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Paul Lane, an Intensivist from tropical Queensland gave this lecture at Bedside Critical Care 2012. The talk can be heard at www.intensivecarenetwork.com
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Tropical MicrobiologyTropical Microbiology
Dr Paul LaneDr Paul Lane
CICM Daydream Is 2012CICM Daydream Is 2012
OutlineOutline
MelioidosisMelioidosis
LeptospirosisLeptospirosis
Questions…Questions…
LeptospirosisLeptospirosis
Zoonotic disease, spirochaetes called Zoonotic disease, spirochaetes called leptospiresleptospiresNatural reservoir in RodentsNatural reservoir in RodentsEnter thru skin cut, intact mucous Enter thru skin cut, intact mucous membranes with subsequent bloodstream membranes with subsequent bloodstream spread to all organsspread to all organsSoldiers, Banana workers (1million/yr)Soldiers, Banana workers (1million/yr)Outbreaks can occur in tropical areas Outbreaks can occur in tropical areas affected by disasteraffected by disaster
PresentationPresentation
Weil’s/ Canecutters diseaseWeil’s/ Canecutters diseaseProinflammatory cytokines activate Toll Proinflammatory cytokines activate Toll like receptors…detonation!like receptors…detonation!Unwell, fever, myalgia, liver, renal injury Unwell, fever, myalgia, liver, renal injury with low plateletswith low plateletsPulmonary Haemorrhage, ARDS…main Pulmonary Haemorrhage, ARDS…main cause of DEATHcause of DEATHVasodilation, inotropesVasodilation, inotropesSpirochaetes found in CNSSpirochaetes found in CNS
Immune responseImmune response
Patients often get worse!!Patients often get worse!!
Cochrane support this!Cochrane support this!
Traditional recommendation is PenicillinTraditional recommendation is Penicillin
Onset of Jarisch Herxheimer reactionOnset of Jarisch Herxheimer reaction
Immune mechanisms play a key role in Immune mechanisms play a key role in pathogenesis of disease, particularly pathogenesis of disease, particularly pulmonarypulmonary
Evolution of my practice…Evolution of my practice…
Constantin etal J Rheum 1996Constantin etal J Rheum 1996
Antineutrophil cytoplasmic antibodies in Antineutrophil cytoplasmic antibodies in leptospirosisleptospirosis
Returned travellers treated with Returned travellers treated with immunosuppression and got better!!immunosuppression and got better!!
Change to meropenum, IV steroids as Change to meropenum, IV steroids as initial therapy….less pulmonary bleedinginitial therapy….less pulmonary bleeding
What’s out thereWhat’s out there
Sri Lanka 2008 outbreak, started IV Sri Lanka 2008 outbreak, started IV methylprednisolone ( 500mg/3dys then methylprednisolone ( 500mg/3dys then oral)…studied 230 patientsoral)…studied 230 patients
20% down to 10%20% down to 10%
Once severe organ dysfunction Once severe organ dysfunction established steroids less helpfulestablished steroids less helpful
Other studiesOther studies
India Shenoy etal 2006 30 patientsIndia Shenoy etal 2006 30 patients
Mumbai floods 2005Mumbai floods 2005
60% vs 18%60% vs 18%
IF GIVEN EARLY….(first 12 hrs)IF GIVEN EARLY….(first 12 hrs)
Other small case series…Other small case series…
Newer advancementsNewer advancements
Cyclophosphamide (IV 60mg/kg stat)Cyclophosphamide (IV 60mg/kg stat)Trivedi etal 2009 Severe Pulmonary Trivedi etal 2009 Severe Pulmonary Involvement…failed steroidsInvolvement…failed steroids90% to 40% mortality90% to 40% mortality
Plasma Exchange ( same author)Plasma Exchange ( same author)236 severe pulm disease…protocol of 2 236 severe pulm disease…protocol of 2 washes 25ml/kg removal and low dose washes 25ml/kg removal and low dose cyclophosphamide…again better survivalcyclophosphamide…again better survival
What do I do…What do I do…
Early steroid (1mg/kg BD MP)Early steroid (1mg/kg BD MP)
Meropenum by infusionMeropenum by infusion
Get aggressive early if lung hitGet aggressive early if lung hit
Early CRRTEarly CRRT
Plasma Exchange +/- CPPlasma Exchange +/- CP
ExtrasExtras
Prophylaxis probably doesn’t workProphylaxis probably doesn’t work
Doxycycline if allergicDoxycycline if allergic
Diagnosis….CLINICALDiagnosis….CLINICAL
Finding Leptospira (CSF, blood, urine)Finding Leptospira (CSF, blood, urine)
Rising titre (MAT)Rising titre (MAT)
Positive IgM (EIA)Positive IgM (EIA)
NATNAT
Questions??Questions??
MelioidosisMelioidosis
Whitmore Disease/ FlandersWhitmore Disease/ Flanders
Bacteria isolated from morphine addicts in Bacteria isolated from morphine addicts in Ragoon 1912Ragoon 1912
B. mallei vs B. pseudomalleiB. mallei vs B. pseudomallei
““Vietnamese Time Bomb”…26yr Vietnamese Time Bomb”…26yr incubationincubation
Inhalation, cut in skin exposed to Inhalation, cut in skin exposed to soil/water, ingestionsoil/water, ingestion
In NQIn NQ
15-25 cases/yr, 1/5 die15-25 cases/yr, 1/5 die
1/3 cases in ‘dry season’1/3 cases in ‘dry season’
Better with public educationBetter with public education
Recent JCU work reveals run off water Recent JCU work reveals run off water during high rainfall contains more during high rainfall contains more organisms then soilorganisms then soil
PresentationPresentation
Acute Fulminant SepsisAcute Fulminant SepsisLethal CAP plus Sepsis (50%)Lethal CAP plus Sepsis (50%)Genitourinary infectionGenitourinary infectionAbscesses/Osteomyelitis/Septic ArthritisAbscesses/Osteomyelitis/Septic ArthritisEncephalitis, ParalysisEncephalitis, ParalysisReactivated disease, often asymptomaticReactivated disease, often asymptomaticChronic Disease (1/16)Chronic Disease (1/16)Prostatic Melioidosis in 20% Prostatic Melioidosis in 20%
PresentationPresentation
DM, excess ETOH, CRF, steroids and DM, excess ETOH, CRF, steroids and Chronic Lung DiseaseChronic Lung DiseaseCan be ‘normal’Can be ‘normal’Normally easily Dx, tell lab-modified Normally easily Dx, tell lab-modified culturecultureSerology occasionally-Neuro/reactivated Serology occasionally-Neuro/reactivated disease.disease.RETURNED TRAVELLER- no advice is RETURNED TRAVELLER- no advice is given….given….
AntibioticsAntibiotics
Resistant organism ( pen, ceph, gent, cipro)Resistant organism ( pen, ceph, gent, cipro)Guidelines for CAP in endemic areasGuidelines for CAP in endemic areas1990’s IV Ceftazadime (14days) 1990’s IV Ceftazadime (14days) oral trimethoprim/sulfamethoxazole (6mths)oral trimethoprim/sulfamethoxazole (6mths)Now Meropenum infusion (lower MIC)Now Meropenum infusion (lower MIC)No seizures, better killing profile and decrease No seizures, better killing profile and decrease endotoxin release ( yet to show better survival)endotoxin release ( yet to show better survival)Dramatic fall in mortality (Stephens, Currie)Dramatic fall in mortality (Stephens, Currie)G CSF??? ( Not in NEJM review)G CSF??? ( Not in NEJM review)
CaseCase
Febrile child.Febrile child.
Limb weakness following lacerationLimb weakness following laceration
Camping in bushCamping in bush
Mild encephalopathyMild encephalopathy
Questions?Questions?