Summary

DOI: 10.1373/clinchem.2015.246033

A 30-year-old African American man with sickle cell disease presented with diffuse joint pain, shortness of breath, nonproductive cough, and chest pain. Chest x-ray and computed tomography scan revealed cavitary lesions in the lungs. In addition, transthoracic echocardiogram showed moderate tricuspid value regurgitation and a 3 × 2.8 cm mass at the base of the posterior tricuspid valve consistent with vegetation. Blood cultures were positive for viridans streptococci. The patient was diagnosed with right-sided infective endocarditis and started on intravenous (IV) antibiotics.



Student Discussion

Student Discussion Document (pdf)

Jalal B. Jalaly,1 Kelly K. Dineen,2 and Ann M. Gronowski1*

1Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, 2School of Law, Albert Gnaegi Center for Health Care Ethics and Bander Center for Medical Business Ethics, Saint Louis University, St. Louis, MO.
*Address correspondence to this author at: Department of Pathology and Immunology, Washington University School of Medicine, Box 8118, 660 S. Euclid, St. Louis, MO 63110. Fax 314-362-1461; e-mail gronowski@wustl.edu.

Case Description

A 30-year-old African American man with sickle cell disease presented with diffuse joint pain, shortness of breath, nonproductive cough, and chest pain. Chest x-ray and computed tomography scan revealed cavitary lesions in the lungs. In addition, transthoracic echocardiogram showed moderate tricuspid value regurgitation and a 3 × 2.8 cm mass at the base of the posterior tricuspid valve consistent with vegetation. Blood cultures were positive for viridans streptococci. The patient was diagnosed with right-sided infective endocarditis and started on intravenous (IV) antibiotics.

While hospitalized, the patient was confrontational, left the hospital frequently, and sometimes refused vital sign monitoring. During his stay, 2 subsequent blood cultures were positive for Pseudomonas aeruginosa and Candida albicans. Given his presentation and history of polysubstance abuse, concern for drug abuse through the IV catheter was raised. The patient refused to submit a urine sample for drug screening; however, blood was drawn with no objections. A serum screen for drugs of abuse was ordered. At our institution, this test requires approval by a laboratory medicine resident and is generally approved only in cases of anuria. On discussing the case with the clinical team, we discovered that the patient had refused urine drug screening and was unaware that serum drug screening was ordered.

Questions to Consider

  • Why is a urine drug screen important in this case?
  • Should informed consent be obtained to test the blood in this case?
  • How can providers select clinical care that may infringe on ethical principles?

Final Publication and Comments

The final published version with discussion and comments from the experts appears in the June 2016 issue of Clinical Chemistry, approximately 3-4 weeks after the Student Discussion is posted.

Educational Centers

If you are associated with an educational center and would like to receive the cases and questions 3-4 weeks in advance of publication, please email clinchem@aacc.org.

AACC is pleased to allow free reproduction and distribution of this Clinical Case Study for personal or classroom discussion use. When photocopying, please make sure the DOI and copyright notice appear on each copy.


DOI: 10.1373/clinchem.2015.246033
Copyright © 2016 American Association for Clinical Chemistry