Introduction: This research presents a complex case of a 70-year-old male with acute metabolic encephalopathy and biochemical septic shock, later attributed to cardioembolic ischemia, resulting from Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteremia with an elusive source of infection.
Case Description: The 70-year-old patient, with a medical history of hypertension and aortic valve stenosis status post-Coronary Artery Bypass Grafting and bioprosthetic valve replacement on dual anti-platelet therapy (clopidogrel and aspirin), was admitted following an unwitnessed fall and a day of vomiting and generalized weakness. Upon arrival, the patient exhibited altered mental status, hypotension, and acidosis. Initial diagnostic workup raised suspicion of biochemical septic shock and a possible postictal state. Upon arrival to the Emergency Department, patient was seen by trauma services for (+) HS, (+) LOC, (+) AP. Patient underwent a PAN-SCAN that showed no acute intracranial hemorrhage or mass effect, no acute post traumatic intrathoracic process, no acute post-traumatic abdominopelvic process nor post-traumatic thoracic or lumbar spine injury. Pelvis X-ray showed no evidence of acute fracture or dislocation. Lab-work was remarkable for acute metabolic acidosis, initial K was 2.35, bicarb 8, lactic acid 4.4, calcium 4.0 and Mag 1.1. Subsequent brain MRI revealed cardioembolic ischemia and subarachnoid hemorrhage concurrent with MSSA bacteremia. A multidisciplinary approach involving ICU, neurology, interventional cardiology, and infectious disease specialists ensued, leading to comprehensive evaluations, including transesophageal echocardiography and MRI of the spine. Despite an exhaustive workup, the source of infection remained elusive. Treatment encompassed fluid resuscitation, corticosteroids, broad-spectrum antibiotics, and antiviral therapy.
Discussion: This case underscores the intricate challenges in managing a patient with biochemical septic shock, cardioembolic ischemia, and MSSA bacteremia without an identified source of infection. Such cases are exceedingly rare, with an incidence of less than 1%. The multidisciplinary approach was instrumental in facilitating a successful outcome, resulting in the patient's complete recovery from the initial encephalopathic state. The study highlights the importance of collaborative care to mitigate the high mortality and poor prognosis associated with similar cases of undetermined MSSA bacteremia.

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