A 64-year-old woman with a history of diabetes mellitus, rheumatoid arthritis, and bilateral total knee replacements presented with complaints of fever and bilateral knee pain. She was hypotensive and required treatment with norepinephrine in the intensive care unit. She also received intravenous doses of cefazolin and gentamicin. Over the next 24 hours, the patient’s condition stabilized clinically. Cultures of blood and fluid from the knee effusions all eventually grewStreptococcus agalactiae . The antibiotics were changed to penicillin G, 3 million units intravenously every 6 hours.
Five days later, the patient began to have melena. Her hemoglobin had gradually decreased from 14.1 to 8.0 g/dL. Emergency upper endoscopy revealed dozens of small black ulcers involving the gastric body and fundus (A through C ). The gastric antrum was spared. Gastric biopsies were negative for Helicobacter pylori . The ulcers were believed to be stress ulcers related to the patient’s episode of septic shock. The patient was treated with omeprazole 20 mg twice daily for 2 months. She had no further bleeding during 9 months of follow-up.
David M. Felig, MD and Ciro J. Carafa, MD
Hackensack University Medical Center, Hackensack, New Jersey
Published in issue: Gastrointestinal Endoscopy, Vol. 51, Issue 5, Page 596, May, 2000