Transcript Case #1 - UNC School of Medicine

Case #1
 Alexa Simon MSIV
 September 19, 2007
 UNC Infectious Disease
CC: Nausea vomiting, fever
 HPI: 56 y/0 AAF with history significant for
ovarian cancer stage IIIC with a complicated
surgical history including debulking surgery in
2005, ileocecal resection, and recent repair of
enterocutaneous fistula presented to Johnston
Memorial with acute onset of nausea, vomiting,
fever and abdominal pain.
HPI cont….
 At JM she was found on CT scan to have fluid
collection in the anterior subcutaneous tissue.
 She was started on Zosyn
 Patient was transferred to Gyn/Onc at UNC and
started on Ceftazidine and Flagyl.
HPI cont….
 She progressively became more hypotension with
increasing 02 requirements:
 Became obtunded and ID consult team was paged.
 The Ob/gyn resident ended phone call to ID saying “I need to
go intubate the patient.”
Tumor History
 Prior to 2005 was healthy
 9/2005: Presents with abdominal pain
 CT with massive ascites and 2 large adnexal masses
 CA-125>300
 9/29/2005: Ex-laporatomy BSO with iliocecal resection,
 Re-anastomosis omentectomy
 Suboptimal debulking mass
 PE with attempted VIR for embolectomy of saddle
embolus
 Multiple MIs
 TPN dependence begins
 12/2005: Chemotherapy began with Taxol
 7/2007: Repair enterocutaneous fistula
Infection History
 10/2006: Candida albicans and coagulase negative staphylococcal
infection at port site
 Rx: Fluconazole and daptomycin for 2 wks
 11/2006: Candida parapsilosis fungemia

Rx: Capsofungin with 8 wks
 1/2007: Coagulase negative staphylococcal and ampicillin
sensitive enterococcal bacteremia
 Rx: Daptomycin
 3/07: Coagulase negative staphylococcal bacteremia

Rx: Daptomycin
 7/2007 coag negative staph line infection and UTIs with
enterococci and candida
 Rx: Linezolid and fluconazole
Additional History
 SH:

Patient denies alcohol, tobacco, drugs
 Family History


Mother had ovarian cancer
Father had prostate cancer
 ROS: unobtainable due to intubation and sedation
Additional History
 Meds









Ceftazidine 2g IV q12
Flagyl 500mg q12
Linezolid 600mg q12
Micafungin 100 mg IV QD
Dopamine GGT
Morphine PRN
Benadryl PRN
Phenergan PRN
Zofran PRN
 Allergies





Zosyn: Rash
Ace Inhibitors: Rash
Vancomycin: Rash
PCN: Rash
Zofran: Rash
Physical Exam
 Vitals: Tmax 36.8/Tc: 35.9 BP:110/58 P:87 CVP:14-17
 Vent: SIMV PS:10 PEEP:5 FIO2%:40 TV 600 Rate 16
 General: Intubated, withdraws from pain 6-7/T
 HEENT: Icteric, PERRLA, no LAD
 CV: RRR 2/6 holosystolic murmur, non radiating on left sternal




border; no rubs or gallops
Lungs: Crackles Bilaterally at bases
Skin: jaundiced, no rash or bruising noted
Abdomen: tender throughout, no rebound, hypoactive bowel
sounds; multiple surgical scars, with palpable subcutaneous
midline mass (not fluctuant)
 No hepatosplenomegaly appreciated
Extremities: 1+ pitting edema bilaterally
Labs:
9.2
20.7
51
27.5
 Ca:7.4
Mg:1.9
 GGT:122
 Differential:
 ANC: 18.0↑
 ALC:0.8
 AMC: 0.8
 AEC:0.2
 ABC: 0
139 112
31
71
3.1 14
Phos:4.6
1.5
6.2
2.2
21.6
20.4
84
74
181
Radiology
 RUQ US:
 Lack visualized flow in portal veins/SMV, some
echogenic material in portal veins concerning
for clot
 Hepatomegaly
 New extrahepatic biliary ductal dilations
CT Adomen/ Pelvis
Radiology
 CTA Abdomen:
 Fluid collections contain focal area of gas with density
within the soft tissues overlaying a anterior abdominal
wall may represent abscess
 Increase in the size of multiple high density lesions seen
in the liver, which contain calcifications.
 Low density fluid in pelvis collection with in abdomen
c/w ascites
 Stable Left pleural effusion
DISCUSSION………..
Her Results:
Microbiology:
Urine Culture: gram positive
cocci in chains
Blood Culture (peripheral and
central line):
GPCs in chains and GPRs
Abdominal abscess: GPCs in
chains
TTE:
Left Ventricle: hyperdynamic EF: 6570%
Mitral Valve: thickened with mild
prolapse, moderate regurgitation
Aortic Valve: trileaflet with mild
thickening
Right Ventricle: normal
Tricupsid Valve: mild thickening
with mobile echo from the atrial
surface consistent with
degenerative, disease and
vegetation, with mild regurgitation
Pulmonary Valve: not well imagine
Infectious Disease Diagnosis
 Bacteremia:


Enterococci (ampicillin sensitive, but gentamicin R)
Bacillus cereus
 Endocarditis of the tricuspid valve
 Antibiotics used: Imepenem/cilastin and daptomycin
used to treat for 12 weeks
B. cereus now…
Bacillus cereus
 Commonly found in soil, inanimate objects, and
mucus membranes healthy people
 Gram positive motile rods with paracentral spores
 Taxonomy of 3 groups: large cell subgroup, small cell,
mixed


Large group is B. anthracis and cereus
They differ by fewer 9 nucleotides
Bacillus cereus cont’d…
 Grows on blood agar as large flat, granular, ground glass,
beta-hemolytic
 Grows aerobically and a facultative anaerobe
 Contains catalase, hemolysins, beta-lactamases, oxididase
 Ferments glucose, maltose, sucrose, trehalose

Does not ferment lactose, xylose, mannitol
 Resistant to heat
 Motile
Bacillus cereus Toxins
 Enterotoxin- can be necrotizing
 Emetic toxin- mitochondrial toxin
 Inhibits mitochondrial fatty-acid oxidation
 Can cause liver failure
 Phospholipases- release lysozyme enzymes (like alpha
toxin c. perfringens)
 Proteases
 Hemolysins-causing cell lysis of leukocytes and
macrophages
 Beta-lactamases thus resistant to most PCNs
Bacillus cereus Infections
 1: Local (burns, trauma, post op, fulminant eye infections)
 2: Bacteremia/septicemia
 3: CNS
 4: Respiratory infection
 5: Endocarditis, pericarditis
 6: Food poisoning, toxin induced
 Increase in non-food poisoning in IVDU, neonates,
malignancy, AIDs, prosthetic parts
 Most common form is GI intoxication from spores by
enterotoxins
Food-Poisoning
 Occurs 6-8hrs after ingesting B. cereus
toxins
 Patients typically have significant emesis
and less frequently diarrhea
 Enterotoxins : hemolysin, non-hemolytic
enterotoxin, enterotoxin T, and cytotoxin K
 Emetic toxin
 No fevers because not systemic disease
 Commonly isolated from reheated foods
Endophthalmitis
 5/10,000 hospital patients
 60% occur after intraocular surgery
 Often due to transient bacterial contamination by conjuctival flora
 4-13% after penetrating trauma
 Once inoculated bacillus spreads through out whole eye
 If motile strain <12 hours to detect inflammatory reaction in the eye
 Symptoms: pain “ache”, redness, blurry vision, ring corneal infiltrate
 Loss retinal function in 18hours if fully virulent (pclR gene and motile)
 High morbidity with loss of vision in infected eye
 Phospholipases toxins responsible for the destructions
 Treatment is injection of antibiotics into the vitreous and vitrectomy, along
with systemic antibiotics.
5 year Review of Cleveland Hospitals
From: 1981-1986
 38 patients with significant Bacillus infections:
 78.9% bacteremia
1/3 IVDU or had indwelling catheters, 4 had cancer
30% IVDU
7.9% endopthalmitis
1.8% Endocarditis (only with IVDU)
Osteomyelitis
Visceral infection- significant morbidity
1 pneumonia and1 necrotizing fasciitis after trauma







Medicine (Baltimore) 1987;66(3):218-23.
5 year Review continued…
 Intravascular device (pacemaker, central line) is a
cause of the nosocomial bacillus bacteremia
 4/38 patients improved after removal intravascular
catheter with out antibiotics
 Endocarditis rare phenomenon with B. Cereus
 Overall patients with primary bacteremia
recovered quicker and had less morbidity then
patient with a localized infection
Medicine (Baltimore) 1987;66(3):218-23.
Bacillus spp. Among hospitalized patients
with Haematological malignancies
 3.4% bacteremic with bacillus spp.
 Most only presented with fever
 Few cases of pneumonia, GI/Hepatic symptoms
 Patients that are granulocytopenic are at risk for
opportunistic infections with bacillus
 Many species can effect neutropenic patients which in
clude B. licheniformis, B. cereus, B. pumilus
 All patient were bacteremic, only few had
pneumonias, endocarditis, or localized infections
Journal of Hospital Infections 2006.;64(2):169-76.
Pseudo Epidemics
 Outbreaks have been seen in dialysis units, ICUs, neonatal
ICUs
 Bacillus spores are sticky







Non-sterile cotton wool
Laundered linens including gowns, sheets
Ventilation systems
Dressings
Hands
Dairy plants- filling machines
Korean dried red pepper
Contaminated Transfusions
 Platelet transfusions: contaminated 0.08-0.7 %
 Stored at room temperatures, thus longer storage time
increase risk of contamination
 Possible contaminants: dipthroid rods, coagulase negative
staph, B. cereus, E. cloacae, E. coli, P. aeruginosa
 Most cases deteriorated with minutes of transfusion
 Leading to hospital outbreaks of infections
 More common with patients with hematological malignancy
 Second to transfusions or long term indwelling catheters
 Blood transfusions no data seen
Treatment
 B. Cereus inherently resistant to most beta-lactams
 Antibiotics known to work:
 Imipenem
 Clindamycin
 In vitro activities of antibiotics on Bacillus spp and Spores
 Aminoglycosides: MIC 2-0.5
 Doxycycline: MIC 0.5
 Vancomycin: MIC 1
 Erythromycin: MIC>16
 Ciprofloxacin: MIC 0.25
 Daptomycin: MIC 1
Journal of Clinical Microbiology 2006;44(10):3814-18
References
 te Boekhorst PA, et al. Clinical significance of bacteriologic screening in platelet





concentrates. Transfusion 2005;45(4):514-19.
Drobniewski FA. Bacillus cereus and related species. Clinical microbiology
reviews 1993;6(4):324-38.
Sliman R, et al. Serious infections caused by bacillus species. Medicine
(Baltimore)1987;66(3):218-23.
Rotman B, Cote MA. Application of real-time biosensor to detect bacteria in
platelet concentrates. Biochemical and biophysical research communications
2003;300(1):197-200.
Yomtovian R, et al. A prospective microbiologic surveillance program to detect
and prevent the transfusion of bacterial contaminated platelets. Transfusion
1993;33(11):902-9.
Guinebretiere MK, et al. Enterotoxigenic profiles of food-poisoning and foodborne bacillus cereus strains. Journal of Clinical Microbiology 2002;40(8):305356.
References (cont’d.)
 Callegan M, et al. Bacillus endophthalmitis: Role of bacterial toxins and
motility during infections. Investigative Ophthalmology and Visual Science
2005;46(9):3233-8.
 Citron DM, Appleman MD. In vitro activities of daptomycin, ciprofloxacin, and
other antimicrobial agents against the cells and spores of clinical isolates of
bacillus species. Journal of Clinical Microbiology 2006;44(10):3814-8.
 Mahler H, et al. Fulminant liver failure in association with the emetic toxin of
bacillus cereus. NEJM 1997;336(16):1142-8.
 Ozkocaman V, et al. Bacillus spp. among hospitalized patients with
haematological malignancies: clinical features, epidemics and outcomes.
Journal of Hospital Infections 2006;64(2):169-76.
Search PubMed
 Bacillus Cereus Bacteremia
 Case Reports
 Reviews
 Differential Diagnosis
 Drug Therapy