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ID Case Conference. Yvonne L. Ballard, MD 30 January 2008. CC: Fatigue, Shortness of Breath 49yo CM had a URI 2-3 weeks PTA. Sx included rhinorrhea, cough, malaise. Sx lasted one week, and resolved. 4 days PTA, recurrent sx developed.

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id case conference

ID Case Conference

Yvonne L. Ballard, MD

30 January 2008

slide2
CC: Fatigue, Shortness of Breath
  • 49yo CM had a URI 2-3 weeks PTA. Sx included rhinorrhea, cough, malaise. Sx lasted one week, and resolved.
  • 4 days PTA, recurrent sx developed.
  • 2 days PTA, pt presented to PCP, who performed a rapid flu test, which was positive. Pt treated with Tamiflu, which he started to take immediately.
  • Sx progressed, and pt called EMS for severe fatigue and difficulty breathing
slide3
PMH: None

PSurgHx:

Appendectomy, age 23

All: NKDA

Meds: Nicorette gum

SocHx:

Lives with wife in CH

4 healthy children

Ages 7, 9, 14, 17

Installs closets

Chewed tobacco

Occ. Beer

No illicits

FamHx:

Mom, dec, Pancreatic CA

Dad, alive, healthy

Brother, alive, healthy

Brother, alive, Colon CA

physical exam
Physical Exam
  • T 36.0, P 130s, BP 157/73, RR 33
  • WD, WN ill man; intubated, sedated
  • NCAT, Pupils dilated, minimally reactive
  • Tachycardic, Reg rhythm, no m/g/r
  • BS coarse bilaterally, diffuse
  • Abd soft, NT, ND, NABS
  • Skin: diffuse maculopapular rash on head, trunk, and extremities
  • Ext: no c/c/e. Cool extremities
slide5

117

91

60

57

4.4

13

6.8

11.9

192

5.4

240

75

4.3

34.1

Labs
  • D-dimer 3397
  • Fibrinogen 857
  • AT III activity 49%
  • BNP 33,187
  • CK 551, MB 24, Trop (–)
  • PT 35, PTT 53, INR 2.6
  • Lactate 7.3
  • ABG 6.93/66/44/58%
  • Etoh Screen Negative

4.5

1.3

8.1

micro data
Micro Data
  • Urine Culture - Negative
  • HIV ELISA - Negative
  • RPR - NR
  • RMSF Serologies - Negative
  • CMV PCR - Negative
  • Skin Lesion HSV 1 and 2 PCR - Negative
  • EBV Serologies – Indicate previous exposure
hospital course
Hospital Course
  • Intubated in the ED
  • Started on Vanc, Zosyn, Levaquin
  • Levophed, Vasopressin, Phenylephrine
  • Bicarb gtt, IVF boluses
  • Three central lines placed
  • Multiple modes of ventilation failed
  • Worsening CXR
  • Propofol gtt
  • PEA Arrest…Successful code
  • Family consented for ECMO
hospital course cont
Hospital Course, cont.
  • Pt desats to 40s while en route to SICU
  • Prep for ECMO begins
  • Pt goes into Asystole
  • Resuscitation unsuccessful
  • Pronounced dead at 2:01 am, after 20 minute code
micro data12
Micro Data
  • Blood Culture, 4/4 bottles positive:
    • Streptococcus pyogenes (Group A Strep)
  • Induced sputum – Group A Strep
  • Right Lung Biopsy – Group A Strep
  • Right Lung Biopsy – Viral Cx Negative
  • Right Lung Biopsy – CMV PCR Negative
micro data13
Micro Data
  • Group A Strep Sensitivity Testing
    • Penicillin G (MIC 0.032)
    • Vancomycin (MIC 1)
    • Levofloxacin (MIC 0.5)
    • Erythromycin (sens)
    • Clindamycin (sens)
group a streptococcus
Group A Streptococcus
  • Aerobic gram + coccus pairs and chains
  • Catalase negative
  • Beta-hemolytic on blood agar
  • Growth inhibited by bacitracin
virulence factors
Virulence Factors
  • M protein
    • Filamentous protein on cell membrane; has antiphagocytic properties
    • Types 1, 3, 12, and 28 most common in shock
    • Pts with decreased serum antibodies to M prot more susceptible to invasive infections
  • Exotoxins
    • Pyrogenic exotoxins A, B, and C; SSA, MF
    • Cause cytotoxicity, pyrogenicity, and enhances lethal effects of endotoxins
streptococcus pyogenes17
Streptococcus pyogenes
  • Clinical presentations:
    • Pharyngitis, Sinusitis, Otitis Media
    • Skin and soft tissue infections
      • Impetigo, Erysipelas, Localized cellulitis
    • Invasive Disease
      • Bacteremia
      • Necrotizing Fasciitis, Gangrenous Myositis
      • Pneumonia
      • Toxic Shock Syndrome
diagnosis of stss
Diagnosis of STSS
  • Isolation of GAS from normally sterile site
  • AND Hypotension
  • PLUS evidence of organ failure (at least 2)
    • Renal failure
    • Coagulopathy
    • Liver involvement
    • ARDS
    • Soft tissue necrosis
    • Erythematous macular rash
slide21
The Epidemiology of Invasive Group A Streptococcal Infection and Potential Vaccine Implications: United States, 2000-2004
  • Data collection from CDC and ABCs
    • Population of 29.7 million persons over 10 US cities
    • San Francisco, Denver, Atlanta, Baltimore, Portland, Albany, Rochester, urban Tennessee, Minnesota, New Mexico, Conneticut
    • January 1, 2000 – December 31, 2004
    • Invasive GAS = isolation of GAS from a normally sterile site or from a wound specimen obtained from a patient with nec fasc or STSS

CID 2007; 45: 853-62

slide22
5400 cases of invasive GAS
  • Avg annual incidence = 3.5 cases per 100,000 persons

CID 2007; 45: 853-62

clinical presentation
Clinical Presentation
  • Cutaneous or soft tissue infection (36%)
  • Primary Bacteremia (29%)
  • Pneumonia (15%)
  • GAS isolated from
    • Blood specimens (77%)
    • Joint Fluid (8%)
    • Surgical Specimens (6%)
    • Peritoneal fluid (2%)
    • Pleural fluid (2%)

CID 2007; 45: 853-62

case fatality rates
Case Fatality Rates
  • Overall, CFR was 13.7%
  • Projections of US population estimate that 8950 – 11,500 invasive GAS infections occur annually, with 1050 – 1850 deaths
  • Predictors of Death
    • Increasing Age
    • Residence in Nursing Home
    • Presence of a Specific Disease Syndrome
    • Emm type (1, 3, 12)
    • Underlying condition

CID 2007; 45: 853-62

slide27
Morbidity and Mortality of Patients with Invasive Group A Streptococcal Infections Admitted to the ICU
  • Chart review of all cases of invasive GAS admitted to ICUs in all Ontario, Toronto b/w Jan 1992 and June 2002
  • 62 total patients
    • 64% with skin/soft tissue infections
    • 20% with pneumonia
    • 68% had positive blood cultures
    • 50% with chronic disease
  • Overall mortality 40%
    • Directly correlated with APACHE II scores and with the number of organ failures
    • 55% had STSS: Mortality rate = 68%

Chest 2006; 130; 1679-1686

treatment
Treatment
  • Hemodynamic Support
  • Surgical Therapy
  • Empiric Antibiotics
    • Clindamycin PLUS:
    • A carbapenem OR a PCN plus beta-lactamase inhibitor
    • IVIG (1 gm/kg day one, then 0.5gm/kg days two and three)
limitations in treatment
Limitations in treatment
  • PCN/Beta-lactamase
    • Studies suggest PCN failure with large organsim burden
    • PBPs decrease in the stationary phase of bacterial growth in vitro
  • IVIG
    • Used as an adjunct to antibiotics
    • Able to neutralize superantigens and facilitates opsonization of streptococci
    • Inadequate evidence to support its use
post influenza pneumonia
Post-Influenza Pneumonia
  • Most common complication of influenza
  • Most frequent in patients with underlying chronic conditions
    • CV or Pulmonary Disease
    • DM, Renal dz, Hemoglobinopathy
    • Immunosuppressed
    • Residents of chronic care facilities
  • Primary Influenza Pneumonia vs. Secondary Bacterial Pneumonia
secondary bacterial pneumonia
Secondary Bacterial Pneumonia
  • Accounts for ~25% of influenza-associated deaths
  • Influenza causes decrease in size of cells and loss of cilia in epithelium lining the trachea and bronchus
  • S. pneumo most common organism (~48%)
  • S. aureus second most common (19%)
  • H. flu also implicated
  • Typically, a relapse of symptoms after some degree of improvement
  • ? Role of Oseltamivir

Curr Med Res Opin. 2007 Dec;23(12):2961-70