitis and antibiotic therapy was switched from levofloxacin to ciprofloxacin with temporary resolution of her symptoms.

The patient was also seen by her gynecologist three days prior to presentation, with recurrence of her symptoms.  A pelvic exam at that time was unremarkable. Cultures taken from the vaginal canal and a repeat urinalysis were both unremarkable.  She was continued on ciprofloxacin and doxycycline was added for additional antimicrobial coverage. Despite the additional antibiotic, her symptoms worsened, with persistent fevers and myalgias in addition to generalized weakness and nausea. 

Physical Exam

On physical exam the patient was found to be febrile with a temperature of 102 degrees Fahrenheit. Her heart rate was 80 with a blood pressure of 100/60. Her respiratory rate was 18 with an oxygen saturation of 100% on room air.

She appeared ill and uncomfortable. Although no cervical lymphadenopathy was appreciated, the musculature of her neck was noted to be diffusely tender to palpation. Her cardiovascular exam disclosed no murmurs and her pulmonary exam was unremarkable. Her abdomen was found to be diffusely tender to palpation without peritoneal signs or organomegaly. An enlarged tender lymph node was noted in her left inguinal region without surrounding erythema or fluctuance. The musculature of her extremities was found to be diffusely tender to palpation and a patchy, macular, blanching rash was noted over her trunk and extremities.


White blood cell count 13,400/mm3, Hemoglobin 11.4 g/dL, Platelets 292,000/mm3

Differential significant for 97% Polymorphonuclear lymphocytes

Liver function tests significant for total bilirubin 1.9 mg/dL, direct bilirubin 1.2 mg/dL, AST 60 U/L, ALT 129 U/L, Alkaline Phosphatase 344 U/L

Amylase and lipase within normal limits

Serum chemistries within normal limits

Urinalysis was significant for 5-10 white blood cells per HPF and trace leukocyte esterase

Chest x-ray demonstrated no evidence of cardiopulmonary disease.

Abdominal ultrasound showed no acute process.

Blood cultures were collected and the patient was started on empiric antibiotic therapy with Vancomycin and Cefotaxime. Within 24 hours, all blood cultures were positive with gram stain showing gram positive cocci in pairs and chains. This organism was later speciated as Lancefield group A, beta-hemolytic streptococci (Streptococcus pyogenes).

Echocardiography demonstrated a15mm x 10mm mobile, subvalvular vegetation involving the papillary muscles of the posterior mitral valve leaflet. (see video showing mitral valve vegetation) Despite antibiotic treatment, she developed confusion and blurred vision with associated headache and photophobia. An ophthalmologic examination disclosed bilateral uveitis and MRI of the brain demonstrated numerous bihemispheric lesions consistent with septic emboli (figure 1).

Video 1

figureA FigureB

Figure 1.  MRI brain showing bihemispheric infarcts consistent with septic emboli

The patient underwent median sternotomy for resection of the vegetation, which was adherent to the papillary muscle, chordae tendinae and posterior wall of the left ventricle, and stained positively for gram positive cocci. (figure 2) Postoperatively, the patient had an uneventful recovery and was discharged home on post-operative day number seven to complete six weeks of intravenous cefotaxime.  At the time of follow-up, the patient was found to be doing well with complete resolution of her prior symptoms.  Repeat laboratory data, including liver function tests, were entirely within normal limits.

Figure2A Figure2B

Figure 2: Microscopic images of endocardial vegetation showing gram positive cocci.

Question 1

Which of the following is the key virulence factor associated with invasive group A streptococcal infection?


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