ID Clinical Case Conference 8607

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ID Clinical Case Conference8/6/07

• Robert Sherertz, MD

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Case 1

• HPI
• 62 Laotian female who was admitted secondary to
  SOB that progressed over a one month period.
• Outpatient CXR showed possible infiltrates
• Chest CT as an outpatient showed nodular
  infiltrates bilaterally and patient was admitted
  for bronchoscopy

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Initial w/u Continued

• PMH
• COPD, but no clear history of smoking
• DM
• SH,FH, ROS
• unavailable secondary to lack of translator

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Initial w/u Continued

• Exam
• T 98.2, pulse 84, respirations 24, BP 103/59
• General NAD
• Neck no JVD
• Chest diffuse wheezes, rhonchi scattered rales
• Cardiac WNL
• Remainder of the exam - WNL

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Initial w/u Continued

• Laboratory
• WBC 10,900
• BC NG
• Chest CT

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Differential Dx

• Infectious
• Noninfectious

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Case 1 - Course

• Bronchoscopy
• Minimal secretions
• Scattered areas of darkly pigmented bronchial
  mucosa
• Bacterial, fungal, and AFB cultures and stains
  sent

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BAL Cultures

• Bacteria negative
• AFB negative
• Fungal culture positive, as below, and penicillium

Staib agar
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Consult Recommendations

• Any additional studies
• Treatment

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Consult Recommendations

• Any additional studies
• LP
• HIV Ab
• CD4 count
• Treatment
• Diflucan 400mg/day

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Case 1 Course Continued

• Improved for 1 month
• Declined during the second month with progressive
  SOB
• Repeat bronchoscopy refused
• ID reconsulted

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Case 1 Course Continued

• HIV Ab negative
• CD4 count 58
• New recommendations?

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Reconsult Considerations

• Fluconazole failure unlikely without prior Rx
• Khan ZU, Antifungal susceptibility of
  Cryptococcus neoformans and Cryptococcus gattii
  isolates from decayed wood of trunk hollows of
  Ficus religiosa and Syzygium cumini trees in
  north-western India. J. Antimicrob. Chemother.
  2007 Aug60(2)312-6. Epub 2007 Jun 6.
• Bicanic T, Symptomatic relapse of HIV-associated
  cryptococcal meningitis after initial fluconazole
  monotherapy the role of fluconazole resistance
  and immune reconstitution. Clin. Infect. Dis.
  2006 Oct 1543(8)1069-73. Epub 2006 Sep 7.

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Reconsult Considerations

• Noncompliance
• Denied with the help of her son translating

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Reconsult Considerations

• Additional organism(s)

Cotton Blue Wet Prep
Lung Histology
Sabarouds Agar
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Penicillium marneffi

• Third most common cause of infection in AIDS
  patients in SE Asia after TB and cryptococcal
  infection. Most common manifestations include
  fever, lymphadenopathy, pneumonia, and skin
  lesions. Dx made gt 50 of time from BM, or lymph
  node or skin Bx touch prep.
• Duong TA. Infection due to Penicillium marneffei,
  an emerging pathogen review of 155 reported
  cases. Clin. Infect. Dis. 1996 Jul23(1)125-30.
• Supparatpinyo K, Disseminated Penicillium
  marneffei infection in southeast Asia. Lancet.
  1994 Jul 9344(8915)110-3.

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Penicillium marneffi

• Occurs most commonly in the rainy season
• Chariyalertsak S, Seasonal variation of
  disseminated Penicillium marneffei infections in
  northern Thailand a clue to the reservoir? J.
  Infect. Dis. 1996 Jun173(6)1490-3.
• Galactomannan 73 of time
• Huang YT, Detection of Circulating Galactomannan
  in Penicillium marneffei Infection and
  Cryptococcosis Among Patients Infected with Human
  Immnunodeficiency Virus. J Clin Microbiol. 2007
  Jun 27 Epub.
• Coinfection with crytococcus neoformans 10
• Deesomchok A, A 12-case series of Penicillium
  marneffei pneumonia. J Med Assoc Thai. 2006
  Apr89(4)441-7.

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Penicillium marneffi

• Skin lesions

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Penicillium marneffei

• Itraconazole drug of choice

Sirisanthana T, Amphotericin B and itraconazole
for treatment of disseminated Penicillium
marneffei infection in human immunodeficiency
virus-infected patients. Clin. Infect. Dis. 1998
May26(5)1107-10. Supparatpinyo K, A
controlled trial of itraconazole to prevent
relapse of Penicillium marneffei infection in
patients infected with the human immunodeficiency
virus. N. Engl. J. Med. 1998 Dec
10339(24)1739-43. Chariyalertsak S, A
controlled trial of itraconazole as primary
prophylaxis for systemic fungal infections in
patients with advanced human immunodeficiency
virus infection in Thailand. CID
200234(2)277-84. Imwidthaya P, Penicillium
marneffei types and drug susceptibility.
Mycopathologia. 2001149(3)109-15.
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Case 1 Course Continued

• Treated with itraconazole
• At two months f/u asymptomatic, gained weight
• CD4 count remains low

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Case 2

• HPI 5/07
• 58 M admitted secondary to one month history of
  progressive LE pain below the knee with
  associated swelling, fever, and chills
• PMH
• DM, ESRD, Hypertension
• Myelodysplasia
• LE cellulitis 2004, 2/07

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Case 2

• SH
• Remote hx of smoking and Etoh abuse
• FH
• Renal failure
• ROS
• Negative except as in HPI

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Case 2

• Exam
• T 98, pulse 65, respirations 20, BP 131/67
• Extremities
• 2 or 3 nodular areas ( 2 cm in size) in both LE
  below the knee
• Remainder of exam WNL

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Case 2

• Laboratory
• WBC 2100 with 53 PMN
• Platelets 52k
• Hgb 6.6
• U/A WNL
• Urine culture NG
• Blood culture NG at 24h

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Case 2

• Course
• Rx with vancomycin with no improvement
• MRI done

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Case 2

• Course
• Continued leg pain
• No fever
• Differential Dx?

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Nephrogenic systemic fibrosis

• Affects primarily lower extremities, but can be
  fatal

Grobner T, Gadolinium and nephrogenic systemic
fibrosis. Kidney Int. 2007 Aug72(3)260-4.
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Nephrogenic systemic fibrosis

• Skin Bx Findings - fibrosis

Grobner T, Gadolinium and nephrogenic systemic
fibrosis. Kidney Int. 2007 Aug72(3)260-4.
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Nephrogenic systemic fibrosis

• Etiology
• Cases have a higher cumulative gadolinium
  exposure and higher ionized calcium and phosphate
• Marckmann P, Case-control study of
  gadodiamide-related nephrogenic systemic
  fibrosis. Nephrol Dial Transplant. 2007 May 4
  Epub ahead of print

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Nephrogenic systemic fibrosis

• Presents a dilemma when faced with evaluating the
  possibility of deep space lower extremity
  infection in setting of CRI or ESRD
• CT with contrast or MRI with contrast