She was initially admitted to the critical care unit for high flow oxygen, however, she admission,
on, 2 sets of blood cultures revealed gram positive bacilli on gram stain. A TEE
rapidly became progressively more hypoxemic despite conventional mechanical ven-
tilation, high frequency oscillatory ventilation and inhaled nitric oxide therapies. The
patient was initially cannulated for venovenous (VV) ECLS. After a few hours on VV
ECLS, pump flows became inadequate and cannula repositioning and replacement
were both unsuccessful at improving flows and oxygenation. As a result the patient was
converted to VA ECLS. Diagnosis for L. pneumophila was made by endotracheal tube
aspirate culture and verified by matrix assisted laser desorption/ionization. Cultures
remained positive for 31 days. Gentle recruitment maneuvers were attempted towards
the end of patient’s ECMO run. The patient remained on VA ECLS for 31 days before
decannulation. She was weaned off mechanical ventilation within a week of decannula-
tion and transferred to the floor. One year after decannulation, the patient had some
mild developmental delays including oral aversion. She has continued to make progress
with outpatient physical and occupational therapies. Results: This is the first known
report of survival after VA ECLS in a neonate with Legionella, and given this disease’s
high mortality rate and high potential for rapid decompensation, ECLS should be
considered as an option for these infants.
1798
MYCOPLASMA HOMINIS: UNEXPLAINED FEVER AND
LEUKOCYTOSIS AFTER VALVE-SPARING AORTIC ROOT
REPLACEMENT
Ashley Black, David Liang, Vidya Rao
Learning Objectives: Mycoplasma hominis, a urogenital tract pathogen, is a rare
cause of mediastinitis and prosthetic valve endocarditis. We describe a novel case
of M. hominismediastinitis and native valve endocarditis following valve spar-
ing aortic root replacement (VSARR). Methods: A 41 year old man underwent
VSARR for an aortic root aneurysm. On postoperative day (POD) 9, he devel-
oped a marked leukocytosis and fever that were refractory to broad spectrum
empiric antibiotic therapy. Comprehensive infectious and rheumatologic evalua-
tions, including serial cultures, imaging, and laboratory studies, were unrevealing.
On POD 16, a fluid collection formed at the superior aspect of his sternum, that
was found to be rim-enhancing on computed tomography (CT) imaging. On
POD 17, a mediastinal exploration and washout was performed. Intraoperative
transesophageal echocardiography (TEE) revealed a mass on the atrial surface of
the mitral valve concerning for endocarditis vs thrombus. A heparin infusion was
initiated, and antimicrobial therapy changed to daptomycin, caspofungin, and
meropenem. On POD 21, pericardial fluid 16-S PCR revealed M. hominis, and
doxycycline and clindamycin were initiated. On POD 28, the mass was no lon-
ger visualized on TEE. The patient developed new onset complete heart block
on POD 41, requiring transvenous pacing. TEE performed revealed a mass on
the anterior mitral leaflet extending to the aortic root suspicious for abscess and
progression of mycoplasma infection. Surgery was deferred due to high operative
risk. Monitoring with serial CT scans and TEEs showed progressive decrease in the
size of mediastinal fluid collections. Leukocytosis and fevers improved, and a per-
manent pacemaker was implanted on POD 60. The patient was discharged home
on POD 61 on intravenous clindamycin and doxycycline. He continues to do
well and will remain on long-term doxycycline monotherapy. Results: M. hominis,
while rare, should be considered in patients with culture negative mediastinitis and
endocarditis who do not improve despite broad-spectrum antimicrobial therapy.
1799
TWO CASES OF LACTOBACILLUS INFECTIVE
ENDOCARDITIS IN THE SETTING OF INTRAVENOUS
DRUG ABUSE
Jordan DeWitt, Angela Harding, Tara Fisher
Learning Objectives: Few cases of infective endocarditis due to Lactobacillus species
have been reported. Outcomes for treatment regimens are limited based on the low
occurrence of this disease and is based on case report level of evidence. Here we pres-
ent two separate cases of Lactobacillus sp. endocarditis and their differing pharmaco-
logic management. Methods: A 26-year-old female presented with severe abdominal
pain. PMH included a remote history IVDA and child birth 6 months prior. An
abdominal CT identified multiple renal and splenic infarcts. Empiric broad spectrum
antibiotics with piperacillin/tazobactam and vancomycin were initiated. On day 2 of
Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.)
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
revealed an echodensity attached to the mitral valve (MV), representing a torn chor-
dae and vegetation. On day 3 of admission, blood cultures resulted as Lactobacillus
species, later identified as Lactobacillus casei. Based on evaluation of available litera-
ture a 6 week course of ampicillin and synergy dosed gentamicin was completed and
further work up for MV replacement followed. The second case, a 40-year-old female
with a PMH significant for current IVDA and hepatitis C presented with a large
aortic valve (AV) vegetation identified on TEE. Broad-spectrum antibiotics including
vancomycin and piperacillin/tazobactam were initiated. The patient developed septic
and cardiogenic shock during admission and was taken for emergent AV replacement.
The blood culture finalized with Lactobacillus jensenii, which has only been reported
7 times in a literature search. Our patient was continued on piperacillin/tazobactam,
and not started on synergistic gentamicin like the previous patient per Infectious Dis-
ease Physician recommendation, due to development of severe acute kidney injury
and need for continuous renal replacement therapy (CRRT). Both patients had nega-
tive repeat blood cultures representing treatment success on the prescribed regimens.
Results:These cases demonstrate multiple treatment options for a rare endocarditis
pathogen with single or combination therapy.
1800
ATYPICAL LYME MENINGITIS WITH PARKINSON DISEASE-
LIKE MANIFESTATIONS
Rachel Patel, Jeffrey Larnard, Nongnooch Poowanawittayakom, Richard Glew
Learning Objectives: Lyme meningitis, caused by the tick-borne spirochete B. burg-
dorferi, typically presents with meningeal symptoms, including headache, fever, and
malaise. We present a case of an elderly man with Lyme meningitis manifesting as
Parkinsonism and fully reversible with ceftriaxone. Methods: A 79-year-old man
with a history of follicular lymphoma in remission experienced 2 months of rap-
idly progressing weakness and persistent headache. He developed a shuffling, wide-
based gait without rigidity, predominantly left-sided bradykinesia, marked intention
tremor, postural tremor, hypomimia, hypophonia, and positive Romberg test. Com-
puted tomography (CT) and CT angiogram of the head did not demonstrate a focal
process, and extensive paraneoplastic work-up was negative. His symptoms initially
were attributed to idiopathic Parkinsonism, although a trial of levodopa-carbidopa
did not mitigate his weakness or gait abnormalities. Cerebral spinal fluid analysis
revealed 6 white blood cells per mm3 with 95% lymphocytes and positive Lyme
serology (titer 2.57 LIV) without evidence of other infection, and cytologic studies
were negative for malignancy. He is a hunter and recalled removing multiple ticks
from his body after each outing, but denied history of a rash. Treatment with ceftazi-
dime 1g IV every 8 hours resulted in rapid improvement and after 2 days he was
switched to ceftriaxone 2 g IV once daily. After 4 days of antibiotics, no bradykinesia
was evident and his tremor diminished. Within 4 weeks of therapy, his headache had
resolved and he walked independently without difficulty. Results: Lyme disease has
variable manifestations affecting the nervous system, including aseptic meningitis,
meningoencephalitis, cranial neuropathy, and radiculitis. To our knowledge, this is
the first reported case of Lyme meningitis presenting with symptoms suggestive of
rapidly progressing Parkinsonism. Lyme meningitis merits consideration in endemic
areas in cases of subacute onset of Parkinsonism of unknown etiology, as it may be
fully reversible with antibiotic therapy.
1801
A RARE BUT INCREASINGLY RECOGNIZED CAUSE FOR
ACUTE RESPIRATORY DISTRESS SYNDROME
Paula Debroy, Juan Ruiz, Perminder Gulani
Learning Objectives: Human metapneumovirus (hMPV) is a well-recognized
cause of infections in children, but data on adult presentation is limited. We report
a case of severe ARDS in a healthy adult secondary to hMPV. Methods: A 36-year
old morbidly obese man with no past medical history presented with progressively
worsening shortness of breath, productive cough, and chills for 4 days. Upon physi-
cal examination he was noted to be in respiratory distress with oxygen saturation
of 83% on non-rebreather mask. A chest X-ray revealed bilateral patchy infiltrates.
He was intubated and placed on mechanical ventilation for acute hypoxemic
respiratory failure. His post-intubation blood gas, ventilator settings, CT-chest,
and echocardiogram findings were consistent with severe acute respiratory distress
syndrome (ARDS). Blood and respiratory cultures, tests for influenza, legionella,