Transcript ID Case Conference

ID Case Conference
21 November 2007
Yvonne Ballard, MD
Neutropenic Fever
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63yo CM with a history of AML M2, who is admitted
on 10/31 for completion of his third cycle of induction.
History of Chemotherapy
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Diagnosed 08/07
08/28/07: Induced with 7+3
09/11/07: BM Bx showed 66% blasts
09/14/07: Re-induced with Capizzi,
completed 9/23/07
– Complicated by Neutropenic Fever, PCP
Pneumonia, VRE Bacteremia, Coag neg staph
Bacteremia. Access replaced three times.
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10/24 – 10/27: Re-induced with Capizzi
10/31: Re-admitted to complete induction,
completed 11/2/07
Hospital Course
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11/2: Completed Chemo, Neutropenic
11/3: Loose BMs, C. diff negative
11/8: Hct drop 25%  12%, SVT, Fevers
began (high of 39.6)
– Antibiotics began: Vanc, Ceftaz, Levo
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11/9: EGD – nonbleeding esophageal
erosion; erythematous gastropathy
11/11: Voriconazole added for persistent
fever
11/13: ID consulted
Medical History
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PMH:
– AML, M2
– Diabetes Mellitus,
Type 2
– Hypertension
– Hypothyroidism
– DJD
– Umbilical Hernia
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Social Hx:
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Lives with wife
Retired
Occ. Etoh
No Tobacco, illicits
Family Hx:
– Mom: HTN
– Dad: Accidental
death
Medications
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Antibiotics:
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– Vancomycin 1.25gm IV
q8h
– Ceftazidime 2gm IV q8h
– Voriconazole 350mg po
q12h
– Bactrim DS MWF
– Valtrex 500mg po bid
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Fluconazole 11/7 - 11/13
Levofloxacin 11/8 - 11/13
Other Meds:
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Atenolol 50mg daily
Lipitor 5mg daily
Nexium 40mg bid
Finasteride 5mg daily
Synthroid 75mcg daily
Compazine 10mg tid
Allergies: Tobramycin –
Rash
Physical Exam
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VS: 36.6 133/74 70 18 98% on RA
Gen: WD, WN man comfortable in NAD
HEENT: NCAT, alopecia, Perrla, Eomi, Conj pale, sclera anicteric
OP with MMM. No overt ulcerations or mucositis. Small, discrete ulcer
on the right lateral aspect of the tongue. Dentition is fair, has one dental
cary.
CV: RRR, Nrml S1S2, No m/g/r
Pulm: CTA b/l, No w/r/r
Abd: Obese, soft, ND, NT, NABS
Ext: 2+ LE pitting edema, nontender
Neuro: Nonfocal
Skin: No rashes. Multiple normal appearing nevi. The pt has a
moderate-sized skin tag on the left neck that appears irritated.
Laboratory Data
135
3.7
103
8
28
0.6
72
9.6
1.9
3.4
10.6
<0.1
29
Urinalysis Negative
29.2
ANC 0.0
CXR: Lungs clear
Discussion
Diagnosis
Rothia mucilaginosa
Culture Data:
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11/8: Blood Culture, periph and PICC
– Positive with Rothia mucilaginosa
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11/11: Repeat Blood Cultures Negative
Rothia mucilaginosa
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Gram positive cocci
Formerly known as Stomatococcus
mucilaginosus
Classified as a separate genus in the family
Micrococcaceae
Normally part of flora of the human oral
cavity, and upper respiratory tract
May be misidentified as Staphylococcus,
Micrococcus, or Streptococcus
Rothia mucilaginosa
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Gram positive cocci in clusters, tetrads, or
pairs
Doesn’t grow on media supplemented with
5% NaCl
Non-motile, Non-spore forming
Weakly catalase positive
Strongly adherent to agar surface
Glucose fermenters
Mucoid capsule
Hydrolizes gelatine and esculin
Rothia mucilaginosa
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Implicated recently in serious infections
– Septicemia
– Endocarditis
– Meningitis
– Pneumonia
– Osteomyelitis
– Peritonitis
– Late prosthetic joint infections
Rothia mucilaginosa
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Risk factors for infection include:
– Indwelling venous catheter
– Leukemia
– Cancer
– Cardiac Valvular disease
– IV Drug abuse
– Severe neutropenia
» Mucosal damage
Literature Review
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Considered an emerging pathogen as a
cause of bacteremia in
immunocompromised patients
Bacteremia due to Stomatococcus mucilaginosus in
neutropenic patients in the setting of a cancer institute
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Retrospective study of 8 patients with positive blood cultures
– All neutropenic (<100 cells/mm3), All fulfilled sepsis criteria
– 7/8 had mucositis
– 8/8 on prophylactic Ciprofloxacin
– 8/8 had Port-A-Cath in place
– 5/8 resistant to quinolones
– Bacteremia occurred at median time of 6.5 days of neutropenia
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Review of 566 febrile neutropenic patients:
– Stomatococcus the 4th most frequent gram positive bacteremia
– Responsible for 5.9% of bloodstream infections
Clin Microbiol Infect 2003; 9: 1068-1072.
Bacterial Meningitis from Rothia mucilaginosa in Patients with
Malignancy or Undergoing Hematopoietic Stem Cell Transplantation
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Patient #1
– On prophylactic fluconazole,
Levofloxacin, and Acyclovir
– Fever, Nausea, HA,
Mucositis
– Initial LP negative, but
repeat on Day 23 showed
evidence of bacterial
infection, and GS positive
– Treated with Meropenem
and intrathecal Vancomycin
– Total tx duration: 6 weeks
– Repeat cultures negative
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Patient #2
– On prophylactic fluconazole,
Levofloxacin, and Acyclovir
– Malaise, HA, Fever
– MS Δs and Fever, Day #18
– LP suggestive of infection
– Treated with Ceftazidime,
Meropenem, Rifampin, and
intrathecal Vancomycin
– CSF never cleared
– Pt became comatose and
eventually died 10 days
later
Lee et al. Pediatr Blood Cancer 2007; DOI 10.1002/pbc
Bacterial Meningitis from Rothia mucilaginosa in Patients with
Malignancy or Undergoing Hematopoietic Stem Cell Transplantation
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18 total case reports of R. mucilaginosa meningitis
– 16 occurred during stem cell transplant
– 14 were neutropenic
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Risk factors identified:
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Profound immunocompromise
Prophylactic antibiotics
Repeated exposure to Broad spectrum antibiotics
Mucositis
Treatment
– All received Vancomycin, 13/18 received 3rd gen. Ceph.
– In vitro sensitivities found Rifampin to be most active drug
tested, and Ampicillin was the most active β-lactam
– 5/8 who received ITV survived
Bacteremia Caused by Rothia mucilaginosa in a Patient with
Shwachman-Diamond Syndrome
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3yr old boy with SDS admitted with fever
Positive blood cultures for R.mucilaginosus
MIC90
– Rifampin, <0.016 mcg/ml
– Erythromycin, <0.016 mcg/ml
– Penicillin, 0.05 mcg/ml
– Teicoplanin, 0.5 mcg/ml
– Vancomycin, 1 mcg/ml
– Linezolid 1 mcg/ml
– Gentamicin, 3 mcg/ml
– Tetracycline, 6 mcg/ml
– Amikacin, 8 mcg/ml
Vaccher, et al. Infection 2007; 35 (3): 209-210.
Bacteremia Caused by Rothia mucilaginosa in a Patient with
Shwachman-Diamond Syndrome
Patient treated empirically with Unasyn
and Netilmicin until cultures returned
 Pt improved quickly
 Discharged home after 5 days of
Rifampin therapy (15mg/kg/day), and
continued for 5 additional days
 Successful recovery at 2-week follow up
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Vaccher, et al. Infection 2007; 35 (3): 209-210.
ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Jan. 1995, p. 268–270. Volume 39, No 1