D.H., a 54-year-old resort owner, has had multiple chronic medical problems, including type 2 diabe
tes mellitus (DM) for 25 years, which has progressed to his having been insulin dependent for the past
10 years; a kidney transplant 5 years ago
with no signs of rejection at last biopsy; hypertension; and pep
tic ulcer disease. His medications include insulin, immunosuppressive agents, and two antihypertensive
drugs. Three days ago he visited his local physician with complaints of left ear, mastoid, and sinus pain.
He was diagnosed with sinusitis and Candida albicans infection (thrush); cephalexin (Keflex) and nystatin
were prescribed. Later in the afternoon he developed nausea, hematemesis, and weakness and was taken
to the emergency department. He was admitted and started on intravenous (IV) antibiotics, but his condi
tion worsened throughout the night; his dyspnea increased and he developed difficulty speaking. He was
flown the next morning to your tertiary referral center and was intubated en route. On arrival, D.H. had
decreased level of consciousness with periods of total unresponsiveness, weakness, and cranial nerve
deficits. His admitting diagnosis is meningitis. He has since developed aspiration pneumonia and atrial
fibrillation. D.H. has continued fever and leukocytosis despite aggressive antibiotic therapy.
Why was D.H. at particular risk for infection?
Major risk factors for infection include post-transplantation immunosuppressive therapy, DM, and
increased age.
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