A 40-year-old man with a 6-year history of insulin-dependent diabetes mellitus and abuse of alcohol and cocaine was admitted to Barnes-Jewish Hospital with altered mental status and abdominal pain. The patient’s blood sugar was 1,755 mg/dL, with a sodium concentration of 116 mmol/L and an anion gap of 34 mmol/L. A diagnosis of diabetic ketoacidosis was made, and the patient was transferred to the medical ICU, where he was treated with IV fluids and insulin. CT of the abdomen was performed, revealing severe acute pancreatitis without evidence of necrosis or pseudocyst formation. As part of the routine surveillance carried out in the medical ICU, a nasal swab culture was performed and found to be positive for CAMRSA. The patient was treated with imipenem for the pancreatitis and was intubated on the third hospital day for respiratory failure attributed to noncardiogenic pulmonary edema with the presence of new pulmonary infiltrates. Acute renal failure also developed on the third hospital day necessitating hemodialysis. On the fourth hospital day, vancomycin, 1.5 g bid, was empirically added to his medical regimen due to progression of the radiographic infiltrates. Over the next 4 days, vancomycin trough levels were obtained that were 18.0 g/mL, 18.5 g/mL, and 35.3 g/mL, respectively. A chest radiograph on the ninth hospital day revealed a cavitary lesion within the right-side infiltrate that was confirmed by CT (Fig 4
). Blood culture findings and BAL performed after receiving 3 days and 7 days of vancomycin, respectively, were positive for PVL-positive CAMRSA (> 105 cfu/mL from the BAL fluid). Transesophageal echocardiography findings were negative for any lesions on the heart valves. The patient was switched to linezolid, 600 mg bid, and rifampin, 300 mg q8h. His medical condition gradually improved while completing a 14-day course of linezolid and rifampin, and he underwent a tracheostomy after 11 days of mechanical ventilation. He was subsequently transferred to a long-term care facility for weaning of mechanical ventilation and physical rehabilitation.