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December 11, 2017


An 80 year old female, at baseline until the day before admission when she became febrile and delirious.

She was admitted, had the usual fever work up, and the only positive result was blood cultures, all of which were grew enterococcus in less than 24 hours.

So they called me.

ID is all about the source for infections, but there isn't one.

So that alone makes it likely endocarditis. Then we add to the mix that the patient has a trans aortic valve replacement (TAVR) 5 months ago.

There is nothing like endovascular hardware to raise the stakes, and TAVR's are not good. It is like the patient read the abstract and applied it to herself:

A total of 250 cases of infective endocarditis occurred in 20 006 patients after T...

Posted By: Mark Crislip  

December 6, 2017

Don't believe everything you think.

I am going to go out on a limb and suggest that injection drug use is a bad idea for patients but great for clinicians that take care of its complications. I have always felt a little guilty that all the great/interesting cases are the result of the pain and suffering of my fellow man.

My service has been booming the last several years thanks to the opioid crisis, with a remarkable up t...

Posted By: Mark Crislip  

December 4, 2017

Heading for Death

After 30 years of taking of infections in IVDA, I remain impressed at the siren call of heroin.

The patient has been in and out of the hospital 4 times in the last three weeks for right sided MRSA endocarditis. He gets a few days of vancomycin and then leaves to get his heroin.

Each time he is admitted the lung abscesses are a little bigger, the vegetation a little larger and th...

Posted By: Mark Crislip  

November 29, 2017

Harm or Benefit

93 year old male, no past medical history of note except a AICD a year ago, is admitted with a gi bleed.

As an outpatient he had been having crops of marble sized red bumps on first his arms, then legs that started two months ago. They had been biopsied and cultured elsewhere and they day after admission the cultures turned positive for M. chelonae.

So they called me.</...

Posted By: Mark Crislip  

November 27, 2017

It Happens

The patient is an elderly male, admitted with fevers, chills and abdominal pain. Nothing of note in the history, he goes nowhere, does little. I understand the feeling.

CT shows inflammation in the abdomen around the ileopsoas. They suppose diverticulitis, although no -osis was seen and give Augmentin. Of course. He does not get much better and a repeat CT shows the inflammatory mass ha...

Posted By: Mark Crislip  

November 22, 2017

A Rapidly Growing Mass

The patient presents with shortness of breath. She is a kidney transplant patient on the usual medication, has no unusual exposures, and the only other symptoms are a nonproductive cough and malaise.

CT shows a pleural effusion and a mass in the right lung that was not present on CT three months ago. Before any diagnostic testing can be done she leaves AMA but returns 3 days later with ...

Posted By: Mark Crislip  

November 20, 2017

Another SAB

If I were a superhero, S. aureus would be my arch enemy. It is the Lex Luthor to my Superman. I was a DC person. And like comic book villains, every time you think it is dead, it comes back, even harder to kill.

First consult of the week was a S. aureus bacteremia (SAB). In my institution SAB is an automatic ID consult, which is as it should be.

There are now m...

Posted By: Mark Crislip  

November 15, 2017

Veni, vidi, vici

I lean towards simplicty. Less is almost always better. Except beer and ice cream. But for the medical record less is almost certainly better unless the goal is to snow your referal base with BS. A good note should be haiku, not the Odyssey.

I am, as I have said many times, an Occam's kind of guy.

Non sunt multiplicanda entia sine necessitate.

Fer sure dude.


Posted By: Mark Crislip  

November 13, 2017

So Many Possibilities

The patient has issues with opiates, having a long history of recalcitrant heroin use.

This time he is in the hospital for right sided endocarditis, complete with septic pulmonary emboli and a vegetation on the tricuspid valve by TTE.

After several weeks of inpatient nafcillin where he occasionally used heroin, he went to a nursing home to finish up his antibiotics.


Posted By: Mark Crislip  

November 8, 2017

More is not better

“Two great tastes that taste great together". That might work for Reese's Peanut Butter Cups but in medicine putting two medical conditions together is rarely beneficial.

The first is the bacteremia of life. Or at least of the dental life. To brush and floss is to be bacteremic:

Positive blood cultures were detected in 29.6% of patients after dental extra...

Posted By: Mark Crislip  

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About This Blog

For the Benefit of Mr Kite, there will be ID tonight. Infectious Diseases! Antibiotics! Viruses and Bacteria and Fungi! Oh my! Exclamation marks!!!!!! No trampolines, nor will any band be playing at 10 to 6. And Henry the Horse died of the Strangles. Sorry. That's the problem with infections.

The endless excitement that is the daily practice of Infectious Diseases in a Portland teaching hospital! The need for meta data!

Every day I make infectious disease rounds in the hospital and see at least one cool case or learn something new. 25 years and I still do not know everything. Why be selfish and keep all of that wonder and knowledge to myself? This blog will be a mostly qod account of days events, a cool ID case, a referenced pearl, and a minimum of 1 horrible, yet ultimately feeble, attempt at humor.

While usually written in the present tense, the cases are not necessarily current and all identifying information is altered or obscured as long as it is not absolutely pertinent to the case. Can't have a female with prostate infection for example.

I write these at night or in spare moments. There is always someone who will quibble about spelling, punctuation or grammar. My response is live with it. It's a blog, not Mandel.

Read and listen to more of me at my multimedia empire linked below.

The first 2 years blog posts have been collected and edited and are available on Amazon as The Puswhisperer, Volumes 1 and 2. Really. Perfect for the pus lover in your life.
Because The World Needs More Mark Crislip (tm).

Disclosure: Mark A. Crislip, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: Pusware LLC
Have a 5% or greater equity interest in: Pusware LLC (owner)

  • Mark Crislip

    Mark Crislip, MD, has been practicing in infectious diseases in Portland, Oregon, since 1990. He is nobody from nowhere, but he has an enormous ego that leads him to think someone might care about what he has to say about infectious diseases. And so he blogs and podcasts and writes on the most endlessly fascinating specialty in all of medicine. Links to his multimedia empire of blogs, podcasts, books, apps and tweets can be found at

    Mark A. Crislip, MD, has disclosed the following relevant financial relationships: Owner, Pusware LLC. He as not talked to a drug rep in over 25 years and does not even eat the pizza provided at conferences. But he is for sale for the right price. Please. Someone. Buy me.

The content of this blog does not necessarily reflect the viewpoints of Medscape.
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