Missing link in a bread-&-butter LVAD driveline infection. | Figure 1

ID-Sameh

Infectious Diseases

Missing link in a bread-&-butter LVAD driveline infection.

71M, with PMH of obesity (BMI 37kg/m^2), DM2, HLD, Ischemic cardiomyopathy (ICM), HFrEF of 10%, s/p HM3 2yrs ago, admitted due to yellowish discharge from driveline exit for the last week. No pain, no fever, WBCS 12.3K, blood culture negative, CT abdomen negative. Admitting team started Vancomycin IV. Driveline exit culture grew S.epidermidis. The first 2 pics are from the day ID saw the pt. The 3rd pic is 4 days after adding a second treatment to IV Vanco.

Q1: Based on the clinical history and photos, what is the primary driver of this presentation?

A) Deep-tissue tracking of a biofilm-producing strain
B) Severe allergic contact dermatitis to dressing adhesive
C) Superficial fungal infection from local moisture trap
D) Expected localized inflammatory response to a chronic driveline

Q2: What critical piece of history explains the secondary S.epidermidis growth?

A) A recent breach in sterile technique during home dressing changes
B) Patient covertly scratching under the dressing to relieve intense itching
C) Recent dental work without appropriate antibiotic prophylaxis
D) Mechanical tension and micro-tearing from an unsecured drive line

Q3: What was the second medication added that led to significant improvement?

A) Escalation to IV Piperacillin/Tazobactam plus Rifampin for broader coverage and biofilm
B) One dose of IV SoluMedrol followed by a quick taper of PO Prednisone
C) Topical high-potency corticosteroid and recommendation to switch to a hypoallergenic dressing
D) Continuous topical triple-antibiotic ointment application under the existing dressing

The author made an update to this case.

Update 1

Q1 B, Q2 B, Q3 C

Upon noting the skin boiling over (=eczema) on the belly and further questioning, the patient admitted intense itching over the rash that he had to insinuate his finger under the sterile dressing to scratch for relief. Triamcinolone oint. saved the day and resolved the missing link of the case.

Diagnosis Added

Allergic contact dermatitis (missing link) that led to contamination of the driveline exit due to severe itching.