Age: 21.0
Sex: M
Vaccine: COVID19
Symptoms: Actinomyces test positive, Axillary pain, Blood creatine increased, Computerised tomogram, Culture positive
Clinical narrative: ED Visit 3/11/21 History of Present Illness 21 year old man pmhx of autism, recurrent abscesses, presents with complaint of L axilla swelling and drainage. Pt received COVID vaccine in L arm on 3/1. Pt did well until 3/5 when he started to complain of pain in the L armpit. Mother examined the area and did not see anything concerning. The pain continued through the weekend, no fevers. Pt felt warm on Monday, no temperature taken. Mother then noted a few "bump" near the L armpit. The bumps continued to swell and be painful on Tuesday, went to pediatrician and was prescribed Keflex. Pt has been taking Keflex but continues to spike fevers, Tmax 102F on Wednesday. Pt had fevers yesterday and today of "about 100." Pt took a nap today, and woke up with the area draining. Mother states that the drainage was smelly pus. Called PCP who recommended evaluation. ED course: Patient observed in the emergency department of antipyretics and did not have any further fever.  I will switch his treatment to clindamycin and provide topical bacitracin and provide strict criteria to come back if pt became febrile instructions provided to mom.   Patient safe for discharge to home. Discharged in improved condition. Written instructions reviewed with family.  3/18/2021 Discharge Summary History of Present Illness 21yo man with h/o autism and multiple soft tissue infections including cellulitis and pilonidal cyst who presented to the ED 3/13/2021 after axillary drainage and fever.  He had been treated outpatient with keflex, but continued to have fevers at home. Re-evaluated at ED and placed on clindamycin. Cultures from outpatient showing skin flora. Mother has been doing several dressings of drainage at home and ongoing fevers up to 102 so was brought to the ED for evaluation. No cough, rhinorrhea, diarrhea, recent travel, known sick contacts.  Summary of hospitalization: He re-presented to ED on 3/13/2021 and was started on vanc/cefepime/flagyl. A CT scan with contrast done to determine extension of abscess, which was fortunately limited to the subcutaneous plane (no infiltration near bone or into muscle fascia). In the ED, patient's creatinine was 1.5. Patient received IVF and his creatinine downtrended to 0.75 on 3/18/21.   The surgical course was uneventful. Successful debridement of the left axillary abscess was performed on 03/4/21. Wound cultures grew Actinomyces Europaeus and S. Epidermidis and Infectious Disease was consulted. Their antibiotic recommendations to discontinue the cefepime/flagyl and start vanc/CTX were followed. Sensitivity analyses showed S. Epidermidis was sensitive to linezolid, tetracyclin, tigecyclin, bactruim and vancomycin. The Actinomyces Europaeus sensitivities have not yet resulted at time of discharge. Per ID recommendations, the vanc and CTX were discontinued and oral doxycycline was started, which should be continued for 6 months. It could be considered to switch to PO amoxicillin after 2 weeks and finish the 6 month course with amoxicillin. This will be discussed during outpatient follow-up. Per ID recommendations, the following labs should be checked 2 weeks after discharge (on 3/29/21) and could be spaced out to every 4 weeks thereafter if normal: CBC with differential, CRP, ESR, BUN, creatinine, AST, ALT.  The patient is scheduled to see (ID) on 5/5/21. Dermatology was consulted per ID recs for evaluation of spots on the chest and back. Per dermatology these spots are keloid, not suspicious for hidradenitis suppurative, there is no need for biopsy. For pilonidal cyst spot dermatology recommends rec hibicleans cream. Immunology was consulted for recurring abscesses and recommended the following tests, which were ordered, in addition to outpatient followup: IgG, IgA, IgM, IgE, specific Ab titers: for strep pneumo IgG (23 serotypes) and tetanus IgG, lymphocyte subsets, T cell memory panel, B cell memory panel, neutrophil DHR, CH50.  A wound VAC was placed on the left axillary wound bed on 03/15/21 and exchanged on 3/17/21.  Patient tolerated the wound vac changes well with 5mg of oxycodone taken 1 hour prior to the vac change. On 03/18/21 patient was discharged with a home wound vac and VNA.  At the time of discharged patient was afebrile, his pain was well controlled, his oxygen saturations were >94% on room air, he was tolerating a regular diet and voiding/stooling without issues.