ID Case Conference

Yvonne L. Ballard, MD

18 March 2008

CC: “I think he has the flu”

18yo CM seen in ED with one-week h/o progressive flu-like symptoms: Sore throat Diffuse myalgias RUQ pain Nausea/Vomiting/Diarrhea Fever, to a maximum of 103º C

5 days PTA developed Right Shoulder and Left Hip pain, Productive Cough, One episode of bloody emesis. Increasing SOB.

Review of Systems:

College student with one roommate

No sick contacts

No recent trauma, no recent rashes

Had recently gone camping on an Outward Bound trip, in North Carolina. No known tick bites

Stepped on a piece of broken pyrex glass in his kitchen three weeks prior

Hallucinations for the past week

PMH: Mild Asthma as a child

Meds: None

Allergies: NKDA

FamHx: None significant

Social History:

College Student

One lifetime sexual partner, last exposure 3 months prior

Mother reports filthy home, has noted squirrels running in/out of the walls

Recent travel to NY

Travel to England, Switzerland within past year

Denies tobacco

Reports social use of Etoh, marijuana

Recent experimentation with hallucinogenic mushrooms

No h/o IVDA

EMS called to patient’s home, and made the following observations: Hypotension Left Hip Tenderness Significant RUQ Pain Decreased

responsiveness

In the ED: Febrile to 39.4 Given Zosyn,

Levaquin, Vancomycin, and Doxycycline

Hypotensive - IVF fluids administered

Pt with progressive hypoxia, intubated, and sent to MICU

Physical Examination

T 36.2, P 115, BP 112/70, RR 20, Pox 100% on 4L NCGen: SomnolentHEENT: Perrla, anicteric, Dry MM, unable to visualize OP. Neck supple.CV: Tachy, reg rhythm, no m/g/rPulm: Diffusely coarse BS with bibasilar cracklesAbd: soft, ND, RUQ tenderness to deep palpation. BS presentSkin: mild jaundice. Tenderness of the left thigh, right shoulder with limited ROM due to pain.Ext: No c/c/e. Moving all extremities.Neuro: Nonfocal

Laboratory Data

121

3.0

87

24

27

1.0110

26.437.3

87

7.3

1.5

2.0

47

2.351

312

LDH 959

13.4

2.1

4.7

Laboratory Data

Coags Normal

D-dimer 2588

Fibrinogen 423

AT III Activity 42%

Serum lactate 2.4

UA negative

Urine tox negative

?

CXR, 11/5 CXR, 11/6

Marked progressive air space opacities bilaterally in the lungs with bilateral air bronchograms. Possible cavitation or necrosis in the right lung. Left pleural effusion. Paratracheal adenopathy.

CXR, 11/11

MRI Pelvis, 11/5

Inflammatory changes of the left pelvis and proximal thigh with cellulitis, myositis of the gluteus musculature, and developing abscess in the fascial layer between the gluteus maximus and medius at the level of the left hip. No evidence for osteomyelitis.

Shoulder MRI, 11/9

Possible increased signal intensity and enhancement along the subdeltoid bursa. No evidence for osteomyelitis.

Abdominal Imaging:

CT Abdomen:1. Hepatosplenomegaly.

2. Thickened gallbladder wall and edema is concerning for cholecystitis. No gallstones were noted. Recommend ultrasound for further evaluation.

RUQ Ultrasound:

1. Sludge-filled gallbladder with marked wall thickening and pericholecystic fluid worrisome for acute cholecystitis. 2. Suggestion of intraluminal sludge or debris within the common bile duct versus ductal wall thickening. 3. Hepatosplenomegaly. 4. Mild nephromegaly.

Discussion…

BLOOD BRONCH WASH

ABSCESS SURGICAL SWAB

SURFACE SWAB

Arcanobacterium haemolyticum

Arcanobacterium haemolyticum

Isolated in 1946 by MacLean, et al.

Isolated from the pharynx of US servicemen and South Pacific natives with exudative pharyngitis

Originally named Corynebacterium haemolyticum (reclassified after genetic analysis)

Arcanobacterium haemolyticum

Gram-positive rodsFacultive anaerobesCatalase negativeNonmotile, branchingNonsporulatingGrows well on blood- or CO2-enriched medium at 37º CAt 48 hrs, each colony has a black opaque dot at the center

Arcanobacterium haemolyticum

Produces two extracellular toxins Phospholipase D (PLD)

Causes hemorrhagic demonecrosis in rabbits Neuraminidase

Human reservoirMost commonly implicated in non-streptococcal pharyngitis in adolescents and young adults Prevalence 0.4 – 1.4%, peak of 2.5% in 15-18 year olds

Male predilection and biphasic presentation Healthy young adults and immunocompromised elderly

Illnesses caused by A. haemolyticum

Pharyngitis

Skin Infections Chronic ulcers Wound infections Cellulitis Paronychia

Sepsis

CNS Infections Brain abcess Meningitis

Endocarditis

Osteomyelitis

Otitis Media

Omphalitis

Sphenoidal sinusitis

Pleural empyema

Cavitary pneumonia

UTI

SBPLinder R. Emerg Infect Dis. 1997;3:145-53.

Parija SC. BMC Infect Dis. 2005;5:68-72.

Tan TY. J Infect. 2006;53:e69-74.

http://www.emedicine.com/derm/images/1617DER0758-01.JPG

Pharyngitis

Clinically indistinguishable from GAS Clinical symptoms:

Fever (40%), Pruritis (33%), LAD (48%) Nonproductive cough and skin rash (33-67%) Pharyngeal erythema in nearly all, and exudate

present in ~70% Associated rash develops after 1-4 days of

symptoms (classically scarlatiniform)

Waagner DC. Pediatr Infect Dis J, 1991; 10: 933-939.

TY Tan, et al. Journal of Infection (2006) 53; e69-e74

TY Tan, et al. Journal of Infection (2006) 53; e69-e74

TY Tan, et al. Journal of Infection (2006) 53; e69-e74

Antimicrobial Susceptibilities

No standardized guidelines for disc susceptibilities

MICs obtained by agar dilution or E-test

Approximate sensitivities using S. aureus breakpoints

Carlson P. Eur J Clin Microbiol Infect Dis. 2000;19:891-3.

http://rfdp.seafdec.org.ph/publication/manual/antibiotics/pic42.jpg

Antimicrobial Susceptibilities

Agent MIC90 Susceptible Resistant

Penicillin 0.12 ≤ 0.15 ≥ 4

Cephalexin 2 ≤ 8 ≥ 32

Erythromycin 0.06 ≤ 0.5 ≥ 8

Doxycycline 0.12 ≤ 4 ≥ 16

Ciprofloxacin 0.5 ≤ 1 ≥ 4

Imipenem 0.015 ≤ 0.008 ≥ 0.03

Clindamycin 0.06 ≤ 0.5 ≥ 4

Vancomycin 0.5 ≤ 4 ≥ 32

TMP-SMX 8/152 ≤ 2/38 ≥ 4/76Carlson P, et. al. Antimicrob Agents Chemother. 1994;38:142-43

Carlson P. Eur J Clin Microbiol Infect Dis. 2000;19:891-3.

Similar Case ReportsPneumonia

Patient Infection Treatment

19 yo M1 Pneumonia Penicillin

15 yo F2

Pneumonia, Bacteremia, Tonsillitis

Penicillin

16 yo M3 Pneumonia Penicillin

1. Skov RL et. al. Eur J Clin Microbiol Infect Dis. 1998;17:578-82.2. Jobanputra RS et. al. J Clin Path. 1975;28:798-800.3. Waller KS et. al. Am J Dis Child. 1991;145:209-10

Similar Case ReportsBacteremia

Patient Infection Treatment

24 yo M1Bacteremia,

Sinus sphenoidalis

Surgical Drainage

Ampicillin + gentamicin + metronidazole

16 yo M2

Bacteremia,

Sinusitis,

Orbital cellulitis

Surgical Drainage

Ceftizoxime + ampicillin + clindamycin

15 yo F3Bacteremia,

TonsillitisPheneticillin

15 yo M4 Bacteremia, Pharyngitis, Meningitis

Cefotaxime 4 g IV TID

+

Gentamicin 240 mg QD1. Cook IF et. al. Med J Aust. 1981;1:366.2. Ford JG. Am J Opthal. 1995;120:261-2.3. Goudswaard J. Scand J Infect Dis. 1988;20:339-340.4. Skov RL et. al. Eur J Clin Microbiol Infect Dis. 1998;17:578-82

Similar Case ReportsAbscess/Other

Patient Infection Treatment

19 yo M1 PyothoraxCetriaxone + Metronidazole

x 1 month

30 yo M2 Breast abscessSurgical drainage

Ampicillin/sulbactam x 5 days

50 yo M2 Cellulitis, Leg abscessWound management

Ampicillin/sulbactam + netelmicin

44 yo M3 Septic arthritis Amoxicillin/clavulanate TID x 10 days

19 yo F4 Tonsillitis, exanthum Azithromycin x 5 days1. Parija SC et. al. BMC Infect Dis. 2005;5:682. Dobinsky S. Eur J Clin Microbiol Infect Dis. 1999;18:804-6.3. Goyal R et. al. Ind J Med Microbiol. 2005;23:63-5.4. Mehta CL. J Am Acad Derm. 2003;48:298-99

Arcanobacterium at UNC Hospitals

Patient Source Treatment

16 yo F Throat Unknown if treated

19 yo M Throat Surgical Swab Amoxicillin/clavulanate x 10 days

11 yo M Throat Treatment unknown

17 yo F Throat Azithromycin

22 yo M Throat IBU

13 yo F Throat APAP, IBU

18 yo MBlood, Surgical &

Surface Swab, Bronch Wash

PCN + Azithromycin

Treatment

Our treatment choice:Penicillin 4 MU IV Q4 hours + Azithromycin 500 mg IV QD

Drug MIC

Penicillin 0.023

Erythromycin < 0.016

Vancomycin 0.75

Clinical Outcomes

Hospital Day

0

10

20

30

40

50

0

200

400

600

800

1000

Temperature WBC t.Bili PLTs

PCN + Azithromycin

Chest CT, 12/2Follow Up

Repeat Cultures NegTTE/TEE NegativeComplete resolution of pulmonary symptomsWound vac placed with exceptional healingTook a semester off from school

Chest CT, 12/2