An 82-year-old woman presented at the Emergency Department (ED) with a suspected hip fracture after a fall at home. Despite gradual weight loss and malaise over the previous months, her medical history was uneventful. At the patient’s request, a do-not-resuscitate/intubate policy was agreed upon at presentation. Shortly after presentation, she developed hypotension (84/35 mmHg). Physical examination further revealed tachycardia (117 beats/minute), oxygen saturation 98% with 2 l/minute of oxygen supplementation, tachypnoea (22 breaths/minute), and a basal body temperature of 36.7°C. Laboratory results showed leucocytosis (20.8 x 109/l), elevated C-reactive protein (282 mg/l), elevated troponin-T (119 ng/l) and a haemoglobin concentration of 7.6 mmol/l. Electrocardiogram and chest X-ray revealed no abnormalities, however the hip X-ray confirmed a left femur fracture. The left thigh was clinically not suspected for internal haemorrhage. She responded positively to fluid resuscitation and showed no signs of organ failure. Three hours after presentation, the patient unexpectedly deteriorated. At the request of the patient and her family, no life prolonging therapy was initiated. She died of refractory shock, most likely due to cardiac failure. To our surprise, four blood culture samples taken at the ED showed gram-positive cocci the next day (figure 1)
WHAT IS YOUR DIAGNOSIS?
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