View
42
Download
0
Category
Tags:
Preview:
DESCRIPTION
Case #1. Alexa Simon MSIV September 19, 2007 UNC Infectious Disease. CC: Nausea vomiting, fever. - PowerPoint PPT Presentation
Citation preview
Case #1
Alexa Simon MSIVSeptember 19, 2007
UNC Infectious Disease
CC: Nausea vomiting, fever
HPI: 56 y/0 AAF with history significant for ovarian cancer stage IIIC with a complicated surgical history including debulking surgery in 2005, ileocecal resection, and recent repair of enterocutaneous fistula presented to Johnston Memorial with acute onset of nausea, vomiting, fever and abdominal pain.
HPI cont….
At JM she was found on CT scan to have fluid collection in the anterior subcutaneous tissue.
She was started on Zosyn
Patient was transferred to Gyn/Onc at UNC and started on Ceftazidine and Flagyl.
HPI cont….She progressively became more hypotension with
increasing 02 requirements:
Became obtunded and ID consult team was paged.
The Ob/gyn resident ended phone call to ID saying “I need to go intubate the patient.”
Tumor HistoryPrior to 2005 was healthy9/2005: Presents with abdominal pain
CT with massive ascites and 2 large adnexal masses CA-125>300
9/29/2005: Ex-laporatomy BSO with iliocecal resection, Re-anastomosis omentectomySuboptimal debulking massPE with attempted VIR for embolectomy of saddle
embolusMultiple MIsTPN dependence begins
12/2005: Chemotherapy began with Taxol7/2007: Repair enterocutaneous fistula
Infection History10/2006: Candida albicans and coagulase negative
staphylococcal infection at port site Rx: Fluconazole and daptomycin for 2 wks
11/2006: Candida parapsilosis fungemia Rx: Capsofungin with 8 wks
1/2007: Coagulase negative staphylococcal and ampicillin sensitive enterococcal bacteremia
Rx: Daptomycin
3/07: Coagulase negative staphylococcal bacteremia Rx: Daptomycin
7/2007 coag negative staph line infection and UTIs with enterococci and candida Rx: Linezolid and fluconazole
Additional HistorySH:
Patient denies alcohol, tobacco, drugs
Family History Mother had ovarian cancer Father had prostate cancer
ROS: unobtainable due to intubation and sedation
Additional HistoryMeds
Ceftazidine 2g IV q12 Flagyl 500mg q12 Linezolid 600mg q12 Micafungin 100 mg IV
QD Dopamine GGT Morphine PRN Benadryl PRN Phenergan PRN Zofran PRN
Allergies
Zosyn: Rash Ace Inhibitors: Rash Vancomycin: Rash PCN: Rash Zofran: Rash
Physical ExamVitals: Tmax 36.8/Tc: 35.9 BP:110/58 P:87 CVP:14-17
Vent: SIMV PS:10 PEEP:5 FIO2%:40 TV 600 Rate 16General: Intubated, withdraws from pain 6-7/THEENT: Icteric, PERRLA, no LADCV: RRR 2/6 holosystolic murmur, non radiating on left
sternal border; no rubs or gallopsLungs: Crackles Bilaterally at basesSkin: jaundiced, no rash or bruising notedAbdomen: tender throughout, no rebound, hypoactive
bowel sounds; multiple surgical scars, with palpable subcutaneous midline mass (not fluctuant)No hepatosplenomegaly appreciated
Extremities: 1+ pitting edema bilaterally
Labs:
Ca:7.4 Mg:1.9 Phos:4.6GGT:122Differential:
ANC: 18.0↑ALC:0.8AMC: 0.8AEC:0.2ABC: 0
20.7
27.5
9.2
51139
3.1
112
14
31
181
20.4
1.571
84 74
21.6
2.26.2
RadiologyRUQ US:
Lack visualized flow in portal veins/SMV, some echogenic material in portal veins concerning for clot
Hepatomegaly
New extrahepatic biliary ductal dilations
CT Adomen/ Pelvis
RadiologyCTA Abdomen:
Fluid collections contain focal area of gas with density within the soft tissues overlaying a anterior abdominal wall may represent abscess
Increase in the size of multiple high density lesions seen in the liver, which contain calcifications.
Low density fluid in pelvis collection with in abdomen c/w ascites
Stable Left pleural effusion
DISCUSSION………..
TTE:Left Ventricle: hyperdynamic EF: 65-70%Mitral Valve: thickened with mild prolapse, moderate regurgitationAortic Valve: trileaflet with mild thickeningRight Ventricle: normalTricupsid Valve: mild thickening with mobile echo from the atrial surface consistent with degenerative, disease and vegetation, with mild regurgitationPulmonary Valve: not well imagine
Microbiology:
Urine Culture: gram positive cocci in chains
Blood Culture (peripheral and central line):GPCs in chains and GPRs
Abdominal abscess: GPCs in chains
Infectious Disease DiagnosisBacteremia:
Enterococci (ampicillin sensitive, but gentamicin R) Bacillus cereus
Endocarditis of the tricuspid valveAntibiotics used: Imepenem/cilastin and
daptomycin used to treat for 12 weeks
B. cereus now…
Bacillus cereusCommonly found in soil, inanimate objects,
and mucus membranes healthy peopleGram positive motile rods with paracentral
sporesTaxonomy of 3 groups: large cell subgroup,
small cell, mixedLarge group is B. anthracis and cereusThey differ by fewer 9 nucleotides
Bacillus cereus cont’d…Grows on blood agar as large flat, granular,
ground glass, beta-hemolytic Grows aerobically and a facultative anaerobeContains catalase, hemolysins, beta-lactamases,
oxididaseFerments glucose, maltose, sucrose, trehalose
Does not ferment lactose, xylose, mannitolResistant to heatMotile
Bacillus cereus ToxinsEnterotoxin- can be necrotizingEmetic toxin- mitochondrial toxin
Inhibits mitochondrial fatty-acid oxidation Can cause liver failure
Phospholipases- release lysozyme enzymes (like alpha toxin c. perfringens)
ProteasesHemolysins-causing cell lysis of leukocytes and
macrophagesBeta-lactamases thus resistant to most PCNs
Bacillus cereus Infections1: Local (burns, trauma, post op, fulminant eye
infections)2: Bacteremia/septicemia3: CNS4: Respiratory infection5: Endocarditis, pericarditis6: Food poisoning, toxin inducedIncrease in non-food poisoning in IVDU, neonates,
malignancy, AIDs, prosthetic partsMost common form is GI intoxication from spores by
enterotoxins
Food-PoisoningOccurs 6-8hrs after ingesting B. cereus
toxins Patients typically have significant
emesis and less frequently diarrheaEnterotoxins : hemolysin, non-
hemolytic enterotoxin, enterotoxin T, and cytotoxin K
Emetic toxinNo fevers because not systemic diseaseCommonly isolated from reheated
foods
Endophthalmitis5/10,000 hospital patients60% occur after intraocular surgery
Often due to transient bacterial contamination by conjuctival flora4-13% after penetrating traumaOnce inoculated bacillus spreads through out whole eye
If motile strain <12 hours to detect inflammatory reaction in the eye
Symptoms: pain “ache”, redness, blurry vision, ring corneal infiltrate Loss retinal function in 18hours if fully virulent (pclR gene and
motile) High morbidity with loss of vision in infected eye
Phospholipases toxins responsible for the destructionsTreatment is injection of antibiotics into the vitreous and vitrectomy,
along with systemic antibiotics.
5 year Review of Cleveland Hospitals
From: 1981-198638 patients with significant Bacillus infections:
78.9% bacteremia 1/3 IVDU or had indwelling catheters, 4 had
cancer30% IVDU7.9% endopthalmitis1.8% Endocarditis (only with IVDU)OsteomyelitisVisceral infection- significant morbidity1 pneumonia and1 necrotizing fasciitis after trauma
Medicine (Baltimore) 1987;66(3):218-23.
5 year Review continued…Intravascular device (pacemaker, central
line) is a cause of the nosocomial bacillus bacteremia
4/38 patients improved after removal intravascular catheter with out antibiotics
Endocarditis rare phenomenon with B. Cereus
Overall patients with primary bacteremia recovered quicker and had less morbidity then patient with a localized infection
Medicine (Baltimore) 1987;66(3):218-23.
Bacillus spp. Among hospitalized patients with Haematological malignancies3.4% bacteremic with bacillus spp.
Most only presented with feverFew cases of pneumonia, GI/Hepatic symptoms
Patients that are granulocytopenic are at risk for opportunistic infections with bacillus
Many species can effect neutropenic patients which in clude B. licheniformis, B. cereus, B. pumilus
All patient were bacteremic, only few had pneumonias, endocarditis, or localized infections
Journal of Hospital Infections 2006.;64(2):169-76.
Pseudo EpidemicsOutbreaks have been seen in dialysis units, ICUs,
neonatal ICUsBacillus spores are sticky
Non-sterile cotton wool Laundered linens including gowns, sheets Ventilation systems Dressings Hands Dairy plants- filling machines Korean dried red pepper
Contaminated TransfusionsPlatelet transfusions: contaminated 0.08-0.7 %
Stored at room temperatures, thus longer storage time increase risk of contamination
Possible contaminants: dipthroid rods, coagulase negative staph, B. cereus, E. cloacae, E. coli, P. aeruginosa
Most cases deteriorated with minutes of transfusionLeading to hospital outbreaks of infectionsMore common with patients with hematological malignancy
Second to transfusions or long term indwelling cathetersBlood transfusions no data seen
TreatmentB. Cereus inherently resistant to most beta-lactamsAntibiotics known to work:
ImipenemClindamycin
In vitro activities of antibiotics on Bacillus spp and SporesAminoglycosides: MIC 2-0.5Doxycycline: MIC 0.5Vancomycin: MIC 1Erythromycin: MIC>16Ciprofloxacin: MIC 0.25Daptomycin: MIC 1 Journal of Clinical Microbiology 2006;44(10):3814-18
References te Boekhorst PA, et al. Clinical significance of bacteriologic screening in platelet
concentrates. Transfusion 2005;45(4):514-19. Drobniewski FA. Bacillus cereus and related species. Clinical microbiology
reviews 1993;6(4):324-38. Sliman R, et al. Serious infections caused by bacillus species. Medicine
(Baltimore)1987;66(3):218-23. Rotman B, Cote MA. Application of real-time biosensor to detect bacteria in
platelet concentrates. Biochemical and biophysical research communications 2003;300(1):197-200.
Yomtovian R, et al. A prospective microbiologic surveillance program to detect and prevent the transfusion of bacterial contaminated platelets. Transfusion 1993;33(11):902-9.
Guinebretiere MK, et al. Enterotoxigenic profiles of food-poisoning and food-borne bacillus cereus strains. Journal of Clinical Microbiology 2002;40(8):3053-56.
References (cont’d.) Callegan M, et al. Bacillus endophthalmitis: Role of bacterial toxins and
motility during infections. Investigative Ophthalmology and Visual Science 2005;46(9):3233-8.
Citron DM, Appleman MD. In vitro activities of daptomycin, ciprofloxacin, and other antimicrobial agents against the cells and spores of clinical isolates of bacillus species. Journal of Clinical Microbiology 2006;44(10):3814-8.
Mahler H, et al. Fulminant liver failure in association with the emetic toxin of
bacillus cereus. NEJM 1997;336(16):1142-8. Ozkocaman V, et al. Bacillus spp. among hospitalized patients with
haematological malignancies: clinical features, epidemics and outcomes. Journal of Hospital Infections 2006;64(2):169-76.
Search PubMedBacillus Cereus Bacteremia
Case ReportsReviewsDifferential DiagnosisDrug Therapy
Recommended