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Unusual cause of complicated pneumonia. MyMy Buu, MD Pediatric Pulmonary Fellow Stanford University School of Medicine. Referral from pediatrician. 2 year old male, fraternal twin born at term, previously healthy. Reason: Persistent pneumonia with effusion despite antibiotic treatment.

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unusual cause of complicated pneumonia

Unusual cause of complicated pneumonia

MyMy Buu, MD

Pediatric Pulmonary Fellow

Stanford University School of Medicine

referral from pediatrician
Referral from pediatrician

2 year old male, fraternal twin born at term, previously healthy.

Reason: Persistent pneumonia with effusion despite antibiotic treatment.

history of present illness
History of Present Illness
  • 9 weeks prior to referral:
    • Low grade high temperatures 99-100.
    • Loss of appetite, lost 3 pounds.
    • Sleep disturbance with arousals.
  • 7 weeks prior:
    • T102.9. No source of fever found on physical exam by PMD.
  • 2 days later:
    • Returned to PMD for persistent fevers. CXR done.
clinical course
Clinical course
  • Treated with
    • IM ceftriaxone x 2 days, then
    • Oral cefdinir x 10 days
  • Clinical symptoms:
    • O2 saturation 100% RA. No respiratory symptoms.
    • Continued to have temps 99-100. Fatigue.
  • Returned to PMD 1 day after completing abx. Surveillance CXR obtained.
admitted to a community hospital
Admitted to a community hospital
  • Recap: 5 week history of fatigue, high normal temperatures, and completion of 10 days of oral antibiotics.
  • Admitted for right sided pneumonia with effusion.
  • Started treatment with antibiotics
    • IV Ceftriaxone (10 days)
    • IV Vancomycin (7 days)
    • PO Azithromycin (5 days)
video assisted thoracoscopy at the community hospital
Video assisted thoracoscopyat the community hospital
  • Pleural fluid:
    • 150ml hazy, pale yellow fluid.
    • 26 WBC: 1% N, 91% L, 4% E, 1% Baso.
    • 23 RBC. Gluc 83. Prot 5.5. pH>7.75
  • Pleurolysis of dense adhesions.
  • Gram stain: Rare RBC.
  • Cultures: Aerobic and anaerobic bacterial and fungal negative. AFB smear and culture negative.
hospital course at community hospital
Hospital course at community hospital
  • Chest tube in place for 5 days.
  • Fevers resolved.
  • PPD neg.
  • MycoplasmaIgG, IgM: neg.
  • Labs:
interval history since discharge
Interval history since discharge
  • Mild fatigue, “sluggish.”
  • Occasional temperature of 100.
  • No respiratory symptoms. Gaining weight (1.9 pounds), improved appetite.
  • 2 weeks after discharge:
    • CRP 4.85. ESR 94. WBC 9.1, 54% neutrophils.
    • Surveillance CXR by PMD.
referral
Referral
  • Referral to Pediatric Pulmonary after 9 weeks of illness.
  • Reason: Persistent pneumonia with effusion despite antibiotic treatment.
past medical history
Past Medical History
  • Ex-38 week fraternal twin, C-section.
  • No recurrent sinopulmonary infections.
  • Surgeries: None.
  • Immunizations: Up to date.

Family History

  • Dad: Allergic rhinitis to cats and pollen.
  • Twin brother: Multiple food allergies.
social history
Social History
  • Lives with Mom, Dad, 6yo sister, 2 yo fraternal twin brother.
  • Mom: Counselor at local high school
  • Dad: Construction manager at VA hospital
  • Attends daycare.

Travel History

  • Travelled to Michigan in early summer.
physical examination
Physical Examination
  • Ht 25-50%tile. Wt 25-50%tile.
  • VS: T36. HR 138. RR 28. O2 sat 96% RA.
  • Gen: NAD, playful, non-toxic.
  • HEENT: TMs nl. Nasal turbinatesnl. Tonsils 1+.
  • Neck: No LAD.
  • Lungs: Decreased BS in right base anteriorly and posteriorly. No wheeze, crackles, rhonchi. Nl effort, chest shape.
  • CV, Abd: Nl. Skin: No rashes. Ext: no cyanosis, clubbing.
differential diagnosis
Differential diagnosis?
  • Inadequately treated community acquired pneumonia with effusion:
    • Inadequate duration of treatment
    • Resistant organism
    • Non-bacterial organism
  • Structural abnormality:
    • Congenital malformations
    • Airway foreign body
    • Pulmonary or extra-pulmonary mass
  • Immunodeficiency
next steps
Next steps?
  • Evaluate effusion
    • Chest US
    • Chest CT
  • Diagnostic bronchoscopy
    • Airway examination
    • BAL
  • Immunodeficiency work up
  • Serology testing
bronchoscopy
Bronchoscopy
  • Normal airway anatomy, mild mucosal edema, scant secretions.
  • No foreign body.
  • Bronchoaveolarlavage:
    • Colorless, clear, frothy.
    • WBC 259: 3% N, 72% L, 22% M, and 2% E.
    • RBC 330.
    • GMS neg.
bal cultures
BAL cultures
  • Gram stain: Rare polys, small mononuclear cells. +GP cocci in pairs.
  • Bacterial culture: Normal resp flora.
  • KOH neg. Fungal culture neg.
  • Viral DFA neg. CMV PCR neg.
  • AFB smear neg. AFB culture neg.
  • Legionella culture neg.
  • Pneumocystis stain neg.
immune work up
Immune work up
  • QuIG and IgG subclasses: normal.
  • Tetanus and strep pneumoniae titers: normal.
  • HIV neg.
  • T and B cell subsets: normal.
  • Dihydrorhodamine: 100% oxidation positive neutrophils.
serology work up
Serology work up
  • Strep pneumonia Ag (urine and serum): neg.
  • Quantiferon neg.
  • Coccidiomyces ID: neg.
  • Histoplasmaab: neg.
  • Hisptoplasma Ag serum: neg, Ag urine: <0.6
  • BlastomycesAb CF: 1:32, 1:64.
  • BlastomycesAbimmunodiffusion: positive.
  • Blastomyces serum Ag: neg.
blastomyces dermatitidis
Blastomyces dermatitidis
  • Epidemiology
  • Clinical presentation
  • Diagnosis
  • Treatment
  • Prognosis
ecology
Ecology
  • Thermally dimorphic fungus.
    • Mycelial form in earth, Conidia inhaled, budding yeast at body temperature.
  • Found in wet earth (animal droppings,decaying vegetation).
  • Ohio and Mississippi river valleys, Midwest states and Canadian provinces that border Great Lakes and St Lawrence River, esp north central Wisconsin and Ontario.
geographic distribution of b dermatitidis
Geographic distribution of B. dermatitidis

Clinics in Chest Medicine, 2009.

epidemiology
Epidemiology
  • Transmission: Inhalation of airborne conidia or direct cutaneous inoculation.
  • Usually affects men.
    • Likely related to environmental exposures.
  • Same incidence regardless of immune status.
  • Disease more severe in immunocompromised patients.
clinical manifestations
Clinical manifestations
  • Acute: Fever, cough, myalgia, arthralgia.
  • Pulmonary:
    • Asymptomatic radiograph abnormality
    • Acute or chronic pneumonia
    • Alveolar or mass-like infiltrate
    • ARDS
    • Massive effusion uncommon and cavitation uncommon
slide39

Skin:

    • Verrucous: raised crusted, irregular shape and sharp border
    • Ulceration: subQ abscess
  • Bones:
    • Osteomyelitis: vertebrae, ribs, skull, long bones
  • CNS: Masses, meningitis

Clin Microbio Reviews, 2010.

diagnosis
Diagnosis
  • Stains: KOH, GMS
  • Culture:
    • Regular medium and selective medium (cycloheximide) for 4-6 weeks
    • Identify by DNA probe (crossreacts with paracoccidioiodes)
  • Histology: Giemsa, PAS
  • Source: BAL, biopsy, sputum, gastric lavage*

Clin Microbio Reviews, 2010. *Peds ID J, 2010

serologies
Serologies
  • Antibody: Serum
    • Complement fixation: sensitivity 40-57%, specificity 30-100%
    • Immunodiffusion: sensitivity 65-80%, specificity 100%
  • Antigen: Serum, urine, BAL, CSF
    • Urine: sensitivity 92%, specificity 79%
    • Crossreacts with histoplasmosis, paracoccidiomycosis.

Clin Microbio Reviews, 2010. Peds ID, 2006.

treatment
Treatment
  • Amphotericin B (AmB): Moderate-severe disease.
  • Itraconazole: Solution more consistent serum levels than capsules, capsules require acidity for absorption.
  • Fluconazole: 2nd line agent, less efficacious than itraconazole.
  • Voriconazole and posaconazole: May be effective, little experience.
treatment monitoring
Treatment monitoring
  • Itraconazole levels >1 mcg/ml @ 2 weeks.
  • Hepatotoxicity: Liver enzymes @ 2 weeks, 4 weeks, then q3 months.

CID, 2008.

back to our patient
Back to our patient…
  • Only positive result was the blastomyces antibody CF and ID.
  • We presumed pulmonary blastomycosis and initiated treatment.
treatment1
Treatment
  • Ceftriaxone and clindamycin (7 days)
  • Itraconazole 10mg/kg po daily (6-12 months)
treatment response
Treatment response

Referral

Itra initiated

Discharge

long term sequelae of pulmonary blastomycosis
Long term sequelae of pulmonary blastomycosis
  • Case series of 8 pediatric patients.
  • 6/8 patients had normal pulmonary function at 4.5 +/- 3.5 years after illness.
  • 2 patients with a prolonged course with residual radiographic abnormalities had mild restriction and obstruction.

Clinical Pediatrics, 2000.

seasonal variation
Seasonal variation

Medical Mycology, 2008.

take home messages
Take home messages
  • Clinical suspicion for Blastomycosis.
  • Diagnostic testing to consider:
    • Antigen testing of BAL, urine.
    • Gastric aspirates for KOH, GMS, culture.

Questions?

references
References

Thank you!

  • Saccente, M, Woods, G. Clinical and laboratory update on Blastomycosis. Clin Microbiology Reviews, 2010;23:367-381.
  • Chapman, S, et al. Clinical practice guidelines for the management of Blastomycosis: 2008 update by the IDSA, CID, 2008;46:1801-12.
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