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December 21, 2016

I don't know what to do.

The buck has stopped with me for a long time. The problem is, the longer I practice medicine, the more I encounter problems that I really have no idea what to do. The last couple of weeks have seen a series of cases that have me flummoxed. But everyone expects an answer from me.

For example.

The patient is a middle aged male from SE Asia was treated for abdominal TB in 2003. Sounds like streptomycin for 2 months and INH and Rifampin for 6 months. He moves to the US two years later.

He has been asymptomatic for the last 14 years. No constitutional or GI symptoms. He has a CT for renal stones that demonstrated enlarged intraabdominal lymph nodes.

The lymph nodes are biopsied. Caseating granulomas. AFB negative. Culture negative.

He was sent to me.</...

Posted By: Mark Crislip  

December 14, 2016

I donít care what the literature says, itís still a bad idea.

That title is heresy coming from me.

The patient is a middle aged IDDM. He comes in with fevers and pleuritic chest pain.

Blood cultures grow MRSA and the CT is consistent with septic emboli although the TTE is negative for vegetations.

The next day, 24 hours into vancomycin therapy, he complains of blurry vision and eye exam shows bilateral endopthalmitis that eventuall...

Posted By: Mark Crislip  

December 12, 2016

You woke me for for THAT ?!?

I have basically been on call since 1990. Except for weekends and vacations, the beeper is on. It is one of the reasons I refuse to use my phone as my primary contact for work: I can turn off my beeper but I cannot turn off my phone and I do occasionally want to escape medicine.

I never mind getting  called because I figure there really is no such thing as a stupid question. Someon...

Posted By: Mark Crislip  

December 7, 2016

Common and Not So Rare?

The patient presented as a fall due to urosepsis with a pan sensitive E. coli.

E. coli bacteremia is a common enough problem, at around 30-50/100,000 population, so the US has around 150,000 cases a year.

The nice thing about E. coli urosepsis is while it may kill the patient up front (that’s not the nice part) it has little predilection for caus...

Posted By: Mark Crislip  

December 6, 2016

Late Relapse

The patient, an elderly male, had sustained enterococcal bacteremia.

He had the 4 star work up: CT and TEE and no source found. No abscess, no vegetation on the valves, no clot on the pacer.

There are cases of enterococcal pacer infections. I count two on PubMed. But there are cases of everything causing an infection and Enterococcus is not high on the list and taking o...

Posted By: Mark Crislip  

November 30, 2016


The patient has ESLD and recurrent ascites. She requires a paracentesis every week to keep the fluid at a manageable level.

She is admitted for a TIPS and a tap show a jump in white cells to 350. SBP is a worry and two days later the cultures grow?

Candida glabrata.


SBP suggests either hematogenous seeding of the ascites or translocation of bacteri...

Posted By: Mark Crislip  

November 28, 2016

Antibiotic Anger

I do not suffer from road rage. I do spend a lot of time in the car going from hospital to hospital, but I listen to Audible as I drive. I am half way through The Wheel of Time, a 15 volume epic and listening to the trials and tribulations of Rand et. al' Thor (Wheel of Time joke) keeps me mellow. And Audible makes me a better driver, since I don’t speed to prolong ...

Posted By: Mark Crislip  

November 23, 2016

Another Odd Bug in an Odd Place

The title sums up one aspect of an ID practice, second only to making the diagnosis before anyone else on the list of what makes ID fun.  Yeah, I am that petty and competative.

The patient is a mostly healthy middle aged male who has a growing red, hot, tender bump on his abdomen.

Urgent care rightly suspects MRSA and gives TMP/Sulfa.

It doesn’t get better.</p...

Posted By: Mark Crislip  

November 21, 2016


The consult was a diverticular abscess in an otherwise healthy male

Cultures from the IR drainage were the usual: an alpha strep and an E. coli susceptible to everything but quinolones.

The patient was on 250 qid cephalexin.


After 31 years in the biz I have tonnes of facts in my head, many of which are of uncertain provenance. Especially in the pre-...

Posted By: Mark Crislip  

November 16, 2016

Recurrent Uncertainty

I think, of the common infectious diseases, cellulitis is the most straight forward.

Not that you suspect it from the way so many approach the disease, fretting about MRSA and Pseudomonas and giving vancomycin and pip/tazo.

And don’t get me started on how often lymphedema is called cellulitis.

Here is a semi sort of classic case of cellulitis with a twist or two.</...

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 as The Puswhisperer, Volumes 1 and 2. Really. Perfect for the pus lover in your life.
Because The World Needs More Mark Crislip (tm).
Flies in the Ointment: Essays on Supplements, Complementary and Alternative Medicine (SCAM).
A carefully selected and edited compendium of my best blog posts from The sections have been edited for redundancy, updated for 2017, and classified into themes including my influenza rants.

All on Amazon.

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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