INFECTIOUS DISEASES CASE PRESENTATIONS

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INFECTIOUS DISEASES CASE PRESENTATIONS

• Dr Peter Leung
• Registrar
• Immunology Infectious Diseases
• John Hunter Hospital

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INFECTIOUS DISEASES CASE PRESENTATION

• Case 1

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Ms TG

• 30-year-old female
• lives with partner
• 2 children
• Non-smoker
• Non-drinker

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Ms TG

• Works with cattle on farm
• Recent holiday to New Zealand
• No significant contact history
• No significant past medical history
• No regular medication
• No known allergies

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Ms TG

• Nov 2004, 5 week history
• Headache
• Entire head, concentrated over frontal and
  occipital regions
• Severe
• Minimal relief from simple analgesia
• Nausea, intermittent vomiting
• Neck stiffness
• Mild photophobia

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Ms TG

• Drenching night sweats
• No rigors nor documented fevers
• Weight loss of 10kg
• No weakness, no sensory changes, no visual
  disturbance

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Ms TG

• Initially presented to MBH
• CT head normal
• LP
• Protein 0.49g/L
• Glucose 3.0mmol/L
• India Ink demonstrated cryptococcus
• Diagnosed cryptococcal meningitis

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Ms TG

• MBH
• respiratory arrest post ictal
• Found in vomitus and incontinent
• Supported with bag and mask
• Patient had no recollection of events
• Subsequently transferred to JHH

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Examination Findings

• Thin
• Holding head
• Afebrile
• BP 105/70 mmHg
• PR 60 reg
• O2 Sat 100 RA

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Examination Findings

• No photophobia
• Neck stiffness (unable to flex gt30)
• Cranial nerves and PNS normal

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Initial Investigations

• Hb 106 MCV 68 WCC 6.2 Plt 301
• Na 134 K 3.7 Cr 59 urea 1.9
• LFT normal

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Initial Management

• Amphotericin B 0.5mg/kg
• Flucytosine 37.5mg/kg QID
• PICC line insertion

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Further Investigations

• Serum cryptococcal antigen titre gt11024
• HIV negative
• Repeat LP
• Cryptococcal Ag gt11024
• WCC 10, protein 0.53g/L, glucose 2.8mmol/L
• India ink positive for cryptococcus
• Cultured Cryptococcus neoformans var gattii

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Further Investigations

• Serial LPs to assess for clearance of
  cryptococcus and to relieve raised ICP
• multiple visual field tests to monitor for visual
  loss from papilloedema
• Serial CSF cryptococcal Ag levels
• MRI brain negative for cryptococcoma

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Progress

• GTC seizures
• Rx Phenytoin
• Treatment related complications
• Leucopenia from 5-FC despite in therapeutic
  range, requiring brief cessation of drug
• Hypokalaemia from Amphotericin B
• ?Cr secondary to Amphotericin B and 5-FC
• PICC site cellulitis

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Progress

• No further seizures
• No further ve cultures for cryptococcus on CSF
• ICP reduced with LPs (opening pressure 17cm
  pre-discharge)
• Subsequently switched onto Fluconazole and
  discharged home mid December 04 with follow up
  appointments arranged

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Early Jan 05

• Re-admission
• Brief admission after repeat LP by LMO
  demonstrated cryptococcus (India Ink) but
  subsequently shown to be culture negative and CSF
  Cryptococcal Ag titre 116
• Discharged home

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Mid-to-late Jan 05

• Re-presented with intractable headache
• CT and MRI showed no focal lesions
• Repeat LP demonstrated raised opening pressure of
  gt38cm H2O
• Lumboperitoneal shunt inserted with rapid
  resolution of symptoms
• Patient discharged early Feb

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Late Feb 05

• Represented after 3 days of increasing headache
• Frontal and temporal regions
• Worse in afternoon
• ?worse with straining
• Also some nausea and vomiting the day before
  admission
• Admitted for Ix and Mx

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Late Feb 05

• Examination revealed bilateral papiloedema,
  fullness around LP shunt sites at the lumbar
  spine and abdominal site
• Taken back to theatre
• Shunt was working

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Late Feb to March 05

• Ongoing worsening headache
• Repeat LP
• Opening pressure 21cm H2O
• India Ink neg for cryptococcus
• WCC 96
• Glucose 1.7mmol/L
• Protein 1.65g/L
• No growth

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Late Feb to March 05

• Repeat MRI V and review of previous MRIs
• Filling defects seen in both sigmoid sinuses
  suggesting partial thrombosis
• Rx anticoagulation

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March 05

• Depressed, non-engaging, lack of initiation
• Citalopram commenced
• Malnourished requiring supplementary NGT feeding
• Constipated with nausea and vomiting
• Drowsy from gabapentin (commenced for both
  headache and seizure control)

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Last 2 Weeks

• Hyponatraemia Na 123
• ?CNS disease ? Citalopram
• ?Extra-cranial cryptococcal deposits
• Persistently raised serum cryptococcal Ag levels
• Liposomal Amphotericin B recommenced pending CT
  chest/abdo/pelvis
• CT
• Deposits in lungs and liver

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Last Week

• Developed receptive dysphasia
• CT and MRI head showed cerebral cryptococcomas

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Last Week

• Dosage of Liposomal Amphotericin B increased
• 5-FC not commenced as previous problem with
  leucopenia
• Waiting to see if clinically responding to
  escalated treatment

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INFECTIOUS DISEASES CASE PRESENTATION

• Case 2

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Mr GC

• 50-year-old male
• Lives with mother
• Works as flagman for RTA
• Non-smoker
• Occasionally alcohol
• Admitted at JHH Dec 2004

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Mr GC

• HIV infection
• Diagnosed 1993
• Claimed to have contracted HIV from heterosexual
  contacts
• Denied IVDU
• Previously on antiretrovirals (Efavirenz/Lamivudin
  e/Abacavir) but not last 6 months secondary to GI
  intolerance
• Relatives unaware of diagnosis

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Mr GC

• AVR
• Severe aortic regurgitation
• Congenital biscuspid aortic valve
• Porcine prosthesis

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Mr GC

• Initially admitted to PMPH
• 2-month-history of lethargy
• 2-week-history of
• Back pain
• Neck pain
• Headache (bitemporal) throbbing
• Mild photophobia
• Fevers, rigors, sweats
• Nausea and vomiting since admission
• No cough/chest pain/dyspnoea/abdo pain/dysuria

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Mr GC

• Transferred to JHH following an abnormal BC
  result ve for yeast

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Medications

• Aspirin 100mg daily
• Carvedilol 6.25mg BD
• Frusemide 20mg daily
• Ramipril 10mg daily
• Bactrim 3 ? per week
• Fluconazole 400mg daily

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Adverse Drug Reactions

• Panadeine forte and morphine caused vomiting

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Examination Findings

• Looked unwell
• Photophobic
• Pain in neck on movement
• Afebrile
• BP 145/90 mmHg
• PR 55 regular
• O2 sat 98 room air

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Examination Findings

• Neck stiffness
• Well hydrated
• Systolic murmur
• No peripheral stigmata of infective endocarditis
• Chest and abdo exam unremarkable

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Initial Investigations

• Hb 161 MCV 90 WCC 5.7 neut 4.3 lymph 0.9
  plt 192
• ESR 26 CRP lt4
• Na 138 K 4.5 Cr 80 urea 3.7
• TP 74 alb 37 glob 37 GGT 149 ALP 125
  AST 28 ALT 60 bili 13
• CXR and CT head normal

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Provisional Diagnosis

• Cryptococcal meningitis with associated fungaemia
  pending identification and sensitivities from
  original blood cultures

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Blood Culture Results

• Cryptococcus neoformans var. neoformans

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Further Investigations

• Serum cryptococcal antigen
• Strongly positive gt11024
• T cell subsets
• CD4 count 40
• HIV viral load
• gt100 103/mL
• LP
• Glucose 1.8mmol/L protein 1.01g/L
• Cryptococcus neoformans var. neoformans

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Treatment

• Initially Fluconazole while waiting for further
  results
• Amphotericin B and 5-Flucytosine IV commenced
  after definitive diagnosis (had total of about 6
  weeks)
• Regular LPs to monitor CSF clearance of
  cryptococcus and to relieve raised ICP
• Antiretrovirals eventually recommenced

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Progress Last 2 Months

• Slow to respond to treatment
• Ongoing headache
• Delirious
• Verbally aggressive
• Refusal to take in oral intake
• Tendency to pull out IV access and NGT
• Deconditioning as a result of prolonged illness

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Progress

• Complications
• Acute renal impairment (? Cr)
• E. coli UTI
• Central line sepsis
• Malnutrition requiring initially TPN but
  subsequently PEG insertion and feeding
• MRSA colonisation

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However.

• Has turned the corner the last 2 weeks
• More alert
• Able to hold brief conversations
• Participating in ward physiotherapy

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What Does the Future Hold for Him

• Have to wait and see.