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One case of sepsis. Chisa Yamada, M.D. Montefiore Medical Center. Case. 45 y/o male CC: fever, chills, nausea, vomiting, dizziness

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one case of sepsis

One case of sepsis

Chisa Yamada, M.D.

Montefiore Medical Center

slide2
Case
  • 45 y/o male
  • CC: fever, chills, nausea, vomiting, dizziness
  • HPI: Patient who has cirrhosis came to ER for one day history of CC. He stated that he hit in his head at work by a box one week prior and got bitten by cat in left hand three days prior to admission. He denied palpitation, SOB. Patient had one episode of melena and coffee ground epistaxis in ER.
slide3
Case
  • PH: ethanol abuse, cirrhosis ( varices, status post TIPS x 2. Chronic thrombocytopenia), HTN, hepatitis C
  • Allergies: NKA
slide4
Case

Physical exams

  • Vitals: T 98.0 (~104), BP 74/44, P 122, R 24, PO2 96.3
  • Neurological: awake, alert oriented
  • Cardiac: regular rhythm, tachycardia, no chest pain
  • Respiratory: clear sound, no SOB, no cough
  • Abdomen: soft, no pain
  • Neck: supple
  • HEENT: PERRL, ecchymosis, nose and gum bleeding
  • Skin: fair, left hand with cat bite ( no inflammation)
  • Extremities: no edema
slide5
Case

Labs

  • Gas: 7.301/45.5/90.1/21.8/96.3
  • CBC: RBC 2.54, WBC 11.8(polys 67, bands 31, lympho 2, eos 0), Hb 8.4, Hct 25.1, Plt 42.0, PT/PTT 16.2/38.5, INR 1.6, D-dimer 1.0
  • Chem: Na 134, Cl 101, K 4.2, Ca 7.5, Glu 155, BUN 43, Creatinine 1.7, SGOT 157, SGPT 34, ALP 82, T-Bil 14.7, D-Bil 5.5, LDH 440, Amylase 82, Lypase 32, CPK 127
  • UA: orange color, turbid appearance, pH 1.024, protein 100, glu negative, ketone trace, occult blood large, bilirubin large, nitrite negative, WBC 29, RBC 30-35, bacteria 2+
slide6
Case

Images

  • CXR: mild CHF
  • CT: Head - (R)maxillary sinus hemorrhage

Abd - Diffuse thickening of small bowel and colon,

gastric varices, ground glass opacity at the

base of left lung

  • KUB: bowel distended
  • Abdominal sono: sludge in gallbladder
  • Duplex abdominal sono: decrease of flow velocity
slide7
Case

Cultures

  • Blood : Gram negative bacillus – Pasteurella pneumotropica identified by Vitek (Penicillin sensitive, Vanco resistant)
  • Urine : negative
  • Sputum : moderate candida albicans
slide8
Case

Hospital course

  • Patient was diagnosed as septic shock leading to ARF and ARDS. Patient was intubated at ER and transferred to MICU. FFP, RBC, platelets were transfused. Hydration, Gentamicin, Vasopressin treatment were started. Since Penicillin sensitive Pasteurella pneumotropica had isolated, Gentamicin was changed to Penicillin. Although, WBC has been increased and fever still spikes and patient’s condition is unchanged. Patient is now treated by Imipenem and Vanco and under observation.
pasteurella species
Pasteurella Species
  • Pasturella. multocida

subsp. multocida

subsp. septica

subsp. gallicida

  • Pasturella. canis
  • Pasturella. stomatis
  • Pasturella. dagmatis

Rare opportunistic human pathogen

  • Pasturella. pneumotropica
  • Pasturella. hemolytica
  • Pasturella. aerogenes
  • Pasturella. caballi
  • Pasturella. bettyae
pasteurella species10
Pasteurella Species
  • Inhabit the oral cavity and GI tract of many animals causing septicemia and pneumonia

dog, cat, mice, rat,, hamster, guinea pig, rabbit

  • Human infection by dog (25%) and cat (75%) bites

Hx of household or domesticated animal contact

Cat bites – Pasteurella

Dog bites – S. aureus, Staphylococcus, Pasteurella

Host

pasteurella species11
Pasteurella Species
  • Toxin production

Leukotoxin – toxic to leukocytes and impair cellular

response and stimulate the inflammatory response

  • Produce polysaccharide capsules

Antiphagocytic and aids in the resistance to intracellular

killing by neutrophils

  • Binding of transferrin

Supply iron necessary for growth

Pathogenesis

pasteurella species12
Pasteurella Species

Clinical manifestations

  • Skin and soft tissue infections – fever, cellulitis
  • Bone and joint infections –

septic arthritis, osteomyelitis, combined both

  • Central nervous system infection –

meningitis, brain abscess, subdural empyema

  • Septicemia and endocarditis
  • Respiratory tract infections –

pneumonia, empyema, sinusitis, bronchitis

  • Intra abdominal infections – peritonitis, apendicitis
  • Others – genitourinary tract, endophthalmitis
pasteurella pneumotropica
Pasteurella Pneumotropica
  • Household pets
  • Sometimes reported in the respiratory floras of persons who have pets, specially if these individuals have some underlying disease such as cirrhosis, or a neoplasm.

Clinical cases

pasteurella pneumotropica14
Pasteurella Pneumotropica
  • Only several cases reported - two septicemia

one septicemia reported with chemo for leukemia

one septicemia reported with no underlying disease

  • Treatment –

generally susceptible to penicillin, ampicillin,

cephalosporins, piperacillin, tetracycline, erythromycin,

chloramphenicol, ceprofloxacin, aminoglycosides,

trimethoprim-sulfamethoxazole

Clinical cases

pasteurella pneumotropica15
Pasteurella Pneumotropica
  • Portal hypertention splenomegaly

thrombo or pancytopenia

varices

  • Decreased production of clotting factors in liver

bleeding

  • Decreased production of complements in liver

opsonins, chemoattractants, anaphylatoxins

complement cascade (AgAb complex, Membrane attack complex)

susceptible to bacterial infection, especially bacterias

that have polysaccharides, lipopolysaccharide of cell

wall in G(-) organism and that produce endotoxins

Cirrhosis and complications in this patient

pasteurella pneumotropica16
Pasteurella Pneumotropica
  • Gram negative coccobacillus
  • Aerobic and facultative anaerobic, non-motile,
  • Grow on blood agar – smooth, convex, nonhemolytic,

0.5-1mm in diameter

  • Variable grow on MacConkey agar
  • Oxidase, catalase, urease, indole, ornithine decarboxylase –

positive

  • Acid production positive - glucose, maltose, galactose

negative – mannitol, sorbitol

  • Reduce nitrates to nitrites

Microbiological features

pasteurella pneumotropica17
Pasteurella Pneumotropica

Differential diagnosis by biochemical reaction

pasteurella pneumotropica18
Pasteurella Pneumotropica

Differential diagnosis by biochemical reaction

pasteurella pneumotropica19
Pasteurella Pneumotropica
  • Culture
  • Biochemical reaction
  • Vitek identification
  • Enzyme-linked immunosorbent assay
  • PCR – primer 16S rRNA

Diagnosis

references
References
  • Frebourg NB. Berthelot G, Hocq R, Chibani A. Lemeland JF. Septicemia due to Pasteurella pneumotropica: 16S rRNA sequencing for diagnosis confirmation.J Clin Microbiol. 2002 Feb; 40(2): 687-9
  • Nozu R. Goto K, Ohashi H, Takakura A, Itoh T. Evaluation of PCR as a means of identification of Pasteurella pneumotropica.Exp Anim. 1999 Jan; 48(1): 51-4
  • Cuodorado-Gomez LM, Arranz-Cazo JA. Pasteurella pneumotropica pneumonia in a patient with AIDS.Clin Infect Dis. 1995 Aug; 21(2): 445-6
  • Holst E, Rollof J, Larsson L, Nielsen JP. Characterizaion and distribution of Pasteurella species recovered from infected humans. J Clin. Micro. 1992 Nov; 30(11): 2984-2987
  • HA Riview of Pasteurella pneumotropica, Charles River Laboratories, Spring 1991
  • Principles and Practice of Infectious Diseases
  • Color Atlas and Textbook of Diagnostic Microbiology
  • Harrison’s Principles of internal Medicine
  • Medical Microbiology & Immunology