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baffling caseFrom: Richard Chudacoff, MD (rchudacoff@mylinuxisp.com)Tue May 31 09:10:36 2005
21 yo G1, GBS negative, admitted through the midwife service 12 days ago. She arrested in dilation, after IUPC and FSE, and underwent an unremarkable low transverse c-section via Pfannenstiel skin incision 10 days ago. 36 hours post-op she spike to 103 degrees F and hand a tender uterus, and was started on Ampicillin, gentamycin and clindamycin (by the resident on call) for post partum endomyometritis. 48 hours post op she was still febrile. ID was consulted, after another exam which noted a still tender uterus and she was switched to vancomycin and meropenem to cover MRSA as well as the usually culprits. She has a history of IBD and grew out C. diff on stool culture and was started on Flagyl. She also started taking scheduled Motrin and Tylenol. She defervesced for 36 hours and the antibiotics were stopped, except for the Flagyl, as were the anti-pyretics. 4 hours later she spiked to 103. Antibiotics and anti-pyrectis were restarted. Pelvic U/S was negative. KUB to r/o foreign body was negative. CT of pelvis was negative, as was chest x-ray, blood cultures and urine culture (from the original workup) and all subsequent cultures have been negative. She defervesed, and was stable for 24 hours. Anti-pyrectics were stopped 48 hours ago, and she then spiked again, despite being on anti-biotics. Repeat CT is negative, as is repeat CXR. Doppler studies of the lower extremities are negative, with great flow bilaterally. GI consults negative. No evidence of cardiac valve abnormalities ruling out SBE. I'm thinking that the only thing left to try is heparin for septic pelvic thrombophelbitis or septic gonadal thrombophelbitis. I thought she might have a drug fever, however she did spike after discontinuation of the wonder drugs. Any thoughts, pearls, questions, and acceptance of transfer to your service would be appreciated.
-- Richard Chudacoff, MD, FACOG
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