Came with a Bang'''''''

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Came with a Bang.......

• Dr Neelam Doshi
• Consultant Microbiologist
• Wythenshawe Hospital
• University Hospitals South Manchester Foundation
  Trust

Occupational Zoonoses 9 July 2009
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Points to cover

• Case history, diagnosis and management
• Diagnostic dilemma
• Adverse incident
• Event meeting
• Lessons learnt
• Disease update

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Case History

• 22 y Kurdish immigrant male, EM SRFT April 2007
  9 pm
• Acute severe right testicular pain
• un able to walk and sleep
• Chills, nausea , increased urinary frequency for
  2 mo.
• No trauma, penile discharge, not sexually active
• No significant past history, drug allergy, fit
  n well
• Smokes 10 cig/d , social drinker
• Shares a house with friends

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Diagnosis

• Vitals T 37.7 C P 107 /min
• BP 93/52 mm Hg RR 18
• G/E, CVS, RS, P/A NAD
• Local Examination
• Tender, swollen right testis, normal appearance
• Provisional Diagnosis
• Testicular torsion
• Urinary tract infection
• Calculi

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Management

• Hb 12 g/dl WCC 10.5(Nf7.9)/cmm
• CRP 28 , Urine dipstick traces nitrates and
  protein
• Blood culture and MSU sent
• Plan 1am
• To theatres for testicular exploration and
  orchiopexy
• On table testis bit dusky but no torsion,
  epididymo-orchitis
• Discharged next day
• Scrotal support ,pain killers and oral
  ciprofloxacillin for 2/52 , though stilll febrile
  38 C

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Re admission

• 5 days later calls 999, EM in agony
• Swollen testis, unable to walk, vomiting ,fever
  with chills
• Pain score 8, T 38 C WCC 9.6, CRP 55,
• ECG normal, Blood cultures done .
• No English, needs interpreter
• Diagnosis
• ?Post operative haematoma
• ?Infection
• IV gent 5 mg/kg and to Urology, ciprofloxacin
  continued

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Diagnostic conundrum

• Microbiology lab phones a gram negative
  cocco-baccilli in b/c taken on first EM
  admission i.e. 8 days before
• Lab dilemma
• Aerobic growth only
• Very slow to grow on chocolate plates _at_Co2, 37
  C
• ?Haemophilus spp , ?others
• Plates left on the bench pending senior BMS
  review, several biochemical test put up for id (
  open bench)
• Day 6 of 2nd admission , aerobic bottle from a
  new b/c set shows a similar gn-cocccobaccili
• In the light of clinical diagnosis of
  epididymo-orchitis and the gram stain , medics
  thought ,?Brucella spp.

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Blood culture Grams stain
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More history

• Microbiologists and the clinician in the presence
  of the friend, at the ward
• Recent long trip in Europe on foot and back of
  lorries in un-sanitary conditions
• In UK for last 2 mo.
• Worked with cattle's/camels/sheep in past (3
  years ago) in country of origin.

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Panic......

• Isolate sent to the Reference lab at Liverpool
• All cultures and tests moved to Cat 3 lab
• Expert ID opinion Prof Beeching sought .
• Clinicians contacted to rationalize Rx to oral
  doxycycline 100 mg bd and rifampicin 600 mg bd
  for 6 weeks and to r/o deep seated infection .To
  send serum for antibodies .
• Difficult traceability of patient as illegal
  immigrant, no GP, had a friends contact no in
  PAS. Needs Kurdish interpreter.
• Now began the real panic!........

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Adverse event meeting

• Urgent meeting Lab/Medics/OH/HSE
• Event summarized
• All work done on open bench( aerosols), 6 staff
  exposed, including me and one in first
  trimester!
• OH letters to the staff about the incident,
  serum as base line and repeat at 3 and 6 mo , the
  warning s/s and wait till id confirmed .
• How things could have been done differently.

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Actions

• Future procedures and precautions
• To process all small gram negative cocco-baccilli
  and those with clinical information suggesting
  high risk pathogens , in safety cabinet .
• To raise awareness through lectures/plate rounds
• Update SOP on how to deal with high risk
  pathogens, stick it on all benches
• High light high risk spp. by usage of yellow
  stickers by clinicians
• Internal lab transfer of cultures of this
  organism

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Bang.......... the news

• Call from VLA
• Confirmed B melitensis 3
• Situation more worse
• Two staff reported flu like symptoms and
  lassitude , repeat bloods/sera taken, Doxycycline
  and rifampicin treatment dose prescribed
• Mental trauma and Fear !!
• Settled only when sera results negative and
  recovered from- what was just a flu!! None
  started the antibiotics! OH NHS records

for 30 yrs.
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Follow Up 15 days later and 2 mo
later Absolutely well , no complications, 6 w Rx
completed, Registered with a GP, Disease
notified with HPU All contacts well till date.
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Brucellosis

• Romanian skeletal remains
• Florence Nightingale and her doctor
  colleague-Crimean fever, spondylitis, and
  neurobrucellosis
• 1886 Bruce discovered the organism
• Bang Pathologist-aborted fetuses of animals
• Intracellular small, poorly staining ,gram
  negative bacilli
• 6 spp.( host and pathogenicity)-melitensis-sheep/c
  attle
• Highly infective Infective dose10 organisms
  only.
• UK free as vaccinate animals 1991, test
  /slaughter scheme, animal movement tracing.

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The disease

• Acute or insidious 1-2 mo
• Intermittent fever (undulating), headache, weight
  loss, tiredness, depression.
• Sequelae OM/ Spondylitis /Epididymo-orchitis,
  psychoneurosis, endocarditis, abortion
• Endemic areas Middle east/Mediterranean
• S. Central America, Asia, Africa, Caribbean.

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Diagnosis

• Culture slow growth B/C, Bone marrow,
  aspirates, poorly staining gram, oxidase and
  urease ,CLED no growth, no X and V ,non motile.
• 4 fold rise in sera titer
• False positive Y enterocolitica / E coli o157
• Routes respiratory/ sexual/ GI /LAI
  /bioterrorism
• High risk activities vets/abattoirs/farmers,
  lambing.
• Treatment

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Conclusions

• Sufficient clinical information
• D/D of scrotal pathologies in immigrants where
  Brucella is endemic.
• Safe working practices
• Protocols for hazardous organisms , Risk
  assessment
• Senior review in difficult isolates
• Training and communication-good
• Due concerns for the fear within staff- drug side
  effects, chronic sequelae, pregnant staff.
• Bio terrorism weapon
• Imported infection.

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References and websites

• Pappas et al. Brucellosis. N Eng J Med. 2005
  352(22) 2325 - 2336.
• Clinical Microbiology Letter Jan 1 2006, Vol 28
  (1).
• Laboratory Acquired infections Are
  microbiologists at risk?
• Young, EJ.An overview of human brucellosis.
  Clinical Infect. Disease 1995 21283-290
• Yurdakul T et al. Epididymo-orchitis as a
  complication of brucellosis .Review of 84
  cases.Urologia Internationalis, 1995, vol. /is.
  55/3(141-142), 0042-1138.
• Health Protection Agency, Colindale ,London
  http//www.hpa.org.uk Guidelines for
  Investigation of Zoonotic diseases April 2009
• CDC website.
• http//svmweb.vetmed.wisc.edu/pbs/zoonoses/-Unive
  rsity of Wisconsin

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Thanks.