Infectious Diseases Emergencies

Case 1 Infectious Diseases Emergencies Henry F. Chambers, MD • 34 y/o M, HIV+ since 1991. CD4 207 (nadir 156), VL 58K. • 1 year ago +RPR of 1:128; R...
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Case 1

Infectious Diseases Emergencies Henry F. Chambers, MD

• 34 y/o M, HIV+ since 1991. CD4 207 (nadir 156), VL 58K. • 1 year ago +RPR of 1:128; Rx benzathine PCN weekly x 3. • RPRs @ 3 mo: 1:128; @ 6 mo 1:64; @ 8 mo 1:64; currently 1:64. • Asymptomatic until right sided Bell's Palsy • LP : OP 18, WBC 27 (97% lymphs), glucose 58, protein 59, RPR negative • Discharged to home on acyclovir

What is the Best Course of Action?

What is the Best Course of Action?

1. 2.

1. 2.

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Add prednisone to the acyclovir regimen, repeat LP Treat for neurosyphilis with benzathine penicillin 2.4 mU once weekly for 3 doses, then repeat LP Send CSF FTA-ABS and if this is positive treat for neurosyphilis with benzathine penicillin 2.4 mU once weekly for 3 doses Send CSF FTA-ABS and if this is positive treat for neurosyphilis with 14 days of high dose intraveneous pencillin Treat for neurosyphilis with 14 days of high dose intravenous penicillin regardless of CSF FTA-ABS

Case 2 • 45M with AIDS, MSM, marginally housed • ARV’s recently restarted, CD4 35 and VL 11K • H/o latent syphilis (never adequately treated), HBV, HCV, active IVDU. • New onset blindness x1 day, affecting the right eye. • Cough, SOB, fevers, and weakness x1week. • Decreased hearing from the right ear x3days.

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Add prednisone to the acyclovir regimen, repeat LP Treat for neurosyphilis with benzathine penicillin 2.4 mU once weekly for 3 doses, then repeat LP Send CSF FTA-ABS and if this is positive treat for neurosyphilis with benzathine penicillin 2.4 mU once weekly for 3 doses Send CSF FTA-ABS and if this is positive treat for neurosyphilis with 14 days of high dose intraveneous pencillin Treat for neurosyphilis with 14 days of high dose intravenous penicillin regardless of CSF FTA-ABS

Exam VS: T 35.9, BP 94/62, HR 80, RR 18, 95% (6LFM) GEN: Moderate distress, ill-appearing. Cachectic. NECK: supple. COR: no murmurs. RESP: Crackles and egophony at R base. Using accessory muscles. SKIN: no rashes. No peripheral manifestations of endocarditis. No e/o abscesses or cellulitis. NEURO: AAOx4. Non-focal

CXR on admission

What is the Diagnosis? 1. 2. 3. 4. 5.

MRSA endocarditis Pneumococcal pneumonia & bacteremia Neurosyphilis Klebsiella pneumonia & bacteremia Pneumocystic pneumonia with ocular involvement

What is the Diagnosis? 1. 2. 3. 4. 5.

MRSA endocarditis Pneumococcal pneumonia & bacteremia Neurosyphilis Klebsiella pneumonia & bacteremia Pneumocystic pneumonia with ocular involvement

More History

Case 3 • 69 y/o Chinese male redness in left eye but w/o pain or vision loss • Iritis and multifocal choroiditis • RPR – neg, • ACE level – wnl, • PPD – “positive” (unknown size), CXR negative • HLA-B27-neg

• PMH: none; MEDS: none • Travel history – – – – – –

Lived in central and NE China for ~ 50 years 1995: Harrisburg, PA for 1 year 1996-98: Returned to China 1998-99: Cincinnati, OH for 15 months 1999 to present: Pleasanton, CA Has driven to LA on 5-6 occasions

• Occupation history – Agriculture teacher – Chef in Chinese restaurant

• HIV risk factors: none • Enjoys gardening, he did go caving once in CA

Direct fundoscopic exam Initial Exam • VS: AF, VSS • GEN: well appearing, pleasant, NAD • HEENT: oropharynx clear, minimal left scleral/conjunctival injection, EOMI • Fundoscopic Exam: OS multifocal choroidal lesions with scleral thickening • Remainder of exam: normal

Arterioles Optic cup

Multifocal choroidal lesions

Fovea Optic disc Vein

MRI Brain/Orbit • CT scans to determine extent of disease and to find alternate site for biopsy

• Enhancement of the lateral aspect of the left sclera, lacrimal gland, and lateral rectus • T2 enhancement within the left globe. • Lesion not amenable for biopsy • Concerning for ocular lymphoma

• Bronchoscopy w/ Wang needle bx of LN – Areas of necrosis in bronchial tree at lingular/left main take off, corresponding to node between LM and aorta – FNA: budding yeast forms, likely c/w crypto vs. cocci vs. histo; does not have appearance of candida, and specimen is from within node itself

– Necrotic lymph node in mediastinum between left main bronchus and aorta – Calcified lymph node within mediastinum in subcarinal space – Two calcified granulomas in left lung

• On hospital day #3 (after 2 doses of Ambisome) ophtho felt that exam was improved from week prior • Serology - serum CRAG – neg, HIV – neg, Urine histo antigen – neg, Histo CF Ab – neg, Cocci CF Ab – neg, Blasto Ab – neg • Ambisome was discontinued • Patient discharged on voriconazole

1 week later…. • Eye exam: resolution of eye findings • F/u scans: resolution of eye findings, decrease in uptake of mediastinal lymph node • Microbiology lab reports positive results from lymph node culture

What Organism Had the Laboratory Isolated? 1. 2. 3. 4. 5. 6.

What Organism Had the Laboratory Isolated? 1. 2. 3. 4. 5. 6.

Blastomyces dermatitidis Histoplasma capsulatum Penicillium marneffei Sporothrix schenckii Coccidioides immitis None of the above

Tuberculous Chorioretinitis and Lymphademitis

Blastomyces dermatitidis Histoplasma capsulatum Penicillium marneffei Sporothrix schenckii Coccidioides immitis None of the above

• 1/3 samples from bronchoscopy positive for Mycobacterium tuberculosis • Budding yeast on original path specimen upon review felt to be an artifact

Case 4

Physical Exam

• 56 y/o M w/ h/o HTN, hyperlipidemia • Complain of respiratory distress and cough for 1 day. • T= 101.7, tachypenic into the 30s and O2 saturation 90% on 100% face mask

• VS: 101.7, 154, 24, 151/82, 90% on 100% FM • GEN: altered MS, resp distress • Oral-clear, Neck-supple • Chest-Bilat scattered rhonchi • CV-tachycardic, regular • Abd-obese, NT • Ext-Symm ROM • Neuro-altered but alert, GCS=15

LABS • • • •

Which of Antimicrobial Regimen Would You Choose? 1. 2. 3. 4.

Ceftriaxone + doxycycline Levofloxacin Ceftriaxone + azithromycin Vancomycin + piperacillin/tazobactam + azithromycin 5. Clindamycin + vancomycin + piperacillin/tazobactam + levofloxacin

WBC = 19.1, Hct =56, Platelets = 341 C02 – 19 Cr-3.2 7.23/46/78

History • • • • •

Ceftriaxone/doxy administered Patient admitted to the ICU Patient intubated for worsening hypoxia Vasopressors for refractory hypotension Antibiotics changed to Vancomycin/Piptazo/Azithromycin • Post-intubation CXR obtained (4 h after admission)

• Extensive consolidation of much of the right lower lobe. Somewhat complex cavities are seen at the posterior medial mid right lower lobe. • Right upper lobe surrounded by approximately 2 to 2-1/2 cm thickness of pleural fluid. Pleural fluid also present in the dependent right lower chest.

Hospital course cont.

Diagnosis? 1. Community-associated MRSA pneumonia 2. Pneumococccal pneumonia 3. Pseudomonas pneumonia 4. Streptococcus pyogenes pneumonia 5. Klebsiella pneumonia 6. Legionella pneumophila pneumonia

• IR guided thoracentesis that evening had “3+ gm + cocci some in pairs” on gram stain

Hospital course cont. • 5 hours later the patient went into cardiac arrest and then died. • Cultures from blood x 2, sputum, and pleural fluid revealed gram + cocci.

Streptococcus pyogenes (GAS)

Case 5 • 35 yo Kenyan female, 38 wks gestation • Fevers for 2 days • Cough w/scant yellow-white sputum, sore throat, myalgias • No SOB, CP, N/V/D, abd pain, HA

Physical Exam • • • • • • • • •

Labs

VS: 37.5, 115/62, 76, 18 (98% on RA) Gen: diaphoretic, NAD HEENT: normal Lungs: normal CV: 1/6 systolic murmur Abdomen: gravid uterus Extremities: trace ankle edema Neuro: non-focal Late decelerations noted on fetal exam

136

106

Hgb 12

6 89

3.4

22

0.8

WBC 12.2 (90% PMNs)

Plt 103 Hct 34

INR 1.2 DFA: influenza A and B, parainfluenza virus 1, 2, and 3, adenovirus, RSV all negative CXR and EKG: not obtained

Hospital Course

Readmission

• Admitted for induction of labor • Prior positive GBS culture → penicillin • Worsening fetal distress → OR for low forceps delivery of a healthy 7# baby girl • The next day the patient c/o shaking chills, but was afebrile and discharged home

• Returns to ER the next day • Persistent fevers, chills, worsening SOB, left sided chest pain, productive cough • No HA, N/V/D, abdominal pain, rash • VS: 35.1 117/70 95 20 (88% on RA)

Labs 133

103

Hgb 11.5

19 89

3.6

17

WBC 2.0

1.0 (95% PMNs)

Liver panel within normal limits

Plt 147 Hct 32

Additional History

Hospital Course

• Traveled to Kenya while 5 months pregnant; worked with HIV+ pts in a TB clinic; went on safari but no animal contact • No malaria ppx; noticed insect bites • Traveled to Idaho two months prior to visit her brother is a vet who takes care of pregnant animals

D 1-2

Vanco added

ICU

Blood cx drawn

DFA neg

Intubated for resp. failure

Antibiotics

BAL: mucopurule ucopurule nt secretions

D 4-5 ↑ consol. Hydro PTX Chest tube

D 5-8 Persistent air leak, 2 more chest tubes

Vanco/mero/levo

Hospital Course (cont.) D9

D 8-10

ECMO

FiO2 1.0 Peep 8

D 11

Thoracotomy for trach, debridement of Flucon necrotic L lung, added subtotal resection of LUL & LLL Vanco/mero/levo/fluconazole

Sputum: OF

CXR: ↑RLL RLL consolidation

CTX/Azithro/Vanco

Negative Lab Results

Hospital Course (cont.) D4

D 3-4

↑ hypoxia

CTX/Azithro

New abx

D 2-3

• • • • • • • • • • •

Multiple blood and sputum cx Legionella cultures and antigen negative Mycoplasma IgM negative (IgG positive) HIV: antibody neg; viral load 50 RBCs, otherwise normal – HIV negative

• Non-contrast head CT: negative • TTE: Mobile 2.1x1.7 cm aortic valve, with valve ring abscess • 3 blood cultures negative (no prior antibiotics)

Head CT Hospital Course • Initially treated with levofloxacin, then switched to ceftriaxone/ampicillin • HD#10: new RLE weakness

Multiple lesions in the brain c/w septic emboli with hemorrhagic conversion

Head CTA

Hospital Course • LP findings: – WBC 104 (78N, 18L, 4M), RBC 97, protein 356, glucose 17 – GS: many WBCs, no organisms (although initially read as gram positive rods) – Cx: negative

• Persistent fevers: vancomycin and doxycycline added • HD#15: acute loss of pedal pulses bilaterally Multiple small (~2mm) mycotic aneurysms

CT of Abd/pelvis

Splenic infarct

Renal infarcts

CT Pelvis/legs

Final Diagnosis? 1. 2. 3. 4. 5. 6.

Gram Stain 100X

Hemophilus aphrophilus Brucella melitensis Abiotrophia defectiva Aspergillus fumigatus Chlamydia psittici Listeria monocytogenes 45 degree angle branching

Embolus cultures

blood brain heart infusion flask

potato flake agar

Aspergillus fumigatus Case 2

Septate hyhae