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ID Case Conference. Yvonne L. Ballard, MD 18 March 2008. CC: “I think he has the flu”. 18yo CM seen in ED with one-week h/o progressive flu-like symptoms: Sore throat Diffuse myalgias RUQ pain Nausea/Vomiting/Diarrhea Fever, to a maximum of 103 º C

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id case conference

ID Case Conference

Yvonne L. Ballard, MD

18 March 2008

cc i think he has the flu
CC: “I think he has the flu”
  • 18yo CM seen in ED with one-week h/o progressive flu-like symptoms:
    • Sore throat
    • Diffuse myalgias
    • RUQ pain
    • Nausea/Vomiting/Diarrhea
    • Fever, to a maximum of 103º C
  • 5 days PTA developed Right Shoulder and Left Hip pain, Productive Cough, One episode of bloody emesis. Increasing SOB.
review of systems
Review of Systems:
  • College student with one roommate
  • No sick contacts
  • No recent trauma, no recent rashes
  • Had recently gone camping on an Outward Bound trip, in North Carolina. No known tick bites
  • Stepped on a piece of broken pyrex glass in his kitchen three weeks prior
  • Hallucinations for the past week
slide4
PMH: Mild Asthma as a child
  • Meds: None
  • Allergies: NKDA
  • FamHx: None significant
social history
College Student

One lifetime sexual partner, last exposure 3 months prior

Mother reports filthy home, has noted squirrels running in/out of the walls

Recent travel to NY

Travel to England, Switzerland within past year

Denies tobacco

Reports social use of Etoh, marijuana

Recent experimentation with hallucinogenic mushrooms

No h/o IVDA

Social History:
slide6
EMS called to patient’s home, and made the following observations:

Hypotension

Left Hip Tenderness

Significant RUQ Pain

Decreased responsiveness

In the ED:

Febrile to 39.4

Given Zosyn, Levaquin, Vancomycin, and Doxycycline

Hypotensive - IVF fluids administered

Pt with progressive hypoxia, intubated, and sent to MICU

physical examination
Physical Examination
  • T 36.2, P 115, BP 112/70, RR 20, Pox 100% on 4L NC
  • Gen: Somnolent
  • HEENT: Perrla, anicteric, Dry MM, unable to visualize OP. Neck supple.
  • CV: Tachy, reg rhythm, no m/g/r
  • Pulm: Diffusely coarse BS with bibasilar crackles
  • Abd: soft, ND, RUQ tenderness to deep palpation. BS present
  • Skin: mild jaundice. Tenderness of the left thigh, right shoulder with limited ROM due to pain.
  • Ext: No c/c/e. Moving all extremities.
  • Neuro: Nonfocal
laboratory data

121

87

27

110

3.0

24

1.0

Laboratory Data

7.3

2.0

1.5

13.4

47

312

4.7

26.4

87

51

2.3

2.1

37.3

LDH 959

laboratory data9
Laboratory Data
  • Coags Normal
  • D-dimer 2588
  • Fibrinogen 423
  • AT III Activity 42%
  • Serum lactate 2.4
  • UA negative
  • Urine tox negative

?

slide10

Marked progressive air space opacities bilaterally in the lungs with bilateral air bronchograms. Possible cavitation or necrosis in the right lung. Left pleural effusion. Paratracheal adenopathy.

CXR, 11/5

CXR, 11/6

mri pelvis 11 5
MRI Pelvis, 11/5

Inflammatory changes of the left pelvis and proximal thigh with cellulitis, myositis of the gluteus musculature, and developing abscess in the fascial layer between the gluteus maximus and medius at the level of the left hip. No evidence for osteomyelitis.

shoulder mri 11 9
Shoulder MRI, 11/9

Possible increased signal intensity and enhancement along the subdeltoid bursa. No evidence for osteomyelitis.

abdominal imaging
Abdominal Imaging:
  • CT Abdomen:1. Hepatosplenomegaly.

2. Thickened gallbladder wall and edema is concerning for cholecystitis. No gallstones were noted. Recommend ultrasound for further evaluation.

  • RUQ Ultrasound:

1. Sludge-filled gallbladder with marked wall thickening and pericholecystic fluid worrisome for acute cholecystitis. 2. Suggestion of intraluminal sludge or debris within the common bile duct versus ductal wall thickening. 3. Hepatosplenomegaly. 4. Mild nephromegaly.

slide16

BLOOD

BRONCH WASH

SURFACE SWAB

ABSCESS

SURGICAL SWAB

Arcanobacterium haemolyticum

arcanobacterium haemolyticum
Arcanobacterium haemolyticum
  • Isolated in 1946 by MacLean, et al.
  • Isolated from the pharynx of US servicemen and South Pacific natives with exudative pharyngitis
  • Originally named Corynebacterium haemolyticum (reclassified after genetic analysis)
arcanobacterium haemolyticum21
Arcanobacterium haemolyticum
  • Gram-positive rods
  • Facultive anaerobes
  • Catalase negative
  • Nonmotile, branching
  • Nonsporulating
  • Grows well on blood- or CO2-enriched medium at 37º C
  • At 48 hrs, each colony has a black opaque dot at the center
arcanobacterium haemolyticum22
Arcanobacterium haemolyticum
  • Produces two extracellular toxins
    • Phospholipase D (PLD)
      • Causes hemorrhagic demonecrosis in rabbits
    • Neuraminidase
  • Human reservoir
  • Most commonly implicated in non-streptococcal pharyngitis in adolescents and young adults
    • Prevalence 0.4 – 1.4%, peak of 2.5% in 15-18 year olds
  • Male predilection and biphasic presentation
    • Healthy young adults and immunocompromised elderly
illnesses caused by a haemolyticum
Pharyngitis

Skin Infections

Chronic ulcers

Wound infections

Cellulitis

Paronychia

Sepsis

CNS Infections

Brain abcess

Meningitis

Endocarditis

Osteomyelitis

Otitis Media

Omphalitis

Sphenoidal sinusitis

Pleural empyema

Cavitary pneumonia

UTI

SBP

Illnesses caused by A. haemolyticum

Linder R. Emerg Infect Dis. 1997;3:145-53.

Parija SC. BMC Infect Dis. 2005;5:68-72.

Tan TY. J Infect. 2006;53:e69-74.

http://www.emedicine.com/derm/images/1617DER0758-01.JPG

pharyngitis
Pharyngitis
  • Clinically indistinguishable from GAS
  • Clinical symptoms:
    • Fever (40%), Pruritis (33%), LAD (48%)
    • Nonproductive cough and skin rash (33-67%)
    • Pharyngeal erythema in nearly all, and exudate present in ~70%
  • Associated rash develops after 1-4 days of symptoms (classically scarlatiniform)

Waagner DC. Pediatr Infect Dis J, 1991; 10: 933-939.

antimicrobial susceptibilities
Antimicrobial Susceptibilities
  • No standardized guidelines for disc susceptibilities
  • MICs obtained by agar dilution or E-test
  • Approximate sensitivities using S. aureus breakpoints

Carlson P. Eur J Clin Microbiol Infect Dis. 2000;19:891-3.

http://rfdp.seafdec.org.ph/publication/manual/antibiotics/pic42.jpg

antimicrobial susceptibilities29
Antimicrobial Susceptibilities

Carlson P, et. al. Antimicrob Agents Chemother. 1994;38:142-43

Carlson P. Eur J Clin Microbiol Infect Dis. 2000;19:891-3.

similar case reports pneumonia
Similar Case ReportsPneumonia

1. Skov RL et. al. Eur J Clin Microbiol Infect Dis. 1998;17:578-82.

2. Jobanputra RS et. al. J Clin Path. 1975;28:798-800.

3. Waller KS et. al. Am J Dis Child. 1991;145:209-10

similar case reports bacteremia
Similar Case ReportsBacteremia
  • Cook IF et. al. Med J Aust. 1981;1:366.
  • Ford JG. Am J Opthal. 1995;120:261-2.
  • Goudswaard J. Scand J Infect Dis. 1988;20:339-340.
  • Skov RL et. al. Eur J Clin Microbiol Infect Dis. 1998;17:578-82
similar case reports abscess other
Similar Case ReportsAbscess/Other
  • Parija SC et. al. BMC Infect Dis. 2005;5:68
  • Dobinsky S. Eur J Clin Microbiol Infect Dis. 1999;18:804-6.
  • Goyal R et. al. Ind J Med Microbiol. 2005;23:63-5.
  • Mehta CL. J Am Acad Derm. 2003;48:298-99
treatment
Our treatment choice:

Penicillin 4 MU IV Q4 hours + Azithromycin 500 mg IV QD

Treatment
clinical outcomes
Clinical Outcomes

PCN + Azithromycin

chest ct 12 2 follow up
Chest CT, 12/2Follow Up
  • Repeat Cultures Neg
  • TTE/TEE Negative
  • Complete resolution of pulmonary symptoms
  • Wound vac placed with exceptional healing
  • Took a semester off from school

Chest CT, 12/2