Case Conference

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Case Conference

• November 14, 2005
• Emily Simpson, M.D.

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DisclosuresSection of Infectious Diseases

• Kevin High, M.D.
• Grant/Research Support Cubist Pharmaceuticals,
  Astellas Pharma US, Inc.
• Consultant Merck Co., Inc.
• Speakers Bureau Pfizer Pharmaceuticals
• James Peacock, M.D.
• Ownership in Common Stock Pfizer
  Pharmaceuticals
• Sam Pegram, M.D.
• Grant/Research Support Roche, Bristol-Myers
  Squibb, Gilead, Schering-Plough, Tibotec
  Pharmaceuticals
• Consultant Abbott Laboratories,
  GlaxoSmithKline, Boehringer Ingelheim, Gilead,
  Roche
• Speakers Bureau Abbott Laboratories,
  GlaxoSmithKline, Boehringer Ingelheim, Merck,
  Pfizer Pharmaceuticals

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Disclosure (continued)Section of Infectious
Diseases

• Aimee Wilkin, M.D.
• Grant/Research Support Abbott Laboratories,
  GlaxoSmithKline, Tibotec Pharmaceuticals,
  Bristol-Myers Squibb Company, Gilead
• Christopher Ohl, M.D.
• Grant/Research Support Cubist Pharmaceuticals,
  Gene-Ohm Sciences, Merck Pharmaceuticals
• Speakers Bureau/Consultant Ortho-McNeil
  Pharmaceuticals, Cubist Pharmaceuticals,
  Sanofi-Aventis Pharmaceuticals, Pfizer
  Pharmaceuticals, Bayer Pharmaceuticals

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Disclosure (continued)Section of Infectious
Diseases

• Tobi Karchmer, M.D.
• Grant/Research Support Gene-Ohm Sciences
• Speakers Bureau Pfizer Pharmaceuticals, Cubist
  Pharmaceuticals, Cepheid,
• Gene-Ohm Sciences
• Consultant C.R. Bard
• Robin Trotman, D.O.
• Speakers Bureau Pfizer Pharmaceuticals

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Case 1

• 66yo male with stage IV retroperitoneal sarcoma
  admitted with elevated INR on coumadin
• PMH
• Leiomyosarcoma
• Chemotherapy with Gemzar and Taxotere, completed
  4/05
• Malignant left pleural effusion, s/p pleuridesis
• Pasturella multocida sepsis 8 months prior
• atrial fibrillation
• PUD
• HTN
• CHF
• Prostate cancer

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Case 1

• Meds
• Coreg
• Lasix
• Ambien
• Coumadin
• Allergies
• Vanc - rash
• PCN

• Social History
• Retired meteorologist
• Former smoker
• Resides in Elon, NC
• ROS
• fatigue

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Case 1

• After reversal of coagulopathy, scheduled for
  placement of right-sided chest port in
  anticipation of resuming chemotherapy
• Placement of port complicated by perforation of
  Rt internal jugular vein and hemothorax requiring
  chest tube placement
• 24 hours later underwent R arm and central
  venography via left basilic vein normal study

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Case 1

• 7 days later
• Developed left-sided facial swelling, erythema,
  and pain along the angle of the mandible
  extending down the neck
• Symptoms developed rapidly over 6-8 hour period
• No trismus, dysphagia or respiratory distress

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Case 1

• PE
• 99.9 115/70 90
• non-toxic
• L sided-facial swelling below zygomatic arch,
  erythema tracking to neck associated tenderness
  along parotid gland
• No sinus tenderness
• OP moist, uvula midline, no tonsilar prominence
  or exudate
• thrush
• cervical adenopathy
• RRR, no murmur
• CTA bil, decreased L base, R-sided chest tube
• benign abdomen
• no other skin findings
• WBC 13,500
• CMP unremarkable

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• ID consult requested
• Differential diagnosis?
• Initial recommendations?

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• Differential diagnosis
• Cellulitis
• Sinusitis
• Odontogenic/ oropharyngeal source
• Sialoadenitis/ parotitis
• Deep fascial space infection
• Suppurative jugular thrombophlebitis Lemierre
  Syndrome

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Deep fascial spaces of the head and neck

• Masseteric space
• Buccal/ parotid space
• Retropharyngeal/ pretracheal space
• Submandibular/ sublingual spaces

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Deep fascial spaces of the head and neck

• Masseteric space
• Buccal/ parotid space
• Retropharyngeal/ pretracheal space
• Submandibular/ sublingual spaces
• Lateral pharyngeal space

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Potential pathways of extension in deep fascial
space infections
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• ID Consult
• Recs
• CT neck with contrast
• ENT consult

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Acute Suppurative Parotitis

• First described in 1836
• President James Garfield died of complications of
  suppurative parotitis following abdominal surgery
  for gunshot wound
• Extremely rare in the antibiotic era

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Acute Suppurative Parotitis

• Clinical manifestations
• fever, systemic toxicity
• rapid development of warm, indurated,
  erythematous cheek
• exquisite local pain and tenderness
• bilateral involvement 15
• inflammation of and purulent drainage from
  Stensons duct
• facial nerve dysfunction is rare and often
  associated with tumor involvement

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Acute Suppurative Parotitis

• Pathogenesis
• Ascension of bacteria through Stensons duct
• Inferior bacteriostatic activity of parotid
  secretions relative to other salivary glands
• Factors associated with infection
• elderly
• post-operative state, usually within 2 weeks
• dehydration
• reduced salivary flow
• ductal obstruction
• preexisting salivary gland disease
• immunosuppression
• alcoholism
• poor oral hygiene

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Acute Suppurative Parotitis

• Microbiology
• Most evidence is anecdotal
• Staphyloccoci predominate
• anaerobes probably important as well

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Acute Suppurative Parotitis

• Microbiology
• Brook I. Laryngoscope. 1991 101 170-172.
• Retrospective analysis of 10-year experience in a
  military hospital examining ductal specimens
  from 23 patients with acute parotitis
• Aerobic and facultative bacteria No.
• S. aureus 8
• a-hemolytic steptococci 3
• S. pneumoniae 2
• H. influenzae 2
• E. coli 1
• Anaerobic bacteria
• Peptococcus spp. 8
• Bacteroides spp. 6
• Propionibacterium acnes 4
• Fusobacterium spp. 3
• Actinomyces israelii 1
• Eubacterium lentum 1

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Acute Suppurative Parotitis

• Diagnosis
• Clinical
• Contrasted CT
• Important to exclude lateral pharyngeal space
  infection and vascular involvement
• Culture of exudate from Stensons duct
• Contamination of culture specimen with oral flora
• Peripheral blood cultures infrequently positive
• Sialography contraindicated in acute infection
  due to risk of ductal rupture

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Acute Suppurative Parotitis

• Management
• Antibiotics
• Aggressive rehydration
• Sialogogues
• Indications for surgical intervention
• lack of improvement with appropriate antibiotic
  therapy
• facial nerve involvement
• involvement of adjacent vital structures,
  including deep fascial spaces
• abscess formation
• Follow-up imaging
• assess gland parenchyma and identify
  abnormalities which may predispose to recurrence

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Acute Suppurative Parotitis

• Complications
• Sepsis
• Abscess formation
• Chronic parotitis
• Jugular vein thrombosis
• Facial paralysis

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Case 1, concluded

• Treatment included
• Broad spectrum antibiotics linezolid,
  clindamycin, meropenem
• lemon drops
• Within 24 hours, near-complete resolution of
  pain, erythema and swelling
• Linezolid was continued for one week
• Repeat infused CT several days later
• Less inflammation, no discrete mass or abscess
  identified
• Pt is doing well, without apparent sequelae of
  infection

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• Comments?

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switching gears
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Case 2

• Pt 1
• 45yo male admitted through ED with hypertensive
  emergency, SOB, hypoxemia, fever
• PMH
• Extensive prior coronary history with prior
  cardiac arrest, MI s/p PTCI, cardiomyopathy
• mild chronic renal insufficiency
• hyperlipidemia
• HIV status unknown
• Social history
• Married, monogamous. Lives in Winston-Salem.
• Formerly installed flooring
• Regular use of cocaine, last was within 24 hours
  of admission. Denies injection drug use. Smokes
  cigarettes, rare etoh consumption.
• No drug allergies
• Meds

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Case 2

• Pt 1
• PE
• temp 101 90 180/110
• well-appearing
• no mucosal lesions
• neck supple
• RRR, II/VI mid-systolic murmur
• Basilar rales
• Benign abdomen
• Chronic stasis changes bil legs
• WBC 6,900
• CMP unremarkable

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Case 2

• Pt 1
• Hospital course
• Blood cultures x2 obtained, admitted to CCU
• BP controlled achieved on home meds. No evidence
  of cardiac ischemia.
• No fever after admission
• 48 hours after admission
• 1 of 2 blood cultures obtained at admission is
  now growing GNR 0.1 CFU/ml on blood agar only
• ? ID Consult

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Case 2

• Pt 2
• 35yo female, previously healthy, transferred from
  OSH with hypoxemic respiratory failure, bibasilar
  infiltrates
• Onset of fever, malaise, productive cough, and
  SOB 1 day after returning home from vacation in
  Bahamas
• Received azithromycin at OSH without improvement
• PMH
• hypothyroidism
• anxiety/ depression
• recent pustular cellulitis treated with TMP/SMX 1
  month prior
• s/p TAH
• Allergy to PCN rash (takes Augmentin without
  difficulty)
• Social/ Family History
• Single, lives in West Jefferson with 17yo
  daughter. No pets.

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Case 2

• Pt 2
• Admitted to MICU
• BAL unrevealing
• Blood/ urine cultures negative
• Initial antibiotics
• ceftriaxone
• azithromycin
• vancomycin
• doxycycline
• HD 4 repeat tracheal aspirate with gt100,000
  CFU/ml Pseudomonas, started on Meropenem
• HD 7 ECMO initiated (6 days total)
• HD 14 hemodynamic instability, fever prompting
  reculture and change in antibiotics, adding
  fluconazole, gentamicin, linezolid to Meropenem
• HD 16 1 of 2 peripheral blood cultures
  obtained 48 hours earlier now growing GNR 0.1
  CFU/ml on blood agar only
• Same GNR isolated from tracheal aspirate (3
  growth) 7 days later

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• Thoughts?

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In both patients, GNR eventually identified as
Flavobacterium species
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Flavobacterium spp.

• Former classification scheme included
  heterogenous group of gram-negative bacteria
• environmental
• yellow-pigmented
• glucose nonfermenters
• oxidase producing
• Members of the genus Flavobacteria have been
  reclassified to other genera
• Myroides
• Chryseobacterium
• Unnamed CDC groups

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Flavobacteria spp.

• Myroides spp.
• grow on MacConkey agar
• rare clinical isolate
• case reports of bacteremia, soft-tissue
  infections
• often not considered pathogenic
• Chyseobacterium spp.
• Do not grow on MacConkey agar
• rare clinical isolate
• low virulence
• isolation usually represents colonization or
  contamination
• resistant to most antibiotics

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Chryseobacterium meningosepticum

• Formerly known as Flavobacterium meningosepticum
• Colonies of this species distinguished from
  others as being smooth and large with weak
  production of yellow pigment
• Uncommon human pathogen
• Nosocomial outbreaks are well-described
• Isolation is often clinically significant
• Historically associated with neonatal meningitis
• significant morbidity and mortality
• associated with prematurity and low birth weight
• Spectrum of infections in adults
• nosocomially acquired
• associated with immune compromise
• respiratory tract followed by bloodstream most
  common sites of infection
• Resistant to most antibiotics, but uniquely
  regarded as susceptible to vancomycin

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Chryseobacterium meningosepticum

• Bloch et al. Medicine (76)1997 30-41.
• Retrospective review conducted at UCSF between
  1984-1994
• Identified 15 positive cultures for C.
  meningosepticum in 14 patients
• 6 patients fulfilled specified criteria for
  infection
• s/s of infection referable to involved organ
  system
• isolation of the organism alone
• Dates of hospitalization of 4 patients
  overlapped, but isolates were phenotypically
  distinct

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Chryseobacterium meningosepticum

• Bloch et al. Medicine (76)1997 30-41.
• Mean age 58yrs, 2 females
• All nosocomially acquired after an avg 28 days
• All had previously received abx, avg 5 drugs
• All immunocomprimised
• 4/6 patients neutropenic at or around the time of
  culture positivity
• Clinical syndromes
• pneumonia (n3)
• Sepsis (n2)
• Cholangitis, secondary sepsis (n1)
• All responded to antibiotic therapy with clinical
  and microbiologic resolution

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Chryseobacterium indologenes

• Colonies are distinguished as being smaller than
  other species and more deeply pigmented
• Rare cause of human disease

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Chryseobacterium indologenes

• Kienzle et al. Burns (27)2001 179-182.
• Report of 3 cases of wound infections with
  Chryseobacteria species in burn patients
• 2/3 C. indologenes
• history of exposure to untreated water as part of
  their first aid treatment
• 1/3 unnamed Chyrseobacterium sp.
• First positive wound culture obtained between
  days 3-5 in all cases and from regions where
  debridement was complete
• 3/3 also had blood or tracheal cultures positive
  for same Chryseobacterium sp.

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Flavobacteria spp.

• After reclassification, there remains a
  heterogenous group of yellow-pigmented
  environmental bacteria
• Multiple unnamed CDC groups
• Rarely recovered from clinical material

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Antimicrobial susceptibility

• MIC breakpoints have not been established by
  NCCLS
• Results of disk diffusion testing are unreliable
• E test suggested as an alternative
• ß-lactamase producing
• Resistent to aminoglycosides, tetracyclines,
  macrolides

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Antimicrobial susceptibility

• Kirby, et al. J Clin Micro (42)2004 445-448
• SENTRY antimicrobial surveillance program
  (1997-2001)
• 50 Chryseobacterium spp. Isolates
• 24 C. meningosepticum
• 20 C. indologenes
• MIC breakpoints for non-Enterobacteriaceae were
  applied
• Newer fluoroquinolones most active
• 98 susceptibility
• Cipro slightly less active at 75
• Rifampin
• 86 susceptibility overall
• TMP-SMX
• 88 susceptibility overall
• Vancomycin showed poor activity
• 88 strains were intermediate

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Case 2, concluded

• Isolates in both patients ultimately identified
  as Flavobacteria group IIb
• Unlikely of any clinical significance in either
  case
• Led to prolonged hospitalization in Pt 1 and
  ordering of costly, invasive tests (TEE) awaiting
  identification
• Led to multiple harassing phone calls to the
  fellow in Pt 2
• Pt 1 ultimately discharged on po Cipro prior to
  definitive identification
• Pt 2 received no directed therapy, recovered,
  discharged to subacute rehab

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Case 2, concluded

• Pertinent points
• Our lab should be reporting identification of
  these bacteria according to current
  classification schemes
• Antibiotic sensitivity variable

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• Comments?