Transcript Infectious Conference

Infectious Conference
Anne Cortez
Hannah Lea David
Hazel Ann David
Jan Kristoper De Guzman
General Data
•
•
•
•
PAB
14/F
GMA, Cavite
Catholic
CC: Altered Sensorium
3 weeks PTA
• Intermittent low grade fever
(38.0C)
• Lysed by Paracetamol 500
mg/tab q4
• No accompanying symptoms
7 days PTA
• Recurrence of fever
• Bitemporal throbbing headache (Grade 8/10)
• Sought consult at a local hospital :CBC (normal
results) and Urinalysis (UTI)
• Cefuroxime 250mg/tab BID (12mkd) for 7
days, Paracetamol 500 mg/tab (12mkdose) q4
• Afforded relief of the symptoms
3 days PTC
•Recurrence of the
symptoms
•Continued
medications
1 day PTA
• Persistence of fever and headache
• Generalized weakness
• (+) vomiting- 1 episode, 1 cup, non-bloody,
previously ingested food
• Rushed to a nearby hospital and was assessed again
to have UTI
• Meds: Cotrimoxazole 500mg/tab BID for 7 days (24
mkd)
• Sent home
• Altered sensorium
Few hours
PTA
• Difficult to arouse, speaks
incomprehensively
• Persistent fever
• Rashes over the chest and
neck area
• Hence admission
Review of Systems
• General: (-) weight loss/gain, (-) anorexia, (-) chills
• Cutaneous: (-) pigmentation, (-) bruises, (-) hair loss, (-) pruritus
• HEENT: (-) lacrimation, (-) eye redness, (-) eye discharge, (-) blurring of
vision (-) nasal discharge, (-) epistaxis (-) sorethroat, (-) oral ulcers
• Cardiac: (-) orthopnea, (-) chest pain, (-) cyanosis
• Respiratory: (-) difficulty of breathing (-) cough (-) cold
• Abdomen: (-) jaundice (-) diarrhea (-) melena (-) hematochezia
• GU: (-) dysuria, (-) frequency
• Endocrine: (-) palpitations, (-) polyuria, (-) polyphagia (-) polydipsia
• Musculoskeletal: (-) swelling, (-) limitation of motion, (-) stiffness (-)
edema
• Hematopoietic: (-) pallor, (-) petechiae, (-) ecchymoses, (-) easy bruisability
• Neurologic: (-) seizures
Past Medical History
•
•
•
•
•
(-) Previous hospitalizations
(-) Surgeries
(-) PTB
(-) Asthma
(-) Allergies
Immunization History
• Completed EPI from the Brgy health center
• Unrecalled dates
• (-) booster doses, MMR, Hep A, Varicella, Flu,
Hib vaccines
Menstrual History
Menarche: 12 yrs. old
Interval: every 28-30 days
Duration: 5-7 days
Amount: 4 pads/day moderately soaked
Severity: (-) dysmenorrhea
Family History
•
•
•
•
•
(-) HPN, DM, Cardiovascular disease
(-) PTB, Asthma,CA
(-) Renal disease
(-) Blood Dyscrasias
(-) Seizure disorders
Family Profile
Age
Sex
Relation
Educ
Occupation Health
Attainment
status
RC
47
M
Father
HS Grad
Watch
repair
technician
Healthy
MC
47
F
Mother
HS Grad
Therapist
Helathy
26
M
Sibling
College
Grad
Supervisor
Healthy
22
F
Sibling
College
Grad
Cashier
Healthy
21
M
Sibling
College
Grad
Unemploye
d
Healthy
19
M
Sibling
College
student
Healthy
15
F
Sibling
HS Student
Healthy
24 hour food Recall
CHO
CHON
Fats
Kcal
Breakfast
½ cup rice
23
Fried pork
2
16
100
2
82
Snack
2 slices of bread
46
Liver spread
4
6
400
1
31
Lunch
1 cup rice
46
Fried chicken
4
8
200
1
41
Dinner
1 cup rice
1 grilled tilapia
ACI: 1160
RENI: 2140
% intake 54.2
46
4
32
200
4
106
Socioeconomic and Environmental
History
• lives with her family in their own two-storey,
well-lit, well-ventilated house made of concrete
and wood.
• Drinking water comes from a commercial
purifying station.
• Garbage is segregated and collected twice a
week.
• The family has a pet dog.
• There are no factories nearby and no cigarette
smoker at home.
HE/EADSS FFIRST
• Home: good interpersonal relationship, secretive
• Education: 2nd year high school student with good
grades, 2nd honor; favorite subject is English; a dancer;
dreams of becoming a doctor
• Eating: picky eater; meat-lover; prefers meat and fish
over vegetables
• Abuse: denies physical, sexual, and emotional abuse
• Drugs: denies use of illicit drugs
• Safety: no hazardous activities, does not drive
• Sexuality: denies sexual activity
• Family/Friends: belongs to a close-knit family, good
family relations, closer to her parents, has many friends
in school
• Image: good sense of self-image, good self-esteem
• Recreation: computer addict, prefers to sit in front of
the computer (FACEBOOK), seldom goes out with
friends, non-smoker, not an alcohol beverage drinker
• Spirituality: claims to regularly attend mass
• Threats & Violence: denies self-harm or harm to
others, no cruelty to animals, never been arrested, no
fights in school, no suicidal ideations
Physical examination
• Lethargic, arousable, well hydrated, adequately nourished,
wheel chair borne, not in cardio-respiratory distress
• BP 110/70 PR 95 RR 28 Temp 37.0°C
• Wt 42kg Length 155 cm (below 0) BMI 17.48 (below 0)
• Warm, moist, no active dermatoses
• Normocephalic head, atraumatic, no lumps, bumps, normal
hair distribution
• Pink palpebral conjunctiva, anicteric sclera, pupils sluggishly
reactive to light
• No tragal tenderness, slightly hyperemic EAC AS, retained
cerumen AD, TM intact
• Oral cavity not visulaized
• Supple neck, no palpable LN, thyroid not enlarged
• Symmetric chest expansion, no retractions, resonant
on percussion, clear and equal breath sounds on both
lung field`s
• Adynamic precordium, apex beat 5th LICS MCL, no
murmurs
• Abdomen globular, normoactive bowel sounds, soft,
non-tender, no hepatosplenomegaly
• Genitalia: SMR 1 Breast: SMR 2
• Pulses full and equal, no cyanosis, no deformities, no
edema
Neurologic Examination
• Drowsy, easily arousable to voice and painful
stimulation, no verbal output
• Pupils 4-5 mm OS
• 3-4 mm OD; conjugate gaze
• No facial asymmetry
• DTRs ++ on all extremities
• No Babinski
• No meningeal irritation
• With nuchal rigidity
Salient features
• 14/F
• Altered sensorium
• 3 week history of
intermittent, low grade
fever, headache,
vomiting,generalized
weakness
• Lethargic, GCS?
• Pupils 4-5 mm,
sluggishly reactive to
light
• DTRs ++ on all
extremities
• (+) Nuchal rigidity, (-)
kernig’s (-) brudzinski
• (-) Babinski
Approach to Diagnosis
• Look for a symptom, sign, or laboratory finding
pointing to an organ system
Headache
Altered
Sensorium
Nuchal
Rigidity
Vomiting
CNS
Focal
Neurologic
Deficit
Is there a
neurologic
problem?
What is
the
problem?
Meningeal
Irritation
Increase
ICP
Working Diagnosis
• t/c Meningitis
Differential Diagnosis
Infectious
Meningeal
Non
Irritation infectious
Non Infectious
• Present in the Patient
– Altered Sensorium
– Fever
– Bitemporal throbbing
headache
– Generalized weakness
– Vomiting
– Rashes
– Sluggish pupils
– (+) Nuchal Rigidity
• Subarachnoid Hemorrhage
–
–
–
–
–
–
–
Afebrile
Acute
Headache
Loss of consciousness
Vomiting
+/- neurologic deficit
Lumbar tap: bloody CSF
Infectious
• Present in the Patient
– Altered Sensorium
– Fever
– Bitemporal throbbing
headache
– Generalized weakness
– Vomiting
– Rashes
– Sluggish pupils
– (+) Nuchal Rigidity
• Meningitis
–
–
–
–
–
–
–
–
Headache
Fever
Nausea
Vomiting
Altered consciousness
Anorexia
Irritability
Neck Pain
Meningitis
Bacterial
Viral
Fungal
Lumbar
Tap
BACTERIAL
VIRAL
FUNGAL
TB
Opening
Pressure
Elevated
(100-300)
Normal or
Slightly
Elevated
Usually
Elevated
Usually
elevated
WBC
100-10,000 or
more; usually
300-2,000
PMNs
predominate
Rarely >1,000
PMNs early but
mononuclear
cells
predominate
through most
of the course
5-500
10-500
Protein
100-500
50-200
25-500
100-3,000
Glucose
Decreased
usually <40 (or
<50% serum
glucose)
Normal or
decreased to
<40
<50
<50
COURSE IN THE WARD
Upon Admission
• Upon admission, patient was put NPO and given D5NSS run
at 18-19gtts/min (100%).
• She was given Paracetamol 300mg/SIVP q4h.
• CBC with platelet revealed leukocytosis.
• Serum sodium was low while serum potassium and
creatinine were normal.
• Cranial CT scan with contrast was done and result was
suggestive of meningitis with hydrocephalus with undue
hypodensity involving the right lentiform nucleus and right
caudate nucleus may be due to vasculitic changes.
• The patient developed rash over the abdomen thus
Diphenhydramine 50mg/IV was administered.
Upon Admission
• Patient was referred to Pedia-Neurology.
• On neurological examination, patient was drowsy, easily
arousable to voice (occasional) and painful stimulation, no
verbal output, pupils 4-5mm OS and 3-4mm OD both
sluggishly reactive to light, (+) conjugate gaze, (+) nuchal
rigidity, no facial asymmetry, moves head side to side,
moves all extremities equally, DTR ++ on all extremities.
There was no atrophy, fasciculation, sensory deficits,
pathological reflexes, nor meningeal irritations.
• Later that day, IVF rate was increased to 20-21gtts/min
(100%) and later shifted to PNSS 1L run at 23-24gtts/min.
Upon Admission
•
•
•
•
•
•
•
•
•
Correction of hyponatremia was started.
RBS and Hgt were also done 30mins prior to LP.
Mannitol was started 0.5g/kg and then revised to 20% given 105mL/SIVP q6h.
Initial anti-TB regimen was Isoniazid 200mg/5mL 9mL qd (10mkd), Rifampicin
200mg/5mL 9mL qd (10mkd), Pyrazinamide 250mg/5mL 15mL qd (21mkd),
Ethambutol 400mg/tab 2tabs qd (22mkd), and Streptomycin 1g/vial + 2cc sterile
water 1.7cc/IM qd (20 mkd).
Lumbar puncture with CSF analysis was done with an opening pressure of 47cm
H2O and closing pressure of 42cm H2O.
Specimen for routine CSF analysis was sent as follows: Test tube#1 Sugar, protein
and cell count differential count , Test tube#2 Gram stain, CSF C & S, with ARD AFB
& India Ink for the fungal, Test tube#3 TB Bactec, Test tube#4 save specimen.
CSF was xanthochromic and slightly turbid. CSF protein was high and differential
count revealed 100% lymphocytes. Total CSF protein was high.
PPD and Chest x-ray (portable) were done. IVF rate was decreased to 20gtts/min
and Mannitol was maintained.
She was started on Dexamethasone 4mg/SIVP (0.14 mkd) q6h and Ranitidine
30mg/SIVP (2.9 mkd) q6h.
2nd Hospital Day
• NGT was inserted.
• Anti-Koch’s medications were revised:
– Isoniazid 200mg/5mL 7.5mL qd
– Rifampicin 200mg/5mL 12.5mL qd
– Pyrazinamide 250mg/5mL 15mL qd, all given via NGT
30mins prebreakfast.
• Patient was on 2-point restraint.
• IVF rate of 20gtts/min was maintained.
• Chest x-ray (portable) revealed suspicious
haziness is seen on left apex.
Official Reading:
Suspicious haziness is seen
on left apex
3rd Hospital Day
• PNSS 1L run at 20gtts/min.
• PPD reading was 0.5cm right volar surface, no
induration.
• Patient was referred to neurosurgery.
• She was still drowsy, awakens to mild stimulus
and occasionally follows commands, pupils were
still dilated 4-5mm OS and 3-4mm OD both
sluggishly reactive to light, (+) nuchal rigidity.
• She was given Paracetamol 500mg/tab 1tab/NGT
q4h for temp > 38.5oC.
4th Hospital Day
• PNSS 1L run at 20gtts/min (100%).
• Repeat cranial CT scan with contrast was
requested.
• She was given Hydrocortisone (Solucortef)
100mg/vial 1vial 1 hour prior to the CT scan and
Diphenhydramine 50mg/IV right before the
procedure.
• Ethambutol 400mg/tab 2tabs once a day was
started.
• Repeat sodium and potassium were both low.
5th Hospital Day
•
•
•
•
•
•
•
•
•
•
blood chemistry showed low serum osmolality, normal urine osmolality, normal
urine sodium & potassium, low serum sodium & normal potassium, high FBS,
normal BUN and low creatinine was requested.
She was referred to Nephrology.
She was still infused with PNSS 1L run at 15gtts/min (75%).
Patient was euvolemic (no edema).
A> most probable cause of hyponatremia is syndrome of inappropriate antidiuretic hormone (SIADH).
Medications given were Furosemide 40mg/SIVP single dose with BP precaution,
NaCl 1gm/tab 1 tab q8h.
Patient was GCS 12 (E4V3M5) with adequate urine output.
Neurosurgery offered CSF diversion procedure for ventriculo-peritoneal shunt
insertion after 2 weeks of anti-Koch’s medications.
She was prescribed with Acetozolamide 250mg/tab 1tab q8h. Later that day, IVF
was discontinued.
Patient was given 6 scoops of milk formula (ENSURE) + 190mL water to make
230mL via NGT every 3 hours.
6th Hospital Day
• Patient had low-grade fever. She was started
on Trimetroprim-Sulfamethoxazole (Cotrimoxazole) 800mg/160mg tablet 1tab BID.
7th Hospital Day
• patient went into respiratory distress. She became tachypneic
(RR=44) and irritable, had rapid, shallow breathing, suprasternal &
subcostal retractions, coarse crackles, wheezing on inspiration and
expiration, and fair air entry. O2sat was 88%.
• Salbutamol challenge was done.
• She was given O2 per nasal cannula at 1-2 lpm and salbutamol
nebulization 1neb q6h.
• After 2 hours, patient’s condition improved with respiratory rate of
34 and 02 sat of 95-96%.
• Patient was comfortable but still showed rapid shallow breathing,
good air entry, minimal supraclavicular and subcostal retractions,
decreased crackles and wheezing.
• ABG, chest x-ray (portable), and CBC with platelet were requested.
Repeat serum Na K. Feeding was decreased to every 4 hours.
Official reading:
Hazed infiltrates superimposed over
the left cardiac shadow, which may
represent pneumonic process
8th Hospital Day
• Patient had low-grade fever
• Salbutamol nebulization was decreased to
1neb every 8 hours.
• Relatives were instructed to turn the patient
side to side every 2 hours.
9th Hospital Day
• Patient had 3 episodes of loose stools, nonmucoid, non-bloody.
• ORS 75 was given through NGT to replace
losses volume per volume.
10th Hospital Day
• NaCl tablets were discontinued. P
• atient had persistent febrile episode and
abdominal pain.
• She still had loose watery stools.
• Urinalysis and CBC with platelet were
requested.
11th Hospital Day
• Patient had 2 episodes of watery stools. PLRS
was given to replace losses volume per
volume.
• Mannitol was decreased to every 8 hours.
Dexamethasone was consumed and then
shifted to Prednisone 10mg/5mL, 15mL BID.
• Ranitidine was discontinued once
Dexamethasone was consumed.
12th Hospital Day
• Patient followed commands, pupils anisocoric,
(+) ptosis L>R, (+) lateral rectus palsy OD,
medial rectus palsy OS, grade 5/10 headache,
and febrile episodes.
• No nuchal rigidity noted.
• Repeat Na and K was requested.
• Cotrimoxazole was discontinued.
Discussion
Meningitis
• Diffuse infection which primarily involves the
meninges
• Most common cause of fever associated with
signs and symptoms of CNS disease in children
Etiology
Causative Agents
Neonates
2 M to 12 years
Groups B and D
Streptococci
E. Coli
Listeria monocytogenes
N. Meningitidis
S. Pneumoniae
H. Influenzae
Type b
Pathogenesis
Bacterial colonization
of the nasopharynx
Attachment to the
epithelial cells , breach
the mucosa and enter
the circulation
Bacterial capsules
interfere with
opsonic phagocytosis
CSF through the
choroid plexus of the
lateral ventricles
meninges
Extracerebral CSF then
Subsrachnoid space
Bacterial Proliferation
Chemotactic Factors
Inflammatory
mediators
Clinical Manifestations
•
•
•
•
•
•
•
•
Fever
Anorexia
Poor feeding
Headache
Myalgias, arthralgias
Petechiae
Purpura
Vomiting
•
•
•
•
•
•
Nuchal rigidity
Back pain
(+) Kernig’s sign
(+) Brundzinski sign
Increase ICP
10-20% focal neurologic
signs
• Seizures
• Alteration of mental
status
Diagnosis
• Lumbar Tap - CSF analysis
Management
Specific
• β-lactam drugs, vancomycin (60 mg/kg/24 hr,
given every 6 hr) and 3rd-generation
cephalosporins (200 mg/kg/24 hr, given every
6 hr) or ceftriaxone (100 mg/kg/24 hr
administered once per day or 50 mg/kg/dose,
given every 12 hr) is recommended as part of
initial empirical therapy
• Duration of 10-14 days
Supportive
•
•
•
•
Ventriculo-peritoneal shunt
Furosemide
Mannitol
Dexamethasone
Preventive
• Rifampin 10 mg/kg/dose every 12 hr
(maximum dose of 600 mg) for 2 days – close
contact
• Pneumococcal vaccine
JOURNAL
Central Nervous System
Tuberculosis in Children: A Review
of 214 Cases
Ahmet Yarami *, Fuat Gurkan*, Murat Elevli ,Murat
Söker*, Kenan Haspolat*, Gökhan Kirba *,§, and M. Ali Ta *
From the * Division of Pediatric Diseases, Medical School,
Dicle University, Diyarbakir, Turkey; Division of Pediatric
Diseases, Medical School, Kocaeli University, Kocaeli, Turkey;
and§ Department of Pulmonology, Medical Clinic, University
of Freiburg, Freiburg, Germany.
PEDIATRICS Vol. 102 No. 5 November 1998, p. e49
Objective: To study the clinical, laboratory, and
treatment features observed in pediatric
patients with tuberculous meningitis in Turkey.
Study Design: retrospective case review study
Methods: Review of medical records for
demographic data, medical history, clinical
manifestations,
auxiliary
test
results,
complications, and treatment of 214 children
with central nervous system tuberculosis (TB)
admitted to Dicle University's hospital
between August 1988 and February 1996.
TABLE 1
Case Definition of CNS TB by Either Microbiologic or Clinical Criteria
Microbiologic case definition; one of the following:
Isolation of M tuberculosis from CSF
Abnormal neurologic signs and symptoms, CSF, or cranial CT consistent with CNS TB,
and isolation of Mtb from any site.
Clinical case definition; abnormal neurologic signs and/or symptoms and more than
two of the following:
Discovery of adult source case with contagious TB who had significant contact with
child
Presence of Mantoux (5 TU) skin test reaction >10 mm of induration, or >5 mm of
induration if child had close contact with infected adult*
CSF abnormalities without evidence of other infectious cause
Abnormalities on cranial CT consistent with CNS TB
*
>15 mm of induration was considered positive for children with BCG (BCG is in the
routine immunization program of Turkey).
Severity of the disease
• Stage I: involves patients with nonspecific
symptoms such as fever, anorexia, intermittent
headache, or vomiting, and with no
definiteneurologic manifestations.
• Stage II: includes patients with drowsiness and
disorientation and with signs of meningeal
irritation and/or evidence of increased
intracranial pressure.
• Stage III: patients were usually unconscious with
paralysis and signs indicating severe intracranial
hypertension.
RESULTS
Demographic and Clinical Characteristics
• 112 out of 214 patients (52%) were boys (male-tofemale ratio was 1.1:1.0)
• Age ranged from 3 months to 15 years, with a mean
age of 4.1 years.
• Seventy-seven percent of the children were younger
than 5 years, and ~44% of the patients were between
12 and 24 months of age.
• More than half (52%) of the patients came from rural
areas (villages), 73 (34%) from townships, and the
remainder (14%) from cities (urban areas).
• 141 (66%) of the patients had a family history of TB,
and 64 (30%) had a Mantoux skin test result of >10
mm of induration.
• Only 22 (13%) of 164 children had a positive acid-fast
bacilli smear in cerebrospinal fluid, and
Mycobacterium tuberculosis was isolated in
49 patients (30%).
• A small percentage of patients were admitted
in the first stage of disease (10%). The other
90% had a neurologic manifestation (120 in
the second stage and 72 in the third stage),
with a longer duration of preadmission
symptoms.
TABLE 3
Symptoms and Signs at Presentation
N = 214
%
Fever
91
Vomiting
87
Changes in personality
63
Seizures
62
Nuchal rigidity
59
Headaches
58
Loss of appetite
45
Weight loss
38
Irritability
30
Cough
29
Cranial nerve paresis
26
Diarrhea/constipation
10
Laboratory data
• 80% of CSF results were compatible with TBM
(ie, predominance of lymphocytes with
elevated protein and reduced glucose
concentrations)
Radiographical features
Hydrocephalus was seen on cranial CT in
80%, parenchymal disease in 26%, and
basilar meningitis in 15%.
Radiographic studies demonstrated abnormal
chest findings in 187 patients (87%) (hilar
adenopathy, 33%; infiltrates, 33%; miliary
pattern, 20%; and pleural effusions, 1%, and
172 (80%) cases with hydrocephalus,26%
with parenchymal disease, 15% with basilar
meningitis, and 2% with tuberculomas.
.
Clinical Course
• All the patients were hospitalized for diagnosis and initial treatment, and
the median hospital stay was 38 days (range, 11-95 days).
• Our patients were treated with a 12-month regimen, initially with
Isoniazid, rifampin, and pyrazinamide or streptomycin, and changed to
only two drugs (Isoniazid and rifampin) after 2 months of therapy.
• Steroids were used as adjunctive therapy in all patients for 3 to 4 weeks
and then gradually tapered as tolerated over a period of 7 to 10 days.
• Of 172 cases with hydrocephalus, 140 (81%) underwent surgical
management.
• Forty-nine patients (23%) died; 32 (65%) of these deaths occurred during
the first 3 days after admission to hospital. Sixty-three percent of deaths
were of children age 5 years or younger, 31% were of children 6 to
10 years of age, and only 6% (3) were of children older than age 10 years.
Outcome of treatment
TABLE 6
Outcome of Treatment
Stage
I
II
III
Total
No.
%
No.
%
No.
%
No.
%
Complete
recovery
13
59
67
56
6
8
86
40
Seizures
1
5
8
7
6
8
15
7
Developm
ental
sequela
8
36
31
26
27
38
66
31
Deaths
0
0
14
12
35
49
49
23
Conclusion
One or more of these findings: a family history
of TB, positive tuberculin skin test results,
abnormal
cranial
computed
tomography, and/or cerebrospinal fluid
analysis compatible with TBM were found in
all but 3 children in the study.