Introduction: Bacillus cereus is a gram-positive, spore-forming, facultative, aerobic rod that is ubiquitous in the environment and is traditionally associated with toxin-mediated emetic and diarrheal illness that results from consuming improperly stored food. While mainly associated with food poisoning, it can cause a variety of systemic and local infections. 

Case: 63-year-old female with history of hemochromatosis and total right hip arthroplasty 10 months prior presented with complaints of worsening right hip pain for the past 2 weeks since falling from standing height. Initial vitals were BP 82/51, HR 100, RR 26, temperature 94.6F, SpO2 100% on room air. Exam revealed a mildly tender small area of ecchymosis to the right medial thigh without fluctuance or erythema. Labs were significant for WBC 3.2K/uL with 53% bandemia, hemoglobin 7.4g/dL, lactic acid 11.9 mmol/L, and ferritin 1,807ng/mL. CT right hip showed no acute pathology. Patient was admitted to the ICU with norepinephrine gtt, broad-spectrum IV antibiotics, and volume resuscitation. Blood cultures resulted positive for bacillus cereus in 2/4 bottles in 1/2 sets. Over the next day patient had a persistent lactic acidosis despite continuous renal replacement therapy, and developed blood-filled bullous lesions to her right thigh raising concern for necrotizing infection. Bedside fasciotomy was performed discovering dusky-appearing, necrotic tissue with serous fluid collections in multiple thigh compartments. Deemed too unstable for complete debridement, family elected for comfort care, expiring around 48 hours from time of admission. 

Final diagnosis: Hemorrhagic bullous lesions and necrotizing soft tissue infection due to Bacillus cereus 

Discussion: Uniquely presented is a B. cereus bacteremia that originated from rapidly progressing, fatal necrotizing soft tissue infection despite lack of penetrating trauma and appropriate antibiotic coverage. Iron overload from hemochromatosis is hypothesized as a risk factor for b. cereus infections due to NEAT surface transporter protein upregulation.