One case of sepsis

1
One case of sepsis

• Chisa Yamada, M.D.
• Montefiore Medical Center

2
Case

• 45 y/o male
• CC fever, chills, nausea, vomiting, dizziness
• HPI Patient who has cirrhosis came to ER for one
  day history of CC. He stated that he hit in his
  head at work by a box one week prior and got
  bitten by cat in left hand three days prior to
  admission. He denied palpitation, SOB. Patient
  had one episode of melena and coffee ground
  epistaxis in ER.

3
Case

• PH ethanol abuse, cirrhosis ( varices, status
  post TIPS x 2. Chronic thrombocytopenia), HTN,
  hepatitis C
• Allergies NKA

4
Case
Physical exams

• Vitals T 98.0 (104), BP 74/44, P 122, R 24, PO2
  96.3
• Neurological awake, alert oriented
• Cardiac regular rhythm, tachycardia, no chest
  pain
• Respiratory clear sound, no SOB, no cough
• Abdomen soft, no pain
• Neck supple
• HEENT PERRL, ecchymosis, nose and gum bleeding
• Skin fair, left hand with cat bite ( no
  inflammation)
• Extremities no edema

5
Case
Labs

• Gas 7.301/45.5/90.1/21.8/96.3
• CBC RBC 2.54, WBC 11.8(polys 67, bands 31,
  lympho 2, eos 0), Hb 8.4, Hct 25.1, Plt 42.0,
  PT/PTT 16.2/38.5, INR 1.6, D-dimer 1.0
• Chem Na 134, Cl 101, K 4.2, Ca 7.5, Glu 155, BUN
  43, Creatinine 1.7, SGOT 157, SGPT 34, ALP 82,
  T-Bil 14.7, D-Bil 5.5, LDH 440, Amylase 82,
  Lypase 32, CPK 127
• UA orange color, turbid appearance, pH 1.024,
  protein 100, glu negative, ketone trace, occult
  blood large, bilirubin large, nitrite negative,
  WBC 29, RBC 30-35, bacteria 2

6
Case
Images

• CXR mild CHF
• CT Head - (R)maxillary sinus hemorrhage
• Abd - Diffuse thickening of small
  bowel and colon,
• gastric varices, ground
  glass opacity at the
• base of left lung
• KUB bowel distended
• Abdominal sono sludge in gallbladder
• Duplex abdominal sono decrease of flow velocity

7
Case
Cultures

• Blood Gram negative bacillus Pasteurella
  pneumotropica identified by Vitek (Penicillin
  sensitive, Vanco resistant)
• Urine negative
• Sputum moderate candida albicans

8
Case
Hospital course

• Patient was diagnosed as septic shock leading to
  ARF and ARDS. Patient was intubated at ER and
  transferred to MICU. FFP, RBC, platelets were
  transfused. Hydration, Gentamicin, Vasopressin
  treatment were started. Since Penicillin
  sensitive Pasteurella pneumotropica had isolated,
  Gentamicin was changed to Penicillin. Although,
  WBC has been increased and fever still spikes and
  patients condition is unchanged. Patient is now
  treated by Imipenem and Vanco and under
  observation.

9
Pasteurella Species
Rare opportunistic human pathogen

• Pasturella. multocida
• subsp. multocida
• subsp. septica
• subsp. gallicida
• Pasturella. canis
• Pasturella. stomatis
• Pasturella. dagmatis

• Pasturella. pneumotropica
• Pasturella. hemolytica
• Pasturella. aerogenes
• Pasturella. caballi
• Pasturella. bettyae

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Pasteurella Species
Host

• Inhabit the oral cavity and GI tract of many
  animals causing septicemia and pneumonia
• dog, cat, mice, rat,, hamster, guinea
  pig, rabbit
• Human infection by dog (25) and cat (75) bites
• Hx of household or domesticated animal
  contact
• Cat bites Pasteurella
• Dog bites S. aureus, Staphylococcus,
  Pasteurella

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Pasteurella Species
Pathogenesis

• Toxin production
• Leukotoxin toxic to leukocytes and
  impair cellular
• response and stimulate the
  inflammatory response
• Produce polysaccharide capsules
• Antiphagocytic and aids in the
  resistance to intracellular
• killing by neutrophils
• Binding of transferrin
• Supply iron necessary for growth

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Pasteurella Species
Clinical manifestations

• Skin and soft tissue infections fever,
  cellulitis
• Bone and joint infections
• septic arthritis, osteomyelitis,
  combined both
• Central nervous system infection
• meningitis, brain abscess,
  subdural empyema
• Septicemia and endocarditis
• Respiratory tract infections
• pneumonia, empyema, sinusitis,
  bronchitis
• Intra abdominal infections peritonitis,
  apendicitis
• Others genitourinary tract, endophthalmitis

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Pasteurella Pneumotropica
Clinical cases

• Household pets
• Sometimes reported in the respiratory floras of
  persons who have pets, specially if these
  individuals have some underlying disease such as
  cirrhosis, or a neoplasm.

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Pasteurella Pneumotropica
Clinical cases

• Only several cases reported - two septicemia
• one septicemia reported with chemo
  for leukemia
• one septicemia reported with no
  underlying disease
• Treatment
• generally susceptible to penicillin,
  ampicillin,
• cephalosporins, piperacillin,
  tetracycline, erythromycin,
• chloramphenicol, ceprofloxacin,
  aminoglycosides,
• trimethoprim-sulfamethoxazole
  

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Pasteurella Pneumotropica
Cirrhosis and complications in this patient

• Portal hypertention splenomegaly
• 
  thrombo or pancytopenia
• 
  varices
• Decreased production of clotting factors in liver
• 
  bleeding
• Decreased production of complements in liver
• opsonins, chemoattractants,
  anaphylatoxins
• complement cascade (AgAb complex,
  Membrane attack complex)
• susceptible to bacterial infection,
  especially bacterias
• that have polysaccharides,
  lipopolysaccharide of cell
• wall in G(-) organism and that
  produce endotoxins

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Pasteurella Pneumotropica
Microbiological features

• Gram negative coccobacillus
• Aerobic and facultative anaerobic, non-motile,
• Grow on blood agar smooth, convex,
  nonhemolytic,
• 
  0.5-1mm in diameter
• Variable grow on MacConkey agar
• Oxidase, catalase, urease, indole, ornithine
  decarboxylase
• positive
• Acid production positive - glucose, maltose,
  galactose
• negative
  mannitol, sorbitol
• Reduce nitrates to nitrites

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Pasteurella Pneumotropica
Differential diagnosis by biochemical reaction
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Pasteurella Pneumotropica
Differential diagnosis by biochemical reaction
19
Pasteurella Pneumotropica
Diagnosis

• Culture
• Biochemical reaction
• Vitek identification
• Enzyme-linked immunosorbent assay
• PCR primer 16S rRNA

20
References

• Frebourg NB. Berthelot G, Hocq R, Chibani A.
  Lemeland JF. Septicemia due to Pasteurella
  pneumotropica 16S rRNA sequencing for diagnosis
  confirmation.J Clin Microbiol. 2002 Feb 40(2)
  687-9
• Nozu R. Goto K, Ohashi H, Takakura A, Itoh T.
  Evaluation of PCR as a means of identification of
  Pasteurella pneumotropica.Exp Anim. 1999 Jan
  48(1) 51-4
• Cuodorado-Gomez LM, Arranz-Cazo JA. Pasteurella
  pneumotropica pneumonia in a patient with
  AIDS.Clin Infect Dis. 1995 Aug 21(2) 445-6
• Holst E, Rollof J, Larsson L, Nielsen JP.
  Characterizaion and distribution of Pasteurella
  species recovered from infected humans. J Clin.
  Micro. 1992 Nov 30(11) 2984-2987
• HA Riview of Pasteurella pneumotropica, Charles
  River Laboratories, Spring 1991
• Principles and Practice of Infectious Diseases
• Color Atlas and Textbook of Diagnostic
  Microbiology
• Harrisons Principles of internal Medicine
• Medical Microbiology Immunology