Infections without borders

Jeannette Guarner, MD

Department of Pathology and Laboratory Medicine

Emory University

Session number CS07

Conflicts: none

Disclosures:

Paid by The Emory Clinic

Worked at CDC 1997-2007, now guest researcher

Brought up in Mexico, thus funny accent

Husband, at Emory University, Chair of Global Health

Images, own and from CDC:

http://phil.cdc.gov/phil/home.asp

http://dpd.cdc.gov/dpdx/HTML/Image_Library.htm

In the past 12 months, I have not had a significant financial interest or other

relationship with the manufacturer(s) of the product(s) or provider(s) of the

service(s) that will be discussed in my presentation.

LUNG NODULES

Case 1

45 year old woman

Severe persistent

cough and shortness of

breath, no fever

10-15 pack tobacco use

Worked up for a lung

mass

Radiology: right lung

cavitary lesion

PPD negative

Bronchoscopy with biopsies negative for

neoplasia

Wedge resection

Operative report describes a large cavitary

lesion and purulent material

Material sent to pathology and microbiology

QUESTION: What is your diagnosis?

1. Cryptococcus

2. Coccidioides

3. Blastomyces

4. Histoplasma

5. Yeasts not further specified

When broad-based budding is seen in

pathology, what have cultures shown:

High percent of cultures are overgrown with

Candida.

Retrospective study, 53 patients:

Blastomyces recovered in 67%

Coccidioides immitis, Candida albicans or Aspergillus

from 4 (10%)

Thus, not all broad based-budding yeasts in the

8 to 15 micron size range are Blastomyces.

Lemos LB, et al. Ann Diagn Pathol. 2000;4:391-406.

Patel AJ, et al Am J Surg Pathol. 2010;34:256-261.

Review of more slides:

Description: Spherules with

multiple endospores (10 to

100µ in size).

Diagnosis: Spherules with

multiple endospores.

Comment: The morphology

is consistent with

Coccidioides spp.

Differential diagnosis:

Rhinosporidium seeberi

which has sporangia with

endospores but is much

larger.

Description: Yeast ranging

in size from 10 to 20µ with

broad-based budding.

Diagnosis: Broad-based

budding yeasts

Comment: The morphology

is consistent with

Blastomyces but other yeast

can present with this

morphology including

Histoplasma, Candida,

Pneumocystis, Coccidiodes

and others.

Guarner J, Brandt ME. Histopathologic diagnosis of fungal

infections in the 21st century. Clin Micro Rev 2011; 24:247-80

QUESTION: Which is the usual epidemiologic

setting of coccidioidomycosis?

1. Having lived in Mississippi

2. Being a migrant from Vietnam

3. Building a house in the outskirts of the

Sonoran Desert

4. Going camping during the summer in the

Colorado Rockies

Epidemiology: Blastomycosis

Blastomyces is isolated

from soil with high content

of organic compounds.

Blastomycosis

Epidemiology: Coccidioidomycosis

TN Kirkland, J Fierer. Coccidioidomycosis: A Reemerging

Infectious Disease. Emerg Infect Dis. 1996:2:192-199

Infectious diseases elicited

history in our patient

In 2005, had a pneumonia

on the right side, for which

she was treated with an

unknown intravenous

antibiotic and azithromycin.

Patient moved to GA in

2009.

Born in Los Angeles and lived there until 2000.

Moved to Chihuahua.

Immunoassay in urine for blastomycosis.

Bd, B. dermatitidis;

Hc, H. capsulatum;

Pb, P. brasiliensis;

Pm, P. marneffei;

Ci, C. immitis;

Af, A. fumigatus;

Ca, C. albicans;

NI, controles.

Durkin M et al. J Clin

Microbiol 2004;

42:4873

Coccidioidomycosis: Alternative

diagnostic methods

IgM and IgG measured using EIA and/or

immunodiffusion False negative serology in up to 38% of patients with

hematogenous infection and 46% of fatal cases

Urine antigens using EIA present in 71% of

patients Cross-reaction in 10% of patients with other endemic

mycosis

Mycology laboratory

Grows easily in the laboratory

(93% sensitivity)

Size

Grouping

EpidemiologyYeasts

Small

(2 -10 µ)

Histoplasma

Cryptococcus

Candida glabrata

Pneuumocystis

Talaromyces

Sporothrix

Large

(>10 µ)

Blastomyces

Coccidioides

Paracoccidioides

Chrysosporium

Parasites:

Toxoplasma,

Leishmania,

Trypanosome

Small yeasts

Large yeasts

Case 2

A 35 years old a farm

worker originally from

Central America

presented with fever

and was found to

have a lung nodule in

a Chest X ray. A PPD

was placed.

His first sputum AFB smears shows:

QUESTION: How many AFB organisms need to be

present in 1 µL of sputum so as to have a positive

smear?

1. 100

2. 1,000

3. 10,000

4. 100,000

Siddiqi K et al. Clinical diagnosis of

smear-negative pulmonary tuberculosis in

low-income countries: the current

evidence. Lancet Infect Dise 2003;3:288

QUESTION: The sputum culture exposed to light

grew the following colonies within 1 week, how

would you classify this mycobacteria?

1. Rapid grower

2. A photochromogen

3. A scotochromogen

4. Not in the Runyon classification

Runyon classification

Not in the classification: M. tuberculosis, M. bovis

Molecular methods

Xpert MTB/RIF at

the Black Lion

Hospital in Addis

Ababa, Ethiopia

Histopathology

More frequently

End of case

The patient took his treatment which included

isoniazid, ethambutol, rifampin, pyrazinamide,

and vitamin B6.

At 2 months he started treatment he started

feeling weak and having nausea. He went to a

physician and his liver function tests were

markedly elevated.

Even though isoniazid was discontinued the

patient went into liver failure and he has been

placed in the waiting list for a liver transplant.

SKIN NODULES

Case 3

41 year old male.

One month history of indurated, erythematous, paineless lesions that started in scalp and have spread.

Had visited friends in New Orleans for Mardi Gras.

Treated unsuccessfully with Bactrim.

As part of the work up an HIV test is ordered.

Sequence of HIV test positivity

Days after infection

10 15 20 25 30

Western

Blot

Rapid tests

Rapid

differential

HIV-1 & HIV-2Third

generation

(IgG/IgM)

IA

Rapid

Ag/Ab

Fourth

generation

(Ag/Ab) IA

Nucleic acid

detection

Infection

0 35

Ag/Ab= antigen and antibody; IA= immunoassays

Masciotra et al, J Clin Virol 2011

New algorithm

Western Blot

Case continues

Negative viral, bacterial and fungal cultures

Negative special stains in the biopsy for AFB,

fungi and syphilis.

RPR reactive with a titer of 1:4 (patient had been

treated for syphilis one year before)

HIV positive with a CD4 cell count of 243

QUESTION: How long does it take for the

RPR to become negative?

1. Two years

2. Five years

3. Never as it measures IgG

4. Depends on the stage

Non treponemal tests

Positives in: 80-90% primary syphilis,

100% secondary syphilis,

~70% late syphilis

Converts to non reactive after: 1 year in primary syphilis,

2 years in secondary syphilis,

5 years in late syphilis

Chronic persisters: usually biological false reaction.

In HIV positive patients, >1:4 titter may indicate active persistent infection or reinfection.

Treponemal tests

Usually positive for life as they detect IgG

against the spirochettes.

Do not detect recent infections, become positive

2-3 weeks after initial infection.

Include:

FTA-ABS: fluorescent label

TP-PA: agglutination

ELISA

Usual sequence of serologic

syphilis diagnosis

RPR

Proceed to titer &

perform

confirmatory test

Confirmatory tests

include: TP-PA, FTA-

ABS or syphilis IgG

ELISA

+

-Diagnosis of syphilis,

present

+Diagnosis of

syphilis unlikely

-

Reverse sequence of serologic

syphilis diagnosis

MMWR, February 11, 2011 / 60(05);133-137

IgG using

instrumentation

RPR

+

Diagnosis of

syphilis, proceed to

titer

Perform another

confirmatory test:

TP-PA or FTA-ABS

Patient does

not have

syphilis

-

+

-Diagnosis of syphilis,

past or present+

Diagnosis of

syphilis unlikely

-140,176

specimens

3.4%56.7%

31.6%

Case continues

Other tests negative a

biopsy was obtained

IHC

Primary and secondary syphilis rates

by state in 2010

Case 2

34 yoga instructor and

avid gardener.

Noticed insect bites after

she went on a trip to

southern Italy.

Within 3 weeks, a non-

pruritic, raised and

erythematous lesion in the

lower leg gradually

enlarged and ulcerated.

She has no

lymphadenopathy.

QUESTION:

What is your diagnosis?

A. Sporothrichosis

B. Sarcoidosis

C. Leishmaniasis

D. Hypersensitivity to insect bite

QUESTION: Which is the vector

of Leishmania?

A. Phlebotomus

B. Triatoma

C. Simulium

D. Glossina

Species

21 of 30 species infect humans.

L. donovani complex with 3 species; L.

mexicana complex with 3 main species; L.

tropica; and others.

Indistinguishable morphologically, but can be

differentiated by isoenzyme analysis, molecular

methods, or monoclonal antibodies.

90 percent of the world's cases of visceral

leishmaniasis are in India, Bangladesh, Nepal,

Sudan, and Brazil.

Clinical forms: Cutaneous

Skin lesions where sandflies fed.

One or more sores which can change in size and

appearance over time.

Painless or painful.

Some swollen

lymph nodes.

Clinical forms: Visceral

(kala-azar)

Fever, weight loss, lymphadenopathy and

hepatosplenomegaly (spleen usually more

enlarged than the liver).

Abnormal CBC: anemia, neutropenia, and

thrombocytopenia.

Some patients develop post kala-azar dermal

leishmaniasis.

HIV opportunistic infection.

Diagnosis: Microscopy

In tissue specimens,

only amastigotes are

seen using Giemsa or

H&E.

Differential diagnosis

Histoplasma (no

kinetoplast) and

Trypanosoma cruzi

(seen in muscle rather

than macrophages).

QUESTION: What is a

kinetoplast?

A. Aggregate of ribosomes

B. DNA-containing granule

C. Lysosome with ingested RNA

D. Calcified mitochondrion

kinetoplastundulating

membrane

flagellum

Diagnosis

Isoenzyme analysis: after isolation using the

biphasic medium (solid blood agar base with

defribinated rabbit blood).

Serology: useful in visceral leishmaniasis but is

of limited value in cutaneous disease; cross

reactivity with Trypanosoma.

Molecular: potential to be more sensitive and

rapid. Amplify a segment of the rRNA internal

transcribed spacer 2 (ITS2) from multiple

Leishmania species.

Treatment

Pentavalent antimonial

Liposomal amphotericin B

Miltefosin

Paromomycin

In the 10th century,

Avicenna gave

detailed

descriptions of

cutaneous

leishmaniasis

(Balkh sore).

Case

A 19 year old woman that camped with

friends in Costa Rica presents with a paiful

nodule in her back.

Some yellow white material is observed on

top of the nodule.

She has expressed the material and wants

you to look at it.

Using a magnifying glass you see:

QUESTION: What is your

diagnosis?

A. Tungasis

B. Myiasis

C. Pediculosis

Geographic distribution

Mexico to South America: Dermatobia hominis

and Cochliomyia hominovorax.

Africa south of the Sahara: Auchmeromyia

luteola and Cordylobia anthropophaga.

Mediterranean basin, Near East, and Central

and Eastern Europe: Wohlfahrtia magnifica.

United States and Canada: W. vigil.

In the New World: Cuterebra species.

Where sheep are tended: Oestrus ovis

Case

34 year old woman comes for a routine

physical exam and nodule in her right arm

is noted by her primary care provider.

She is a missionary that has spent several

months in rural Mexico.

She is referred to dermatology and a

biopsy is obtained.

QUESTION: Which bacteria has been

found to be an endosymbiont with

filarial nematodes?

A. Deinococcus

B. Salinibacter

C. Bdellovibrio

D. Wolbachia

Anterior and posterior ends of microfilariae found in

humans. A, Wuchereria bancrofti. B, Brugia malayi.

C, Loa loa. D, Onchocerca volvulus. E, Mansonella

perstans. F, Mansonella streptocerca. G, Mansonella

ozzardi.

Brugia malayi

Wuchereria bancrofti

Mansonella

Diagnosis

Sample: venous blood

Periodicity

Loa loa—midday (10 AM to 2 PM)

Brugia or Wuchereria—at night, after 8 PM

Mansonella—any time

Onchocerca—any time

Case

A 27 year old man presented with a

nodular lesion in the right thigh that

occurred after he sustained a cut while

snorkeling in the Caribbean.

There were no systemic symptoms such

as fever or malaise.

The nodule was resected.

QUESTION: What is your

diagnosis?

A. Fungus

B. Protozoan

C. Algae

D. Parasite egg

Prototheca

Only algae known to be a pathogen in humans.

Spherical, unicellular organisms 3 to 20 um in

diameter.

Reproduction is asexual – during cell maturation

the cytoplasm undergoes a process of cleavage

to form 2 to 20 endospores (morula).

The sporangia (mother cells) break under

pressure from the enlarging endospores; release

of spores is passive.

LIVER NODULE

Case 5

21 year old man from New Zealand.

Came to US to get a masters in epidemiology.

Presents with fevers, headache and abdominal

pain that have been going on for 3 days.

Temp 38.9°C; BP 105/54

Exam: tenderness to palpation in LUQ

Labs: WBC 14.1 (normal 4.2-9.1); platelets

104,000; ALT 200 (normal <45); AST 172

(normal 15-41); ALP (97 (normal 32-91)

Differential diagnosis

Sepsis

Abdominal MRI demonstrated a 12x9x9

cm septated left liver lobe mass:

Echinococcosis

Amebiasis

Pyogenic liver abscess

Neoplasia

QUESTION: Which of the following

is the definitive host of

echinococci?

A. Dog

B. Horse

C. Sheep

D. Cow

Echinococcosis

Echinococcosis

Echinococcus: radiology

M Stojkovic et al: PLOS Neglected Tropical Diseases. 2012

Echinococcus: cytology & histology

Echinococcus: laboratory diagnosis

Antibody detection: False-positive

reactions may occur in persons with other

helminthic infections, cancer, and chronic

immune disorders. Negative results do not

rule out echinococcosis.

Methods: Indirect hemagglutination (IHA),

indirect fluorescent antibody (IFA) tests,

and enzyme immunoassays (EIA).

Amebiasis

Entamoeba dispar

and E. histolytica are

morphologically

identical.

E. histolytica: wide

disease spectrum:

asymptomatic,

dysentery,

liver abscess

Serology

Tests

Back to our case

Streptococcus anginosus

ArginineVP

Streptococcus anginosus group

The group includes: S. constellatus, S.

anginosus and S intermedius. (previously called

milleri).

Produce acetoin from glucose (characteristic

buttery odor --Voges-Proskauer test), ferment

lactose, trehalose, salicin, and sucrose, and

hydrolyze esculin and arginine.

Produce pyogenic abscess.