CASE PRESENTATION
A 63-year-old Caucasian female with past medical history of osteoporosis on actonel and no prior hospitalizations, presented to the Emergency Department (ED) on January 25, 2020 with complaints of fever of 101.1 F, polyarthralgia, myalgia, and diffuse weakness. Patient admitted to performing an intense cross fit workout four days prior, leading to diffuse myalgias in upper and lower extremities associated with chills and shaking at night. This ED visit was preceded by a visit to urgent care, a day before for similar symptoms. Radiography of the right shoulder was negative for fracture. She was prescribed toradol for the diffuse myalgias and severe right shoulder pain. Since then the myalgias had worsened with additional finding of decreased urine output causing her to present to the ED. Associated symptoms included fever, chills, decreased activity, weakness, decreased urine output, and dark colored urine. She denied any prior instance of a similar episode. Patient also denied any recent trauma, travel, any new exposures, or any sick contacts. Patient is up to date on her vaccinations. Review of systems was negative for rhinorrhea, chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea, dysuria, swelling, numbness, and tingling. No pertinent family history of arthritis or skin disease. Patient is an elementary school teacher who participates in regimented workout routines and exercise bootcamps. Patient reported allergy to Penicillin. Vital signs were blood pressure of 99/55, heart rate of 89, respiratory rate of 18, and temperature of 101.1 F. Physical exam on admission revealed no rashes or skin lesions, muscle strength was 5/5 bilaterally in upper and lower extremities, sensation was intact peripherally, and cranial nerves were grossly intact. Positive findings included tenderness to palpation of the bilateral calves and upper extremities. Patient also noted right posterolateral shoulder pain radiating to the proximal arm, worse with overhead movement, abduction, and external rotation with adduction. Pertinent labs showed no leukocytosis. Hematocrit of 36.4% and mean corpuscular volume of 89 fl. AST and ALT were elevated at 163 and 186 respectively. Lactic acid was 1.6 mmol/L, C-reactive protein was elevated at 22.5 mg/L and ESR was 35. Elevated creatine kinase of 322 U/L. Normal magnesium of 1.7 mEq/L and phosphorus of 2.2 mg/dL. Urine analysis (UA) showed pyuria of 12 white blood cells with moderate blood. UA was negative for glucose, bilirubin, ketones and nitrates. Chest radiograph showed no acute disease. X-ray of the right shoulder showed mild degenerative changes of glenohumeral joint. Transesophageal echocardiography was negative for vegetations, electrocardiogram showed sinus tachycardia, and magnetic resonance imaging showed no evidence of osteomyelitis. Tests for lyme disease, andInfluenza A&B showed negative findings. Blood culture showed growth of gram-positive bacteremia in chains, later found to beGroup C Streptococcus .
The patient was admitted to inpatient services with a diagnosis of sepsis secondary to gram positive bacteremia. On the day of admission, her sequential organ failure assessment (SOFA) score was 3 with thrombocytopenia and hyperbilirubinemia. On day 2 of hospitalization, infectious disease favored the diagnosis of Right arm and forearm cellulitis with gram positive bacteremia. Clinical exam showed edema, erythema, and significant warmth in her right upper extremity. Tenderness to palpation was also noted to the right lower extremity below the knee. On day 3 of hospitalization, the general floor nurse noted expansion of rash with a new cutaneous finding on the left arm and left lower leg. Patient denied any pruritus of the new rash. Physical exam revealed oval shaped macular rashes throughout arms and legs bilaterally with warmth and tenderness to palpation (Figure 1 ). Decreased active and passive range of motion was also noted bilaterally. Patient was admitted to the intensive care unit (ICU) with concern of necrotizing fasciitis. Further imaging revealed no emphysema tracking up fascial planes or rim enhancing abscess and no crepitation on palpation made necrotizing fasciitis unlikely.
The provisional diagnosis was Group C streptococcus bacteremia associated with diffuse myalgias and cutaneous manifestations. Treatment was initiated with vancomycin, flagyl and cefepime which was switched to doxycycline and ceftriaxone due to suspicion for lyme disease and positive growth for gram positive cocci in chains. With this course of antibiotics patient’s clinical symptoms began to improve. Six days later the rash started regressing and the patient reported subjective relief of pain. On the day of discharge, the patient was afebrile and reported almost complete resolution of pain and rash. No leukocytosis was found, and repeat cultures were negative for growth. Transmitinits also resolved. Patient was discharged from the hospital in stable, improved condition. Patient was switched to oral ceftin to complete the antibiotic course.