Necrotizing FasciitisNecrotizing Fasciitis

HistoryHistory 66 y female66 y female

PMH : DM , HTN , IHD , Hypothyroidism PMH : DM , HTN , IHD , Hypothyroidism Pernicious anemia , ETOHPernicious anemia , ETOH

Med: Atenolol , ASA , Nitrospray , Med: Atenolol , ASA , Nitrospray ,

Thyroxin , B12 & AtrovastatinThyroxin , B12 & Atrovastatin

HistoryHistory Presented to Seven Oaks HospitalPresented to Seven Oaks Hospital

1/12 SOBE , Anasarca & decreased UOP1/12 SOBE , Anasarca & decreased UOP

1/7 angina & melena ( 2 minimal )1/7 angina & melena ( 2 minimal )

No orthopnea , PND , wheeze , coughNo orthopnea , PND , wheeze , cough

No palpitation , LOCNo palpitation , LOC

No heartburn , vomiting or hematemisisNo heartburn , vomiting or hematemisis

No blood in urineNo blood in urine

HistoryHistory In ER : hemodynamicaly stableIn ER : hemodynamicaly stable

Sat 94% RA A & OSat 94% RA A & O

Generalized edemaGeneralized edema

No chronic liver disease signsNo chronic liver disease signs

? Hypovolemic? Hypovolemic

Chest : clearChest : clear

DRE +ve bloodDRE +ve blood

HistoryHistory WBC 2.1 poly 1.3 Hb 65 MCV20WBC 2.1 poly 1.3 Hb 65 MCV20 INR 1.7 PTT 54INR 1.7 PTT 54

Creat , BUN & lytes NCreat , BUN & lytes N

AST 110 ALT 70 Albumen 20 AST 110 ALT 70 Albumen 20 Billirubin total 70 direct 40Billirubin total 70 direct 40

UA 0.3- 1 protein NO active sediment UA 0.3- 1 protein NO active sediment

HistoryHistory

Admission Dx Admission Dx pancytopenia pancytopenia ? Malignancy? Malignancy

Rx PRBC , FFP & HASRx PRBC , FFP & HAS

Within hours of admission Within hours of admission Fever , SOB & Hypotension Fever , SOB & Hypotension

No response to IVF , Bronchodilator No response to IVF , Bronchodilator

HistoryHistory Transferred to ICU Transferred to ICU

Worsening work of breathingWorsening work of breathing

On 15 l O2 NRBM On 15 l O2 NRBM

PH 7.3 PCO2 33 PO2 76 HCO3 16PH 7.3 PCO2 33 PO2 76 HCO3 16

Intubated , Neosenphrine Intubated , Neosenphrine

Swan Ganz Swan Ganz septic septic

CXR CXR Lt effusion Lt effusion

HistoryHistory Pleural tapping Pleural tapping LDH 2995 Glucose 0.3 Protein 38LDH 2995 Glucose 0.3 Protein 38

Transferred to ICM St.BTransferred to ICM St.B Shock , Acute renal failure Craet 200 Shock , Acute renal failure Craet 200 Lactaic acidosis 13 MelenaLactaic acidosis 13 Melena Rhabdomyolysis Myogolbin 5000Rhabdomyolysis Myogolbin 5000 ACS TnT 0.05 t wave inversionACS TnT 0.05 t wave inversion

Hospital CourseHospital Course In ICMIn ICM

Seen by 3 services on the same time Seen by 3 services on the same time

(reading the chart together) (reading the chart together)

ID ID meropenem & Vanco meropenem & Vanco

Renal Renal CRRT CRRT

GI GI were scoping the pateint next door were scoping the pateint next door

they didn’t mind scoping this patient !they didn’t mind scoping this patient !

Hospital CourseHospital Course Pleural fluid & Blood C/S Pleural fluid & Blood C/S Group C Beta streptGroup C Beta strept

Abx switch to Penicillin G continuous infusion Abx switch to Penicillin G continuous infusion

Cortisol 1750Cortisol 1750

Not candidate for activated protein CNot candidate for activated protein C

Hospital CourseHospital Course Upper GI scope Upper GI scope diffuse gastritis diffuse gastritis started on pantprazolestarted on pantprazole

Not candidate for activated protein CNot candidate for activated protein C

Recovered from shock Recovered from shock

Transferred to medicine Transferred to medicine

Group C Strept.Group C Strept. G +ve cocci , facultative anaerobesG +ve cocci , facultative anaerobes

Vast majority are pathogenicVast majority are pathogenic

Uncommon cause of bacteremiaUncommon cause of bacteremia

Predisposition Predisposition old age , animal exposure old age , animal exposure

, immunosupression, immunosupression

Group C Strept.Group C Strept. Dx Dx hemolytic pattern on blood agar medium hemolytic pattern on blood agar medium

In case in the absence of overt focal disease& +ve In case in the absence of overt focal disease& +ve Blood C/SBlood C/S search for an abscess, endocarditis or search for an abscess, endocarditis or

a suppurative process in an obscure area a suppurative process in an obscure area

Usually it is part polymicrobial infectionUsually it is part polymicrobial infection

it is important for the microbiology lab to identify it is important for the microbiology lab to identify

all species in a specimen from a closed space all species in a specimen from a closed space

or bacteremic process. or bacteremic process.

Group C Strept.Group C Strept. 5 y retrospective study5 y retrospective study

GCBHS caused 0.05 / 1000 admissionsGCBHS caused 0.05 / 1000 admissions

Data from 10/13 patientsData from 10/13 patients primary bacteremia (4 cases),primary bacteremia (4 cases), pneumonia (2cases), endocarditis (2 cases) pneumonia (2cases), endocarditis (2 cases) meningitis, intraabdominal infection & pericarditismeningitis, intraabdominal infection & pericarditis

6 Streptococcus equisimilis; 3 S. equi; 6 Streptococcus equisimilis; 3 S. equi; 2 S. dysgalactiae; and 1 S. zooepidemicus 2 S. dysgalactiae; and 1 S. zooepidemicus

Diagn Microbiol Infect Dis. 1992 FebDiagn Microbiol Infect Dis. 1992 Feb

Group C Strept.Group C Strept. 8 y retrospective study in 5 hospitals8 y retrospective study in 5 hospitals

78 cases 78 cases 16 bacteremia 16 bacteremia sources primary bacteremia,sources primary bacteremia, cutaneous , meningitis and pneumonia cutaneous , meningitis and pneumonia Higher rates of underlying diseases,Higher rates of underlying diseases, ETOH abuse, liver diseases, and cutaneous ETOH abuse, liver diseases, and cutaneous

infections, and lower rates of exposure to animals or infections, and lower rates of exposure to animals or raw products raw products

Morbidity and mortality were 20% to 30% Morbidity and mortality were 20% to 30% Arch Intern Med. 1995 Jun Arch Intern Med. 1995 Jun

Group C Strept.Group C Strept. Exquisitely susceptible to penicillin Exquisitely susceptible to penicillin

MIC should be performed in life-threatening MIC should be performed in life-threatening infections infections

meningitis, brain abscess, endocarditismeningitis, brain abscess, endocarditis

An aminoglycoside, for synergyAn aminoglycoside, for synergy

Group C Strept.Group C Strept. In penicillin allergic patients In penicillin allergic patients

clindamycin & macrolideclindamycin & macrolide

In high resistance or immunocompromised patients In high resistance or immunocompromised patients

vancomycinvancomycin

Drainage of abscesses is essential Drainage of abscesses is essential

IVIG & GCBHSIVIG & GCBHS

Multicenter randomized Plc control Multicenter randomized Plc control

Jan 1999 Jan 1999 May 2001 May 2001

streptococcal toxic shock syndrome STSS pateintsstreptococcal toxic shock syndrome STSS pateints

Patients could be included before lab confirmation Patients could be included before lab confirmation site of infection or family history strept infectionsite of infection or family history strept infection

Rapid antigen test from throat or skinRapid antigen test from throat or skin CID 2003CID 2003

IVIG & GCBHSIVIG & GCBHS

IVIG 1mg/kg day 1 & 0.5 mg/kg day 2&3IVIG 1mg/kg day 1 & 0.5 mg/kg day 2&3 or Albumen 1%or Albumen 1%

All patients received clindamycin 600mg TIDAll patients received clindamycin 600mg TID & Penicillin 12 gm / day& Penicillin 12 gm / day

Primary outcome 28 days mortalityPrimary outcome 28 days mortality

Secondary outcomes time to shock resolutionSecondary outcomes time to shock resolution 180 days survival & organ dysfunction180 days survival & organ dysfunction

IVIG & GCBHSIVIG & GCBHS

Small number of patients ?may be the reason Small number of patients ?may be the reason for non significance resultsfor non significance results

low incidence of STSSlow incidence of STSS

53% +ve BC & 41% tissue culture53% +ve BC & 41% tissue culture

NO side effects NO side effects