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ID Case Conference

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 103 º C

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ID Case Conference

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  1. ID Case Conference Yvonne L. Ballard, MD 18 March 2008

  2. 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.

  3. 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

  4. PMH: Mild Asthma as a child • Meds: None • Allergies: NKDA • FamHx: None significant

  5. 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 Social History:

  6. 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

  7. Physical Examination • T 36.2, P 115, BP 112/70, RR 20, Pox 100% on 4L NC • Gen: Somnolent • HEENT: Perrla, anicteric, Dry MM, unable to visualize OP. Neck supple. • CV: Tachy, reg rhythm, no m/g/r • Pulm: Diffusely coarse BS with bibasilar crackles • Abd: soft, ND, RUQ tenderness to deep palpation. BS present • Skin: 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

  8. 121 87 27 110 3.0 24 1.0 Laboratory Data 7.3 2.0 1.5 13.4 47 312 4.7 26.4 87 51 2.3 2.1 37.3 LDH 959

  9. Laboratory Data • Coags Normal • D-dimer 2588 • Fibrinogen 423 • AT III Activity 42% • Serum lactate 2.4 • UA negative • Urine tox negative ?

  10. 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, 11/5 CXR, 11/6

  11. CXR, 11/11

  12. 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.

  13. Shoulder MRI, 11/9 Possible increased signal intensity and enhancement along the subdeltoid bursa. No evidence for osteomyelitis.

  14. 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.

  15. Discussion…

  16. BLOOD BRONCH WASH SURFACE SWAB ABSCESS SURGICAL SWAB Arcanobacterium haemolyticum

  17. 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)

  18. Arcanobacterium haemolyticum • Gram-positive rods • Facultive anaerobes • Catalase negative • Nonmotile, branching • Nonsporulating • Grows well on blood- or CO2-enriched medium at 37º C • At 48 hrs, each colony has a black opaque dot at the center

  19. Arcanobacterium haemolyticum • Produces two extracellular toxins • Phospholipase D (PLD) • Causes hemorrhagic demonecrosis in rabbits • Neuraminidase • Human reservoir • Most 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

  20. 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 SBP Illnesses caused by A. haemolyticum Linder 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

  21. 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.

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

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

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

  25. 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

  26. Antimicrobial Susceptibilities Carlson P, et. al. Antimicrob Agents Chemother. 1994;38:142-43 Carlson P. Eur J Clin Microbiol Infect Dis. 2000;19:891-3.

  27. Similar Case ReportsPneumonia 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

  28. Similar Case ReportsBacteremia • Cook IF et. al. Med J Aust. 1981;1:366. • Ford JG. Am J Opthal. 1995;120:261-2. • Goudswaard J. Scand J Infect Dis. 1988;20:339-340. • Skov RL et. al. Eur J Clin Microbiol Infect Dis. 1998;17:578-82

  29. Similar Case ReportsAbscess/Other • Parija SC et. al. BMC Infect Dis. 2005;5:68 • Dobinsky S. Eur J Clin Microbiol Infect Dis. 1999;18:804-6. • Goyal R et. al. Ind J Med Microbiol. 2005;23:63-5. • Mehta CL. J Am Acad Derm. 2003;48:298-99

  30. Arcanobacterium at UNC Hospitals

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

  32. Clinical Outcomes PCN + Azithromycin

  33. Chest CT, 12/2Follow Up • Repeat Cultures Neg • TTE/TEE Negative • Complete resolution of pulmonary symptoms • Wound vac placed with exceptional healing • Took a semester off from school Chest CT, 12/2

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