We report a case of bacterial endocarditis due to Erysipelothrix rhusiopathiae in a homeless man with no animal exposure. His course was complicated by an allergic reaction to ampicillin, urinary bladder infection, respiratory failure, and acute kidney injury. He recovered completely after aortic valve replacement and a 6-week course of intravenous ceftriaxone. 1. Background Erysipelothrix rhusiopathiae is a gram-positive rod causing swine erysipelas. It is a zoonotic infection in humans, with meat (swine) and fish handlers being at greatest risk. It most commonly causes erysipeloid, a localized cellulitis caused by direct bacterial invasion of cuts or abrasions in the skin. However, the skin infection can become generalized, and the organism can produce acute systemic septicemia. We report the case of a patient with E. rhusiopathiae bacteremia complicated by renal failure, respiratory failure, and aortic valve endocarditis. 2. Case Presentation A 51-year-old Caucasian man without significant past medical history presented to a community hospital with a two-week history of shortness of breath and new onset chest pain. These symptoms were accompanied by the appearance of a rash on his fingers that spread up to his hands and wrists, but which had resolved before presentation to health care. Physical exam was significant for fever to 38.1°C, but otherwise normal vital signs. There was diffuse rhonchi heard bilaterally and a diastolic murmur heard best at the heart base. Significant laboratory values included: WBC count 14,500/mm3 with 40% segmental neutrophils and 44% bands, hematocrit 25.4%, blood urea nitrogen 96？mg/dL, and serum creatinine 2.4？mg/dL. The liver function tests were normal, as was the coagulation profile. Urinalysis was significant for hematuria with >100 white blood cells. Leukocyte esterase was positive. Electrocardiogram showed a normal sinus rhythm without conduction abnormalities, and his initial chest X-ray was normal. The patient had a history of moderate alcohol use. He had a remote history of intravenous heroin abuse, although he had not used in 20 years. He was homeless, lived in his car, and worked as a mechanic. He denied any exposures to pigs or fish, although he occasionally encountered deer and rabbits in the woods where he lived. He denied eating any undercooked meat. The patient was pancultured, and intravenous ampicillin-sulbactam was initiated. On the fourth hospital day, the lab reported that the blood cultures were growing a gram-positive rod they could not identify, and the cultures were sent to a reference laboratory
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