Transcript ID Case Conference 10-10-07

ID Case Conference 11-28-07
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
CC: neck pain
43 year old woman without significant PMH who
presents with neck pain. She initially presented to her
primary care physician in August 2007 with mild neck
discomfort and feeling “like my head is too heavy for my
neck.”
She initially thought it was from sleeping on the couch
for a week but the pain persisted after she slept in her
bed.
She was diagnosed with probable musculoskeletal
strain and treated with NSAIDS and physical therapy.
The pain persisted.
HPI (cont)
In late-October 2007 she had a sudden onset of neck
swelling and trouble swallowing. She was admitted to
her local hospital and started on steroids and
antibiotics.
CT scan of the neck revealed bone destruction of C2 &
C3 with ventral soft tissue swelling concerning for a
mass.
An open biopsy was done 11/5/07 in the OR and
pathology revealed only inflamed mucosa with fibrosis.
This was not sent for culture.
HPI (Cont)
She was discharged without steroids or
antibiotics and referred to UNC ENT clinic for
further evaluation of her neck mass.
UNC ENT physician saw the patient on
10/20/07. After reviewing the CT scan from the
outside hospital, the physician put the patient in
a C-collar, admitted her to the hospital, called ID
and neurosurgery.
PMH
Mild anxiety, controlled with low dose paxil
H/o Bartholin gland cysts in July 2007 – it was excised
and drained at her local ED then 36 hours later she had
fevers and chills with drainage. She had multiple I&Ds
and ultimately a surgical excision with drain placement
in August 2007 (she was sleeping on the couch
because of the wounds)
10 days of clindamycin for +MRSA culture in the wound, no
blood cultures, wound resolved.
G4P4004 – h/o C sections
Medications
Allergies – sulfa, flagyl
Home Meds – Roxicet PRN, Paxil 10mg po daily
Social History
Denies alcohol, tobacco, or drug use.
Has one dog at home – dog is not ill.
No recent travel.
The patient’s husband is in the military and spent 10 months in
Afghanistan in 2004 and 2 more weeks there just prior to her
illness. He was overseas October 12-28 and her neck swelling
occurred just after he returned.
She reports that 3 soldiers from her husband’s regimen
contracted TB while abroad, no known TB in her husband.
Social/Family History
Currently works as a housewife. Previously
worked as a preschool teacher where they
required yearly PPDs (last negative 16 months
ago)
Colon cancer in her father
3 Children – ages 19, 16, and 6.5. History of a
4th child who died at a young age in an accident.
ROS
20 lb weight loss in the past month – blamed it
on pure liquid diet since the neck swelling
No fevers, no chills
No recent tooth infections – history of root canals
in 2002 and 2003
Complains of difficulty swallowing
No bowel or bladder dysfunction, no weakness
or numbness
Physical Exam
Afebrile – P 74, R 18, BP 134/75,
97% on RA
INAD, wearing c-collar
EOMI, PERRLA, nonicteric
No e/e on OP
No JVD
No LAD appreciated in cervical,
supraclavicular, axillary, or inguinal
regions
RRR no murmurs
CTAB
No rashes or skin lesions, no nail
lesions
A&Ox3, pleasant and cooperative,
talkative.
Soft NT NABS
No c/c/e, pulses 2+ and equal in
BU and LE
Normal tone, full ROM present. No
tenderness to palpation of thoracic
or lumbar spine. No apparent
tenderness to palpation when I
watched neurosurgery palpate the
patient’s cervical spine.
CN II-XII intact, strength 5/5 in BU
and LE, reflexes 2+ in BU and LE,
cerebellar exam intact
Labs
141 103 6 102 9.1
1.7
4.0 29 0.6
3.8
6.9
12.0
35.5
N-4.6
L-1.5
M-0.4
E-0.2
B-0.0
301
ESR 35
TProt 7.3
Alb 3.8
Uric Acid 5.0
LD 440
TBili 0.5
AST 36
ALT 67
Alk Phos 110
GGT 131
TSH 0.22
PT 13.4
PTT 35.4
INR 1.2
Discussion
“A Diagnostic test was performed…”
FNA and BIOPSY of ventral soft tissue mass done by
ENT in the OR
Negative gram stain
No AFB seen on smear
Pathology
- Polypoid fragments of benign squamous mucosa with
parakeratosis and submucosal chronic inflammation.
- No granulomatous inflammation or carcinoma identified.
- AFB and GMS stains negative for AFB or fungi.
Micro results from biopsy
GRAM STAIN RESULT BELOW
1+ POLYMORPHONUCLEAR LEUKOCYTES
1+ GRAM POSITIVE COCCI
2007-11-25RESULT 1Oxacillin Resistant Staphylococcus aureus 3+
2007-11-25PENICILLINR
2007-11-25OXACILLINR
2007-11-25GENTAMICINS
2007-11-25VANCOMYCIN MIC2S
2007-11-25ERYTHROMYCINR
2007-11-25CLINDAMYCINS
2007-11-25TRIMETH/SULFAMETS
2007-11-25DOXYCYCLINES
Vertebral Osteomyelitis
First described by Hippocrates and Galen
Prior to antibiotics was fatal in 25% of cases
Incidence of vertebral osteomyelitis may be
increasing 2/2 increased rates of nosocomial
bacteremia, increasing population age, and
higher rates of IV drug use.
Most common site is lumbar, followed by
thoracic. Cervical is rare.
Probable Organisms
Staph aureus is >50% of cases
Both HA-ORSA and CA-ORSA are making up an increasing
percentage.
Enteric gram negative bacilli – asso w/ urinary tract
instrumentation
Pseudomonas aeroginosa and candida are seen with
catheter-related blood stream infections or IV drug use
Group B and G strep in pts w/ DM
TB
Organisms based on geography
Brucella melitensis – middle east and
mediterranean
Burkholderia pseudomallei – periequatorial
regions
Salmonella and entamoeba histolytica – Africa or
South America
Signs and Sx
Neck and back pain. Usually begins insidiously and
progressively worsens over weeks to months.
Series of 64 pts w/ spontaneous hematogenous
vertebral osteo w/o h/o IV drug abuse:
Mean age 59
Mean duration of sx was 48 days prior to hospital admission
Neurologic impairment present in 28%
Blood cultures positive in 72% of cases
Fever inconsistent – 52% in reivew from 1979, only
30% in review from 2005
Signs
Tenderness to gentle spinal percussion is the most
reliable clinical sign
WBC may be elevated or normal, elevations in ESR and
CRP present in >80% of pts
Diagnosis is made by bone biopsy
In one review article 31% of pts w/ vertebral osteo had
infective endocarditis as well
Risk factors for IE were heart condition, heart failure, positive
blood cultures, and gram positive organisms
Management
IV antibiotics directed at causative organism
Surgery indicated for
Progression of disease despite adequate antibiotic
therapy
Threatened or actual cord compression due to spinal
instability or vertebral collapse
Epidural or paravertebral abscesses
Long term outcome of 253 patients
with vertebral osteomyelitis – CID
2002
Eleven percent of the patients died
Residual disability occurred in more than one-third of the
survivors
Relapse occurred in 14%.
Median duration of follow-up was 6.5 years (range, 2 days to 38
years).
Independent risk factors for adverse outcome (death or qualified
recovery) were neurologic compromise, time to diagnosis, and
hospital acquisition of infection (P< or =.004).
Surgical treatment resulted in recovery or improvement in 86
(79%) of 109 patients.
References
Nolla JM, Ariza J, Gómez-Vaquero C, Fiter J, Bermejo J, Valverde J, Escofet
DR, Gudiol F. Spontaneous pyogenic vertebral osteomyelitis in nondrug
users. Semin Arthritis Rheum. 2002 Feb;31(4):271-8.
Priest DH, Peacock JE Jr. Hematogenous vertebral osteomyelitis due to
Staphylococcus aureus in the adult: clinical features and therapeutic
outcomes. South Med J. 2005 Sep;98(9):854-62.
Torda AJ, Gottlieb T, Bradbury R. Pyogenic vertebral osteomyelitis: analysis of
20 cases and review. Clin Infect Dis. 1995 Feb;20(2):320-8.
McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term
outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis.
2002 May 15;34(10):1342-50. Epub 2002 Apr 22.
UpToDate
Mandell’s Principles and Practices of Infectious Disease, 6th Ed.