Transcript MELIOIDOSIS - Antonio Carlos Jr. 16082008

GOOD MORNING!
MEDICAL GRANDROUNDS
Antonio A. Carlos, Jr., MD
First Year Resident
12 June 2008
THE GREAT IMITATOR
OBJECTIVES
1. To present a case of liver abscess with an
unusual cause;
2. To give an overview on the etiology and
management of liver abscess;
3. To discuss melioidosis, its diagnosis and
management.
Santiago City, Isabela
Santiago City, Isabela
IDENTIFYING DATA
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E. B.
58 year-old female
Married
Farmer
Non-diabetic
Non-hypertensive
CHIEF COMPLAINT
Abdominal pain
HISTORY OF PRESENT ILLNESS
8 months prior to admission,
 crampy left upper quadrant abdominal pain
 occur intermittently
 no fever, vomiting, and diarrhea
 consulted at a local hospital
 abdominal ultrasound showed the presence of
three hepatic nodules
 no treatment was done due to financial
constraints
 lost to follow-up
2 months prior to admission,
 intermittent abdominal pain
 consulted in another local hospital
 abdominal CT scan showed the presence of
five hepatic nodules
 advised biopsy of the nodules
 opted to seek second opinion
2 weeks prior to admission,
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consulted a gastroenterologist in Manila
EGD was done
showed gastric ulcer
biopsy of the ulcer showed positive for
Helicobacter pylori
 started on H. pylori regimen
 advised admission for the work-up of the
hepatic nodules
PAST MEDICAL HISTORY
(-) Hypertension
(-) Diabetes
(-) Bronchial asthma
(-) Tuberculosis
FAMILY MEDICAL HISTORY
(+) Hepatitis A
(+) Bronchial asthma
(-) Hypertension
(-) Diabetes
(-) Tuberculosis
PERSONAL/SOCIAL HISTORY
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Farmer
Non-smoker
Non-alcoholic beverage drinker
No known allergies
REVIEW OF SYSTEMS
(-) weight loss
(-) fever
(-) cough and colds
(-) loss of appetite
(-) easy fatigability
(-) chest pain
(-) palpitations
PHYSICAL EXAMINATION
GS: conscious, coherent, ambulatory,
not in respiratory distress
VS: BP 100/70 HR 82 RR 18 T 36.9
HEENT: anicteric sclerae, pale palpebral
conjunctivae, no nasoaural discharge,
no CLAD
CL: symmetric chest expansion,
clear breath sounds
CVS: adynamic precordium, normal rate,
regular rhythm, distinct S1 and S2
ABD: flat, normoactive bowel sounds, soft,
(+) direct tenderness on LUQ,
no guarding, no organomegaly
EXT: no edema, no cyanosis,
full and equal pulses
SALIENT FEATURES
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58 year-old female
farmer
left upper quadrant abdominal pain
abdominal CT scan finding of hepatic nodules
“What is the nature of the hepatic
nodules?”
DAY OF ADMISSION
 Primary Impression
Hepatocellular carcinoma
 Differential Diagnosis
Liver Abscess
EB
Abdominal Pain
Hepatic Nodules
Hepatocellular CA
Primary
Metastatic
Liver Abscess
Etiology??
 CBC
 CT Guided Liver Biopsy
Gram Stain
Culture and Sensitivity
AFB Smear and Culture
Cell Block
1st HOSPITAL DAY
 Patient had febrile episodes, maximum
temperature of 39.4°C
 Blood culture was done
 Started on Metronidazole 50mg/IV q8°
Ciprofloxacin 500mg/tab, 1 tablet 2x a day
Paracetamol 500mg/tab, 1 tablet every 4 hours
2nd HOSPITAL DAY
 Patient still had febrile episodes
 CBC done
 Referred to Infectious Disease Service
“What is the focus of the fever?”
 Patient was seen by the Infectious
Disease Service
Transfer IV site
Urinalysis
Chest x-ray
EB
Hepatocellular CA
Primary
Metastatic
Liver Abscess Phlebitis UTI
Etiology??
PTB
3rd HOSPITAL DAY
 Patient was still febrile
 Liver aspirate culture grew gram negative
rods, T/C Pseudomonas
 Ciprofloxacin was discontinued
 Piperacillin-Tazobactam 4.5g/IV every
8 hours was started
4th HOSPITAL DAY
 Liver biopsy showed negative for malignant
cells
 Cytomorphologic features consistent with an
acute suppurative infection
 Liver aspirate culture grew Burkholderia
pseudomallei
 Piperacillin-Tazobactam was shifted to
Ceftazidime 1g/IV every 8 hours
EB
Hepatocellular CA
Primary
Metastatic
Liver Abscess
Burkholderia pseudomallei
PTB
5th HOSPITAL DAY
 Blood culture and sensitivity showed no
growth after 5 days
 Day 1 afebrile
6th HOSPITAL DAY
 Day 2 afebrile
 Patient decided that blood transfusion
would be done in Isabela
 Patient was discharged with follow-up
after 2 months
FINAL DIAGNOSIS
 Melioidosis
 Cannot totally rule out
Pulmonary Tuberculosis
 Peptic ulcer disease
RECOMMENDATION
 PTB work-up should be done
MELIOIDOSIS
HISTORICAL BACKGROUND
 Named from the Greek “melis” (distemper of
asses) and “eidos” (resemblance)
 First described by pathologist Alfred Whitmore
among morphia addicts in Burma in 1911
 In 1917, Stanton and Fletcher identified the
bacteria that cause the disease
 100 cases identified during the French
occupation of Vietnam in 1948-1954
 300 cases identified during the American
occupation in the 1970’s, popularly known as
the “Vietnamese Time Bomb”
EPIDEMIOLOGY
 Regarded as endemic to Southeast Asia and
Northern Australia
 Corresponds approximately to latitudes
o
o
between 20 N and 20 S
Fig. 1 Worldwide distribution of melioidosis
REPORTED CASES
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In Australia, 40 cases per 100,000 in 2002
In Thailand, 1,100 cases between 2004-2005
In Malaysia, 50 cases in 2002
In Singapore, 57 cases in 2004
In Taiwan, 43 cases in 2004
In Philippines, not reported in the world
literature
ETIOLOGIC AGENT
Burkholderia pseudomallei
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gram negative bacillus
bipolar staining
safety pin appearance
saprophytic
considered a Category 3
pathogen by the CDC
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Resilient organism
capable of surviving
hostile environmental
conditions
Produces several
virulence factors:
exopolysaccharides and lipase
phospholipase C
hemolysin
protease
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Often called the Great
Imitator
RISK FACTORS
 Exposure to aquatic environments and
agricultural lands
 Diabetes mellitus
 Chronic obstructive pulmonary disease
 Use of steroids
CLINICAL SYNDROMES
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Sepsis
Pneumonia
Liver abscess
Splenic abscess
Skin and soft tissue abscess
4 DISEASE CATEGORIES (CDC, 2000)
1. Acute localized infection
▪ localized as a nodule
▪ results from inoculation through a break in the skin
2. Acute pulmonary infection
▪ produce a clinical picture ranging from mild
bronchitis to severe pneumonia
▪ radiologic findings include nodule, upper lobe
consolidation, cavitary lesions
3. Acute bloodstream infection
▪ patients with underlying illness such as diabetes,
renal failure are affected by this type of disease
▪ usually results in septic shock
4. Chronic suppurative infection
▪ involves the liver, lung, spleen, lymph nodes
▪ may become dormant with exacerbation occurring
after primary infection
MODES OF ACQUISITION
1. Inoculation
▪ major mode of acquisition
▪ wounds to the feet of rice farmers are
common sites of inoculation
▪ 25% in the Darwin study gave a history of
an inoculation injury prior to presentation
2. Inhalation
▪ based on studies of US soldier helicopter crew
in Vietnam
▪ non-ambulant patients in Singapore acquired
the disease without exposure to soil or water
3. Ingestion
▪ contamination of potable water in two
outbreaks in Northern Australia
INCUBATION PERIOD
 Incubation period of melioidosis is not clearly
defined
 In the Darwin Series, an incubation period of 121 days has been defined
 Incubation periods of as long as 24 to 29 years
in ex-servicemen who were in Papua New
Guinea and Vietnam have been described
(hence the Vietnamese time bomb)
DIAGNOSIS
 Isolation of B.
pseudomallei remains
the gold standard in
diagnosis
 A modified Ashdown
medium with colistin
is commonly used
 Monoclonal antibody
latex agglutination
test
 Shown to agglutinate
blood culture fluid
positive to B.
pseudomallei
 Sensitivity of 95%
Specificity of 99.7%
TREATMENT
Characteristics of Antimicrobial:
 It should have a bactericidal effect;
 Should be able to penetrate phagocytic cells;
 Eliminate or inhibit glycocalyx
 Treatment of Melioidosis is divided into two
stages:
1. an intravenous high intensity stage
2. an oral maintenance stage to prevent
recurrence
Intravenous Intensive Phase
 Intravenous ceftazidime is the current drug
of choice for melioidosis
 Meropenem, imipenem, cefoperazonesulbactam are also active
 Amoxicillim-clavulanate may be used if none
of the above are available
Maintenance Phase
 Treatment with cotrimoxazole and doxycycline
be used for 12 to 20 weeks to reduce the rate of
recurrence
 Co-amoxiclav is an alternative for those who
are unable to take cotrimoxazole or
doxycycline
PROGNOSIS
 Without access to antibiotics, the septicemic
form of melioidosis has a mortality that
exceeds 90%
 With appropriate antibiotics, mortality rate is
about 10% for uncomplicated cases
 Relapse rate occurs in 10 to 20% of patients
BIOLOGIC WEAPONS AGENT
 CDC classified melioidosis as Category B
biological weapons agent
 Good candidate as a bioweapon because it is
easily available in the tropics, easy to cultivate,
sturdy, high potential to become bacteremic
 Countries studying melioidosis as a bioweapon
are USA, Russia, and Egypt
ACKNOWLEDGMENT
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Dr. Miguel Fores
Dr. Tarcela Gler
Dr. Jodor Lim
Dr. Mabel Aloc
Dr. Sasa Samson
Dr. Ronnie Benitez
Dr. John Jarin
Dr. JC Sevilla
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Arianne
Ivy
Abbey
Mara
Gelo
Ed B.
MM
THANK YOU!
CBC
Hemoglobin
April 23, 2008
9.3
Hematocrit
WBC
Neutrophils
Lymphocytes
Eosinophils
Monocytes
Basophils
Platelet
30.9
9.91
84
10
1
5
0
263,000
CBC
April 25, 2008
Hemoglobin
8.6
Hematocrit
28.6
WBC
5.91
Neutrophils
65
Lymphocytes
19
Eosinophils
4
Monocytes
12
Basophils
0
Platelet
220,000
Urinalysis
Color
Yellow
Transparency
Clear
pH
Acidic
Specific Gravity
1.025
Sugar
Negative
Proteins
Negative
Ketones
Negative
Nitrites
Negative
Leukocyte Esterase
Negative
Blood
0
RBC
0
WBC
0–1
Epithelial Cells
2
Bacteria
3
 Consider calcified
granuloma in the left
apex.
 The rest of the lungs are
clear.
 Heart and other chest
structures are within
normal limits
Site of Collection: Post Liver Biopsy April 23, 2008
Results:
Identified Organism/s:
Burkholderia pseudomallei
Light growth
Sensitivities:
Amikacin
Ticarcillin/Clavulanic acid
Piperacillin/Tazobactam
Cotrimoxazole
Ceftazidime
Cefepime
Ciprofloxacin
6R
28 S
29 S
32 S
25 S
18 S
24 S