InfectionCasePresentation Dr. Fusun ALATAS Eskisehir Osmangazi University, TheMedicalSchool, Department of ChestDiseases
39 yearsold, housewife Complaints: Cough, stomachachse, nausea, weakness, dyspnea, sweat History: Thepatient had cough, weakness, sweatcompliantsforonemonth, but suddenstartedstomachachse, nauseaanddyspneawereaddedonedayago. Smoking:No Asbest exposure: Environmentalexposurefor 24 years
PhysicalExamination : BP: 110/70 mmHgPulse: 108/min RR:18/minFever: 36.7oC RespiratorySystemExamination: VT andsonoritywasdecreased at rightbasal Crackles at rightmiddlezoneandbreathingsoundsdecreased at basal
Laboratoryfindings: Leucocytes: 10900 mm/3Hb: 13 gr/dlPlt: 135000 mm/3 Sed: 94 mm/h CRP: 27 mg/dl T.protein: 4,1 gr/dl, Alb: 2,2 gr/dl ABG: PaO2: 65 mmHg, PaCO2: 27mmHg O2Sat: %91 pH: 7,51 ECG: Sinustachycardia
Question 1: What is yourdiagnosisforthiscase? A- Lungcancer B- BOOP C- Pulmonarylymphoma D- Pulmonaryembolism E- Parapneumoniceffusion
Question 2: What do you plan fordiagnostictests ? A- BT, thoracentesis B- Ventilation-perfusionscintigraphy, thoracentesis C- Bronchoscopy D- PET-BT E- Dynamic spiral BT, thoracentesis, d-dimerlevels
d-dimer : 555,8 ug/dl
Thoracentesis: Serousfluid PleuralfluidSerum LDH (U/L) 327 403 Protein (gr/dl) 3.1 4.1 Albumin (gr/dl) 1.8 2.2 Glucose (mg/dl) 72 85 Exudate Slide: PMNL
Question 3: What is yourdiagnosis at this moment? A- Lungcancer + pulmonaryembolism B- Pulmonaryembolism C- BOOP D- Pulmonarylymphoma E- Parapneumoniceffusion + pulmonaryembolism
D- dimer No of CasesSensitivitySpecificity NPV (CI 95%) (CI 95%) (CI 95%) ClassicELISA 1579 97-99 40-46 96-99 Vidas DD 639 98-100 40-49 98-100 ClassicLatex 364 87-96 48-62 83-94 Simplired 1317 82-91 65-71 94-97 Liatest 386 98-100 29-41 96-100
Conditionscauseincreasedlevels of D-dimer • Patients in intensivecareunits • Patients at post-operativeperiod • Peripheralvesseldisease • Cancer • Inflammatorydiseases • Elderlypatients • Trauma Kelly J. ArchInternMed.162;2000
Dynamic spiral BT Diameter of mainpulmonaryartery: app. 24 mm Diameter of rightmainpulmonaryartery: app. 15 mm Diameter of leftmainpulmonaryartery: app. 12 mm Fillingdefectcompatiblewithemboluswasobserved in upperlobeposterordistalbranch of rightlung
Riskfactors • Acquired: • Age • Prolongedimmobilization / trauma / surgery • Cancer • Previous VTE • Comorbidities /obesity • Pregnancy/ Postpartum • Oralcontraceptive • Central venouscathater • Antiphospholipid antibodies • Hyperhomocysteinemia • Longtravels • Hereditary: • FactorV Leiden • ProtrombinG20210 • Deficiency of protein C • Deficiency of protein S • Deficiency of antithrombin III
SLE + APS+ steroidusagewerepresent in patient’shistory. Congenital risk factorwas not determined. Thetreatment of patientwaschangedto LMWH duetocoumadinusagehistory. Increaseddyspnea, purulentsputumandfever (38oC) wereobserved at thirdday of hospitalization.
Sputum; Gram stain: Increased PNL, ARB: (- ) Gram stain: Few gram positivecoccusand gram negativebacillus ARB: (-) Gram stain: Few gram positivecoccusand gram negativebacillus ARB: (-) Sputumculture: negative Bloodculture: negative Pleuralfluidculture: negative
Question 4: Ifthepatientwasdiagnosed as PTE andacceptedhavedepressedimmunity, whatwouldyournext plan? A- Begin3rd generationnonpseudomonalcephalosporintreatment, clinicalandradiologicalfollow-up • B- Begin 2nd generationcephalosporin,performtransthoracicbiopsy • C- Begincarbapenem, follow-uppleuralfluidwithserialthoracentesis • D- Performfiberopticbronchoscopytoevaluateintrabrochialareaandtake sterile samplethenbegincarbapenem+amicasin. Plan transthoracicbiopsy at thesame time. • E- Evaluatethepleurawiththoracoscopyandsamplingifrequired, insert thetubeandbegin 3rd generationnonpseudomonalcephalosporintreatment
FOB findings: Anypathologicalchangeswere not observedexceptextensivepurulentsecretion in tracheaandrightbronchus. Carbapenemtreatmentwasstarted. Sterile BAL: Gram stain: Gram positivecoccus, rare gram negativebacillus ARB: (-)
Sterile BAL culture : Nocardiaspp TMP-SMT wasaddedtotreatment. Carbapenemandamikacinwerestopped at 10thday of treatment.
3rd day of treatment
20 thday of treatment
Pretreatment 20 thday of treatment
Pretreatment 20 thday of treatment
Pretreatment 20 thday of treatment
Pretreatment 20 thday of treatment
PulmonaryNocardiosis • Bacterias of Nocardiaspeciesarepresent in nature, soilandwaterwidespread • Mostlysaprophyte • EdmondNocardwasfirstdescribed in animals in 1888 • Firstdescribed in humansbyEppinger in 1890 Ambrosioni J. Infection 2010; 20
Risk Factors Decreasedcellularimmunity has an important role Transplantationpatients Patientswithleukaemia PatientswithAIDS Patientswhoreceiveprolongedtreatmentswithcorticosteroidsorcytotoxictherapywereunder risk. Cases in normal hostwerealsoreported. Clark NM.Am J Transplant. 2009;9 Suppl 4:S70-7 Martinez R. CurrOpinPulmMed 2008; 14: 219-27.
Thepresentation of pulmonarynocardiosis is highlyvariablebothclinicallyandradiographically. Acute, subacuteandchronicinfectionswithNocardiaspp. havebeenreportedtocause a variety of nonspecificmanifestations, such as anorexia, cough, pleuralpain, dyspnoeaandhaemoptysis. Theincidencewaslowduetomimicedbymalignantandgranulomatousdiseases Conant EF.J ThoracImaging. 1992 ; 7:75-84. Ambrosioni J. Infections 2010; 20
Chestradiographsdemonstrate a variety of findings, such as lobarinfiltrates, cavitation, nodules/massandpleuralinvolvement. Buckley JA. J ComputAssistTomogr 1995; 19: 726-32
Specimens • Bronchialwashing • • BAL • • Sputum • • Abscesses • • Wounddrainages • Tissues • Cerebrospinalfluids Brown –Elliot BA, et al. ClinMicrobiolRev 2006; 19: 259-82.
Theorganism is weaklyacid-fast, but this is usuallylost on subculture. A modifiyeZiehl-Neelsenstain is bestfordemonstratingnocardia. Growth of theorganism in culturemaytake 2-4 weeks Theusage of moleculartechniqueslike PCR arerestricted at the moment
Treatment Therapy is recommendedfor a minimum of 6 weeks, althoughrelapsesoccurlessfrequentlyiftreatment is continuedto 12 weeks. TMP-SMZ (TMP first 4 week 15mg/kg/d, 5 month 10 mg/kg/d) Imipenem4 x 500 mg + Amikacin 1 gr/d Ceftriakson 2 gr/d + Amikacin 1 gr/d Linezolid 2 x 600 mg po • Ambrosioni J. Infections 2010; 20 • Türk Toraks Dergisi 2009; Cilt 10. Ek 5. Vol 10: Suppl 5.
Prognosis The mortality rates were 41% for PN and 64% for disseminated nocardiosis; when Nocardia disseminated to the central nervous system, the mortality was 100%. Martinez R. Respirology 2007;12: 394-400
Masslikeconsolidation Pulmonaryactinomycosis Pulmonarynocardiosis • Pulmonarylymphoma Pulmonaryaspergillosis BAC Lipoidpneumonia
