Transcript ID Case Conference 10-10-07

ID Case Conference 10-10-07
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
CC: Foot Ulcer
52 yo woman w/ DM and Charcot foot who presents
with worsening swelling and redness around diabetic
foot ulcer.
Patient reports that her foot ulcer had been present for
several years, but that it changed about 1 week ago.
She denies any known history of trauma.
Her daughter was the one to notice that the ulcer on the
bottom of her left foot was red and swollen, smelled
horribly, and had a black area with white splotches.
The patient claims she feels no pain in the area but has
had decreased sensation in that foot from neuropathy.
ABX Course
Patient was initially started on Zosyn, received 4
days of therapy then lost IV access and got
levaquin/clinda x 1 dose until IV access could be
secured.
ID was consulted for assistance with ABX
PMH
CVA '03 - short term memory deficits per
daughter
HTN
DM TYPE 2
HYPERLIPIDEMIA
OBESITY
CHF
PMH (Cont)
Soc Hx - Lives in Burlington, and she hasn't
worked since her stroke in '03. Denies any etoh,
tobacco, or illict drug use. No recent travel. No
contact with dogs or birds. Has a cat – h/o bites
to the hand but no bites or licks on the foot.
Fam Hx - Aunt with Breast CA, Cousin with
Breast CA, FH of DM, HTN, Hyperlipidemia.
Medications
NKDA
ASA 81MG ONCE DAILY
EFFEXOR XR 225 MG ONCE DAILY
ENALAPRIL MALEATE 20MG TWO TIMES A DAY
FUROSEMIDE 60MG ONCE DAILY
HYDROCHLOROTHIAZIDE 25MG ONCE DAILY
METFORMIN HCL 1000MG TWO TIMES A DAY
NORVASC 10 MG ONCE DAILY
PLAVIX 75MG ONCE DAILY
SIMVASTATIN 80 MG ONCE DAILY
TOPROL XL 150MG ONCE DAILY
ROS
She admits to polyuria/polyphasia. She denies
any fevers or chills, but reports nausea and
vomitting this am, where she vomitted water x3
this morning and couldn't keep her medications
down. Patient denies any increased swelling in
her legs.
Physical Exam
BP 147/86
HR 90
RR 20
T 37.0
97% RA
NAD, alert/oriented x3,
appropriate
EOMI, PERRLA
MMM, OP clear
no palpable cervical nodes
no carotid bruits
RRR, no m/r/g
CTAB, nonlabored
soft, nontender, + bowel
sounds, obese
FROM
CN 2-12 Grossly Intact
moves all 4 extre's well
LE exam – next slide
Foot Exam
2x2 cm wound over plantar surface of Left foot;
moderate purulent drainage; moderate erythema
& swelling. Area of fluctuance present over ulcer
2-3+ pitting edema of lower extremities and feet.
Well circumscribed area of erythema and heat
on left lower leg and left foot. no clubbing,
cyanosis.
Labs
130 95
4.4 27
13.5
10.3
29.1
N-12.4
L-0.2
M-0.5
E-0.1
B-0.0
42
255
1.9
304
CRP >45
ESR 140
Ferritin 462
Hgb A1C 7.0
Diagnostic Studies
X-ray of foot on admission demonstrated
presence of cortical bone effacement,
concerning for osteomyelitis.
xray
MRI
Subtle enhancement seen within the distal cuboid overlying the
large skin ulcer as above may represent osteitis. Early
osteomyelitis cannot be fully excluded and follow-up plain
radiographs in 7 to 10 days is advised to assess for interval
progression.
Diffuse cellulitis and/or edema of left foot and ankle.
Small joint effusion. A septic joint cannot be fully excluded;
however, no signal abnormalities in the adjacent bones are seen
to suggest this diagnosis.
Abnormal enhancement at the base of the metatarsals are most
likely secondary to advanced neuropathic arthropathy.
Discussion
Blood Culture Results
3/3 blood cultures positive for
Pasteurella multocida 3+
Oxacillin Susceptible Staphylococcus aureus 3+
2007-07-24PENICILLINR
2007-07-24OXACILLINS
2007-07-24GENTAMICINS
2007-07-24VANCOMYCIN MIC2S
2007-07-24ERYTHROMYCINR
2007-07-24CLINDAMYCINS
2007-07-24TRIMETH/SULFAMETS
2007-07-24DOXYCYCLINES
Streptococcus species 3+
Polymicrobial Bacteremia
including pasteurella multocida
Microbiology
Zoonotic (related to animal sources)
Short, encapsulated gram negative coccobacilli
Aerobic, facultatively anaerobic
Small, gray, shining colonies on blood agar
Grow well on sheep blood, chocolate, MHA
Growth uncommon on MacConkey
Resistance associated with degree of encapsulation
Epidemiolgy
Found worldwide
Commensals in the upper respiratory tract of
fowl and mammals
Carrier rate 55% in dogs and 60-90% of cats
Causes a variety of disease in animals
Fowl cholera
mastitis
Epidemiology (cont.)
0.6-1.8 cases of P. multocida infection per 100,000 per
year
Most commonly transmitted to humans through bites
(cat, dog, other felines, horses, pigs, rats, rabbits,
wolves)
Isolated from 50% of dog and 75% of cat bites
Infections not related to bites probably stem from
contact with animal secretions
Clinical Manifestations
Soft tissue, bone, and joint infection (usuallly
following animal bites/scratches)
Oral and respiratory infections
Serious invasive infection
Soft tissue infection
Rapid development of intense inflammatory
response, often within hours of bite
Purulent drainage in 40%, lymphangitis in 20%,
regional adenopathy in 10%
Necrotizing fascitis can occur
Image
See UpToDate
Available online at UNC Health Sciences Library
[on campus only]
Septic arthritis
Septic arthritis most commonly involves a single joint,
usually the knee. Predilection for joints already
damaged (RA, DJD, prostheses). Bite usually distal to
involved joint without direct penetration.
NOT preceded by a bite or scratch in 1/3 of cases
(hematogenous spread)
More than 50% of patients with septic arthritis are
immunosuppressed.
Osteomyelitis
Local extension of soft-tissue infection or direct
innoculation
Cat bites > dog bites because of the sharp little teeth
that go down to bone
Treatment requires at least 4 weeks of IV antibiotics
followed by oral antibiotics
50% of patients experience slow healing, nonunion,
joint fusion, limitations of motion, or residual deformity
Poor functional outcome in hand infections
Respiratory infections
Usually have underlying COPD (37%),
bronchiectasis (21%), malignancy (15%),
cirrhosis (8%)
Pneumonia, pharyngitis, sinusitis, lung
abscesses
Other infections
Endocarditis: 15 case reports
Meningitis: 50% of cases infants < 1 year, 30% adults >
60 years
Peritonitis: usually associated with peritoneal dialysis
(cat had punctured dialysis tubing in 65%)
Endophthalmitis
Bacteremia
Bacteremia
Most are immunocompromised (cirrhosis,
malignancy/chemotherapy)
Mortality approximately 30%
Commonly accompanies a localized infection
Often seen with liver dysfunction
Bacteremia (cont)
Very rare
In the past 5 years,
we’ve had 4 positive
pasteurella multocida
isolates from blood at
UNC
Fun fact –pasteurella
bacteremia at UNC is
associated with Shaughnessy
exposure (no causation. all
patients had positive blood
cultures prior to exposure. I
promise I wash my hands!)
Association with liver disease
Cirrhosis of any etiology, hepatitis, infiltrating
tumors
Impairment of reticuloendothelial system makes
patient prone to infection with encapsulated
organisms
Treatment
Penicillin is drug of choice
If PCN allergic, quinolone, doxycycline, 1st
generation cephalosporin, septra
In cases of septic arthritis, IV abx and serial joint
aspirations
Our Patient
Pip/tazo chosen for good coverage of pasteurella, OSSA, and
anaerobes/pseudomonas (given diabetic foot ulcer)
Intensive debriedments and IV abx x 2 months showed only mild
clinical improvement, no change in ESR
Repeat wound culture confirmed OSSA, no further positive
cultures for pasteurella. All repeat blood cultures negative to
date.
Currently getting hyperbaric oxygen therapy via our vascular
surgery colleagues
Continuing IV Abx – trying to save the foot
Sources
Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s
Principles of Internal Medicine, 15th edition.
Book available online via the UNC-CH Libraries
Tseng, Su, Liu, & Lee. Pasteurella multocida bacteremia due to
non-bite animal exposure in cirrhotic patients: report of two
cases. Journal of Microbiology, Immunology, and Infection.
2001; 34: 293-296.
Morris MJ, Mcallister CK. Bacteremia Due to Pasteurella
multocida.
Talan, Citron, Abrahamian, Moran, Goldstein. Bacteriologic
Analysis of Infected Dog and Cat Bites. The New England
Journal of Medicine. Vol 340, number 2. 1999.
Sources (continued)
Levinson, Jawetz. Medical Microbiology and Board Review.
McGraw-Hill, 1998. Pgs 133-134.
UpToDate [available online at UNC HSL – on campus only]
Mandell’s Principles and Practices of Infectious Disease, 6th Ed.
Book available online via the UNC-CH Libraries
Weber, DJ, Wolfson, JS, Swartz, MN, Hooper, DC. Pasteurella
multocida infections. Report of 34 cases and review of the
literature. Medicine (Baltimore) 1984; 63:133.
Weber, DJ, Hansen, AR. Infections resulting from animal bites.
Infect Dis Clin North Am 1991; 5:663.
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Pasteurella Multocida
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