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Came with a Bang.......

Came with a Bang. Dr Neelam Doshi Consultant Microbiologist Wythenshawe Hospital University Hospitals South Manchester Foundation Trust. Occupational Zoonoses 9 July 2009. Points to cover. Case history, diagnosis and management Diagnostic dilemma Adverse incident Event meeting

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Came with a Bang.......

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  1. Came with a Bang....... Dr Neelam Doshi Consultant Microbiologist Wythenshawe Hospital University Hospitals South Manchester Foundation Trust Occupational Zoonoses 9 July 2009

  2. Points to cover • Case history, diagnosis and management • Diagnostic dilemma • Adverse incident • Event meeting • Lessons learnt • Disease update

  3. Case History • 22 y Kurdish immigrant male, EM SRFT April 2007 9 pm • Acute severe right testicular pain • un able to walk and sleep • Chills, nausea , increased urinary frequency for 2 mo. • No trauma, penile discharge, not sexually active • No significant past history, drug allergy, fit ‘n’ well • Smokes 10 cig/d , social drinker • Shares a house with friends

  4. Diagnosis • Vitals T 37.7° C P 107 /min BP 93/52 mm Hg RR 18 • G/E, CVS, RS, P/A : NAD Local Examination Tender, swollen right testis, normal appearance Provisional Diagnosis • Testicular torsion • Urinary tract infection • Calculi

  5. Management • Hb: 12 g/dl WCC : 10.5(Nφ=7.9)/cmm • CRP: 28 , Urine dipstick: traces nitrates and protein • Blood culture and MSU sent • Plan: 1am To theatres for testicular exploration and orchiopexy On table: testis bit dusky but no torsion, epididymo-orchitis+ • Discharged next day : Scrotal support ,pain killers and oral ciprofloxacillin for 2/52 , though stilll febrile 38 ° C

  6. Re admission • 5 days later calls 999, EM in agony • Swollen testis, unable to walk, vomiting ,fever with chills • Pain score : 8, T: 38 ° C WCC : 9.6, CRP 55, • ECG normal, Blood cultures done . • No English, needs interpreter Diagnosis • ?Post operative haematoma • ?Infection • IV gent 5 mg/kg and to Urology, ciprofloxacin continued

  7. Diagnostic conundrum • Microbiology lab phones a gram negative cocco-baccilli in b/c taken on first EM admission i.e. 8 days before • Lab dilemma • Aerobic growth only • Very slow to grow on chocolate plates @Co2, 37 ° C • ?Haemophilus spp , ?others • Plates left on the bench pending senior BMS review, several biochemical test put up for id ( open bench) • Day 6 of 2nd admission , aerobic bottle from a new b/c set shows a similar gn-cocccobaccili • In the light of clinical diagnosis of epididymo-orchitis and the gram stain , medics thought ,?Brucella spp.

  8. Blood cultureGram’s stain

  9. More history • Microbiologists and the clinician in the presence of the friend, at the ward • Recent long trip in Europe on foot and back of lorries in un-sanitary conditions • In UK for last 2 mo. • Worked with cattle's/camels/sheep in past (3 years ago) in country of origin.

  10. Panic...... • Isolate sent to the Reference lab at Liverpool • All cultures and tests moved to Cat 3 lab • Expert ID opinion Prof Beeching sought . • Clinicians contacted to rationalize Rx to oral doxycycline 100 mg bd and rifampicin 600 mg bd for 6 weeks and to r/o deep seated infection .To send serum for antibodies . • Difficult traceability of patient as illegal immigrant, no GP, had a friends contact no in PAS. Needs Kurdish interpreter. • Now began the real panic!........

  11. Adverse event meeting • Urgent meeting :Lab/Medics/OH/HSE • Event summarized • All work done on open bench( aerosols), 6 staff exposed, including me and one in first trimester! • OH – letters to the staff about the incident, serum as base line and repeat at 3 and 6 mo , the warning s/s and wait till id confirmed . • How things could have been done differently.

  12. Actions • Future procedures and precautions • To process all small gram negative cocco-baccilli and those with clinical information suggesting high risk pathogens , in safety cabinet . • To raise awareness through lectures/plate rounds • Update SOP on how to deal with high risk pathogens, stick it on all benches • High light high risk spp. by usage of yellow stickers by clinicians • Internal lab transfer of cultures of this organism

  13. Bang.......... the news • Call from VLA • Confirmed B melitensis 3 • Situation more worse • Two staff reported flu like symptoms and lassitude , repeat bloods/sera taken, Doxycycline and rifampicin treatment dose prescribed • Mental trauma and Fear !! Settled only when sera results negative and recovered from- what was just a flu!! None started the antibiotics! OH NHS records • for 30 yrs.

  14. Follow Up : 15 days later and 2 mo later Absolutely well , no complications, 6 w Rx completed, Registered with a GP, Disease notified with HPU All contacts well till date.

  15. Brucellosis • Romanian skeletal remains • Florence Nightingale and her doctor colleague-Crimean fever, spondylitis, and neurobrucellosis • 1886 Bruce discovered the organism • Bang Pathologist-aborted fetuses of animals • Intracellular small, poorly staining ,gram negative bacilli • 6 spp.( host and pathogenicity)-melitensis-sheep/cattle • Highly infective : Infective dose10 organisms only. • UK: free as vaccinate animals 1991, test /slaughter scheme, animal movement tracing.

  16. The disease • Acute or insidious 1-2 mo • Intermittent fever (undulating), headache, weight loss, tiredness, depression. • Sequelae: OM/ Spondylitis /Epididymo-orchitis, psychoneurosis, endocarditis, abortion • Endemic areas: Middle east/Mediterranean S. & Central America, Asia, Africa, Caribbean.

  17. Diagnosis • Culture: slow growth : B/C, Bone marrow, aspirates, poorly staining gram, oxidase and urease +,CLED no growth, no X and V ,non motile. • 4 fold rise in sera titer • False positive Y enterocolitica / E coli o157 • Routes: respiratory/ sexual/ GI /LAI /bioterrorism • High risk activities: vets/abattoirs/farmers, lambing. • Treatment

  18. Conclusions • Sufficient clinical information • D/D of scrotal pathologies in immigrants where Brucella is endemic. • Safe working practices • Protocols for hazardous organisms , Risk assessment • Senior review in difficult isolates • Training and communication-good • Due concerns for the fear within staff- drug side effects, chronic sequelae, pregnant staff. • Bio terrorism weapon • Imported infection.

  19. References and websites • Pappas et al.Brucellosis. N Eng J Med. 2005; 352(22): 2325 - 2336. • Clinical Microbiology Letter Jan 1 2006, Vol 28 (1). Laboratory Acquired infections :Are microbiologists at risk? • Young, EJ.An overview of human brucellosis. Clinical Infect. Disease 1995 21:283-290 • Yurdakul T et al.Epididymo-orchitis as a complication of brucellosis .Review of 84 cases.Urologia Internationalis, 1995, vol. /is. 55/3(141-142), 0042-1138. • Health Protection Agency, Colindale ,London http://www.hpa.org.uk Guidelines for Investigation of Zoonotic diseases April 2009 • CDC website. • http://svmweb.vetmed.wisc.edu/pbs/zoonoses/-University of Wisconsin

  20. Thanks…….

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