51-Year-Old Hospitalized Man With a Painful Leg

A 51-year-old Somali man was admitted to an inpatient cardiology service at Saint Marys Hospital, a Mayo Clinic–affiliated hospital in Rochester, MN, with symptoms of fever and progressively worsening shortness of breath. Chest radiography demonstrated substantial pulmonary edema secondary to volume overload in the setting of acute worsening of chronic renal failure. Initial laboratory investigation yielded the following notable results (reference ranges provided parenthetically): leukocyte count, 30.3 × 109/L (3.5-10.5 × 109/L); blood urea nitrogen, 142 mg/dL (8-24 mg/dL); and creatinine, 12.6 mg/dL (0.9-1.4 mg/dL). Blood cultures were positive for Streptococcus pneumoniae in 4 of 6 specimens at 12.4 hours, and a nasal swab polymerase chain reaction was positive for H1N1 influenza. He underwent urgent dialysis, an intravenous antibiotic regimen of vancomycin and levofloxacin was initiated, and his clinical status was stabilized. His current presentation was complicated by a more than 10-year history of type 2 diabetes mellitus with poor control (glycated hemoglobin, 9.1% [4.0%-6.0%] at admission and 12.7% 1 year previously despite insulin therapy) and end-organ damage, including proliferative retinopathy, neuropathy, and nephropathy. His medical regimen consisted of the aforementioned antibiotics, scheduled dialysis, insulin therapy, and prophylactic heparin. The next 7 days of his hospitalization were unremarkable, with anticipated discharge on hospital day 8.