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“What empiric antifungal antibiotic would you use for meningitis?”

“What empiric antifungal antibiotic would you use for meningitis?”. UNC Wednesday Conference Case #1 Kees van Dam. HPI. 25 yo Caucasian female with history of severe Cystic Fibrosis underwent a double lung transplant on 1/10/07.

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“What empiric antifungal antibiotic would you use for meningitis?”

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  1. “What empiric antifungal antibiotic would you use for meningitis?” UNC Wednesday Conference Case #1 Kees van Dam

  2. HPI • 25 yo Caucasian female with history of severe Cystic Fibrosis underwent a double lung transplant on 1/10/07. • On 1/11/07 she underwent evacuation of a left sided hemothorax as well as takedown and revision of the left pulmonary artery anastomosis.

  3. HPI • Post-operative course further complicated by episode of asystole after central line placement (sp) resuscitation. • Renal failure thought to be due to tacrolimus. Patient had been on CVVHD since 12307.

  4. HPI • She was difficult to “wean” from ventilator but on 2/5/07 was successfully extubated. • She had been on TPN during this time. • She has required epogen for anemia and has had several blood transfusions, most recently on 2/8/07

  5. HPI • During the night of the 9th, an RN was drawing blood from the patient who appeared confused and asked RN what she was doing. Patient then began staring into space and gasping for breath. She was given narcan for possible dilaudid OD. She had twitching all over for a few hours. She was intubated. Neurology called, MRI of brain performed.

  6. MRI: 2/9/2007 • 1. Leptomeningeal enhancement, most prominently seen over the posterior parietal and occipital lobes.

  7. HPI • Critical Care Fellow on Transplant Service was preparing for LP and called ID Fellow on call with question “What empiric antifungals should we place this patient on after LP?”

  8. Past Medical History • Cystic fibrosis: • Severe pulmonary disease on 4L via NC continuously • Portal gastropathy • Hepatic disease • Pancreatic insufficiency • H/O Multi-drug resistant pseudomonas. • Massive hemoptysis in 2005. • Hypertrophic pulmonary osteoarthropathy

  9. Social History • She was living nearby in a temporary house with her father prior to transplant surgery. Had worked as social worker in the midwest. No etoh, no tobacco. Travel history unknown.

  10. Family History • M: alive. Has mitral valve prolapse. F: alive. No pmhx. Sibs: older brother no pmhx. extended family members w/ CF

  11. Medications: Antibiotics • Tobramycin 160mg IV X 1 on 01/25/07 • Fluconazole 50 IV QD started 01/23/07 02/04/07 • Ciprofloxacin 400mg IV qhs 1/25/07  presentCefepime 1g IV Q12H--> changed 2grams iv q 12--> • Vancomycin 1 gram IV 2/9/07--> • Flagyl 500 mg q 6 2/9/07--> • Acyclovir 250mg iv qday 2/907--> • Abelcet 300mg iv qday 2/9/07--> • Nystatin swish • Chlorhexadine mouth care

  12. Other Medications: • Insulin gtt • Dilaudid PCA Heparin gtt (off) • Dopamine gttCyclosporine 6mg/hr (gtt started 01/21/07) • Methylprednisolone 10mg/12.5mg I bid • Azathioprine 100mg IV qd • Nexium 40mg QD • Epoetin 4000units m/w/f • Bupivicane via thoracic epidural • Albuterol MDI q6 • ADEK vitamins po bid • Ativan • TPN --stopped today

  13. Allergies • AUGMENTIN • Keflex • Chloramphenicol • Azithromyicn

  14. PE • Tmax 37.5 maps 50-80 ,pulse in 80s, rr 18-20 pox 98 on 4L until intubation Now on SIMV 100% 10/5 Tv 500 • Primary team exam: • General: “jerking” • HEENT: NC/AT, pupils ovoid, not reactive • CV: RRR, NL no mgrLung: good air mvt • Abd: soft, no bs Ext: 2+ LE edema, clubbing present

  15. Labs: • CO2 22 • BUN 26 H • Creatinine 1.6 H • Albumin 1.6 • Bilirubin (total) 4.7 • Biliruin (direct) 4.2 • AST 66 • ALT 51 • Alk P 671GGT 314 • WBC 3.2 • HGB 8.4HCT 24.7 • Platelets 53 • Microbiology: • 2/9/07: CVAD TEMP BLOOD pending • 2/9/07: peripheral Blood pending

  16. CXR:

  17. Labs: • LP: opening pressure 20cmH20: • CSF ANALYSIS tube #14 • YELLOW • RBC 7635 • TNC 15 20 • Neutrophils 11 % Lymphocytes 22 % Monocytes 67 % Protein 295 • Glucose 63

  18. Labs: • CSF: Gram stain • 1+ PMN’s 2+ YEAST

  19. Discussion

  20. CF BAL 1/31/07: right Probable Smooth Pseudomonas aeruginosa 3+ FURTHER I.D. BY CONSULTATION ONLY Probable Stenotrophomonas maltophilia 1+ FURTHER I.D. BY CONSULTATION ONLY 1/25/07 SPUTUM INDUCED Smooth Pseudomonas aeruginosa 2+ TICARC/CLAVULAN R PIPER/TAZOBACT S IMIPENEM R CEFEPIME R CEFTAZIDIME R GENTAMICIN R TOBRAMYCIN I AMIKACIN R TRIMETH/SULFAMET R LEVOFLOXACIN R CF BAL 1/19/07:RLML: Probable coagulase-negative Staphylococcus species 1+ 2 Probable Smooth Pseudomonas aeruginosa I.D. BY CONSULTATION ONLY CF ADULT BAL 2007-01-19 at 0820 Site: RLML Probable Smooth Pseudomonas aeruginosa <10,000 ORGANISMS/ML NOTE 1/19/07 BAL RLML had been sent for VIRAL, AFB AND FUNGAL cultures and had failed to grow any organism other than candida. PNEUMOCYSTIS DF NEGATIVE CMV PCR, QUAL NEGATIVE Micro:

  21. CF TRACHEAL (PRE-TRANSPLANT LUNGS) 1/10/07: 1 Smooth Pseudomonas aeruginosa 4+ PIPERACILLIN MIC 8 S TICARC/CLAV MIC 64 S MEROPENEM R PIP/TAZO MIC 8 S IMIPENEM R IMIPENEM MIC 1 S CEFEPIME MIC 8 S CEFTAZIDIME MIC 2 S GENTAMICIN MIC 32 R TOBRAMYCIN MIC 32 R AMIKACIN R TRIMETH/SULFAMET R CIPROFLOXACIN R CIPROFLOXAC MIC 0.25 S LEVOFLOXACIN R COLISTIN MIC 2 AMIKACIN MIC 4 S AZTREONAM MIC 16 I 2 Mucoid Pseudomonas aeruginosa 4+ TICARC/CLAVULAN S PIPER/TAZOBACT S CEFTAZIDIME S GENTAMICIN R TOBRAMYCIN S TRIMETH/SULFAMET R CIPROFLOXACIN S LEVOFLOXACIN S 3 Stenotrophomonas maltophilia <1+ 3 COLONIES TICARC/CLAV MIC 64 I CEFTAZIDIME MIC >=256 R TRIMETH/SULFAMET S LEVOFLOXACIN R MINOCYCLINE S Micro:

  22. Course: • ID Abx recs: • ABELCET 5MG/KG IV QD • FLUCYTOSINE 25MG/KG QDAY WITH FLUCONAZOLE 400MG IV X1 5MG/KG IV GANCYCLOVIR QOD • CONTINUE: • CEFEPIME 2 GRAMS IV Q 12 VANCOMYCIN 1 GRAM QDAY

  23. Labs: CSF • Gram Stain: Yeast was error, there were no yeast visualizable on gram stain 2/9/07 • Fungal stain: no fungal elements • AFB stain: no organism • Crypto Ag: Negative 2/9/07 • Bacterial cultures: No growth

  24. Course: • 3PM, RN noticed anisocoria and L pupil non-reactive. • Neurology STAT dose mannitol and w/ dilantin. • Pt went for stat head Ct:

  25. CT head 2/11/07 • A right frontal ventriculostomy catheter • Diffuse sulcal effacement with thickening of the cortex. • Loss of gray-white differentiation and hypodensity in the left parieto-occipital region. • There is diffuse hypodensity of the cerebellum and brainstem. • The basilar cisterns are nearly completely effaced. • The lateral ventricles are smaller • Impression: • Worsened diffuse cerebral edema

  26. Course: • Neurosurgery saw pt: on exam she had lost cough, gag reflexes, corneal reflexes,she had flexed RUE, semipurposeful with bilateral extended LE. • Concern for herniation: placed EVD • ICP 35-40 10th-11th

  27. Course: 1/11/07 • off sedation x 1 hr • no EO, R 7mm ovular and NR and L 8 mm ovular , NR no corneals • no cough • no gag • no motor response to central pain • no oculocephalic no oculovestibular (cold calorics)

  28. Labs: CSF • Bacterial cultures: No growth • AFB: no growth • Fungal culture no growth • CSF: VDRL negative • Arbovirus Panel Serum : Negative EEE, WEE, St. Louis, Lacrosse, West Nile Virus

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