INFECTIOUS DISEASES

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INFECTIOUS DISEASES CASE CONFERENCE

• Pimpawan Boapimp, MD
• Wake Forest Baptist Medical Center
• August 2, 2004

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CASE I
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HPI

• 49 y/o BM
• DM, HTN, h/o ETOH abuse
• s/p cholecystectomy in 2002
• lost 25 lbs over 4 weeks
• intermittent fever and night sweats
• and intermittent Rt flank pain x 2 weeks worse
  with inhalation

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• saw PCP labs were normal
• had CT abd and pelvis scheduled one week after
  that
• CT showed small fluid collection
• Pt was sent to ED
• denied F/C, N/V
• was seen by surgical team in ED and underwent CT
  guided aspiration by a radiologist

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CT scan Abd and Pelvis

• 4.0 x 1.7 cm low attenuation, rim enhancing
  lesion adjacent to the posterior aspect of the
  right hepatic lobe is most consistent in
  appearance with subhepatic abscess.
• This lesion contacts both the posterior aspect of
  the right hepatic lobe and adjacent abdominal
  wall.
• Status post cholecystectomy.
• Colonic diverticulosis without evidence of acute
  diverticulitis.

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• 2 CC of purulent material and blood was obtained
  and sent for C/S
• Was started on Clindamycin and admitted
• Allergy- Unasyn causes rash
• Meds - Glucotrol and Enalapril

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Physical Examination

• VS T 97.1 P 65 RR 20 BP 124/70
• PO 96 RA
• GA AO X3, NAD, afebrile
• HEENT WNL
• Neck supple
• Chest CTA bilaterally
• Heart RSR, no murmur

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Physical Examination

• Abd benign
• Ext no edema
• NS no focal deficit
• Back Rt flank pain on palpation
• LN no lymphadenopathy

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Diagnostic Data

• CBC
• WBC 6.5 Hb 13.2 Hct 38.4 Plt 282
• N 49 L 42 M 7
• CMP
• Cr 1, liver enzymes- WNL
• TTE No vegetation

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CULTURE

• Abscess STREPTOCOCCI, BETA HEMOLYTIC
  GROUP B
• SENSITIVITY MIC
• PENICILLIN G 0.06 SUSCEPTIBLE
• ERYTHROMYCIN 2
  RESISTANT
• CLINDAMYCIN
• VANCOMYCIN
• AMOX/CLAVULANIC
• MEROPENEM
• CEFTRIAXONE
• CEFUROXIME
• GATIFLOXACIN
• TETRACYCLINE 8
  RESISTANT
• TMP/SMX

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• BC no growth (after ATBs)

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• ID was consulted
• suggested bone scan, colonoscopy, TEE
• change ATBs to cefotaxime
• repeat CT abd in 2-3 weeks

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TEE

• No vegetation
• Normal LV function

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Bone Scan

• Increased radiotracer noted within the right
  maxilla. Unclear if this is within the lower
  aspect of the sinus versus within the bone.
• Clinical correlation recommended.
• Degenerative changes noted within bilateral
  shoulders and within a mid thoracic vertebral
  body.

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Colonoscopy

• Scheduled as an OPD procedure
• Was D/Cd home with Cefotaxime x 3 weeks with CT
  abd in 2-3 weeks

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CASE II
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• 84 y/o WF
• Rt hip replacement in Feb 2003
• was admitted for back pain
• one week PTA , pt started having back pain, both
  sides, band-like
• worse with movement
• sometimes pain radiated to Rt leg

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• N/V x one day
• no skin rashes
• no F/C, night sweats
• no GU symptoms

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• Allergy None
• PMH HTN, IBS, gout, OA, osteoporosis,
• Strep Gr B bacteremia in June
• 2003 Txd with dicloxacillin for
• 14 days ( TTE no vegetation)
• FHX negative
• ROS otherwise negative

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Physical Examination

• VS T 100.1 P 90 RR 18 BP 110/40
• PO 99 RA
• GA elderly WF, well-nourished, NAD
• HEENT WNL
• Neck supple
• Chest CTA bilaterally
• Heart RSR, SEM grade I-II/VI at LSB

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Physical Examination

• Abd distended but not tender, BS present
• no organomegaly
• Ext no edema
• Back mild tenderness at Lt lumbar
  paraspinal area
• NS no focal deficit

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Diagnostic Data

• UC grew E. coli -Zosyn was started
• BC grew strep/enterococci
• Vancomycin was added
• MRI showed poss. discitis at L3-L4
• TTE, TEE no vegetation
• Bone scan showed increased uptake at L1 and L4
  bodies most likely represent degenerative
  compression fractures

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• CT abd and pelvis showed ascites
• Final BC- Streptococcus Group B
• was D/Cd home with Rocephin X 6 weeks

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Group B streptococcus (GBS)

• Since the 1970s, GBS has been recognized mainly
  as a pathogen in neonates and peripartum women.
• But the incidence of adult GBS infection rose
  steadily
• Risk factors for invasive GBS infection
• -DM, malignancy, HIV
• -Liver disease

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Clinical Syndromes

• Bacteremia without clear source
• Skin and soft tissue infection
• - foot and decubitus ulcers
• - cellulitis, abscesses
• - necrotizing fasciitis
• - balanitis
• - sternal wound infections after CABG

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Clinical Syndromes

• UTI
• Pneumonia
• Bone and joint infections
• Cardiac
• - Endocarditis mainly occurs on native valves,
  involving valves Lt Rt
• - often associated with large, friable
  vegetations
• - high mortality rate
• - myocarditis/pericarditis

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Clinical Syndromes

• CNS infection
• hematogenously seeded endophthalmitis-rare
• IV catheter infection

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• Duration of therapy
• -10 days for skin and soft tissue infections
• -2 - 3 weeks for meningitis,
• -a minimum of four weeks for osteomyelitis or
  endocarditis
• Significant and rising resistance to macrolides,
  tetracyclines, and clindamycin

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• Factors associated with worse outcome - age 65
  years
• - CNS disease
• - alcoholism
• - shock
• - renal failure
• - impaired level of consciousness
• - confinement to bed

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Group B streptococcal disease in nonpregnant
adults.

• Farley MM.
• Emory University School of Medicine Atlanta, GA
• Clin Infect Dis. 2001 Aug 1533(4)556-61.
• 2-4 folds increases in incidence of invasive GBS
  infection over the last 2 decades
• rates 4.1-7.2 case per 100,000 nonpregnant adults
• Recurrent infection occurs in 4.3 of survivors.

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• Capsular serotypes Ia, III, and V account for the
  majority of disease in nonpregnant adults.
• Meningitis and endocarditis are less common but
  associated with serious morbidity and mortality.

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• GBS are susceptible to penicillin but MIC are
  4-fold to 8-fold higher than for group A
  streptococci.
• Resistance to erythromycin and clindamycin is
  increasing.

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Relapsing invasive group B streptococcal
infection in adults.

• Harrison LH, et al.
• Ann Intern Med. 1995 Sep 15123(6)421-7.
• Nov 1991- Sep 1993
• 751 residents of Maryland 18 years of age or
  older with invasive GBS infection
• 449 were nonpregnant

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• 395 patients with invasive GBS infection who
  survived the first episode
• median duration of follow up was 23 months
• 17 (4.3 95 CI, 2.6 to 6.9) had second
  episode.
• 5 additional pts had first episode after
• Sep 03
• Several patients had endocarditis or
  osteomyelitis during the second episode.

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• GBS isolates from both episodes were obtained
  from 18 of 22 patients.
• Of the 18 isolate pairs, 13 (72 CI, 46 to
  90) had identical REAC patterns.
• Recurrent infection caused by the same strain,
  the interval between episodes was shorter (mean,
  14 weeks) than that among patients with recurrent
  infection caused by another strain (mean, 43
  weeks P 0.05).

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• The second episode occurred an average of 24
  weeks after the first episode (range, 2 to 95
  weeks)
• The mean age of patients with recurrent infection
  was 60 years (range, 27 to 89 years).
• All patients had at least one serious underlying
  medical condition including cancer, diabetes,
  cirrhosis, and renal transplantation.

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• All adults with a first GBS bacteremic episode
  should have a careful physical examination to
  identify deep-site infection, i.e., endocarditis
  or osteomyelitis, and further evaluation as
  indicated.
• Patients with recurrent GBS should be routinely
  evaluated more thoroughly for deep-site
  infection echocardiography should be done during
  these routine evaluations.

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• Although the precise duration of therapy in
  patients with these syndromes is unknown, a
  prolonged course of parenteral therapy with
  antibiotic agents is warranted.