Transcript cases - VCOMcc

Infectious Diseases
Affecting the CNS - CASES
FEBRUARY 20, 2015
STANLEY D. MILLER, MD
INFECTIOUS DISEASES
Case #1
Presentation
◦ 32 year old AA male c/o 4 day history of frequent falls, headache, fever,
diplopia, and photophobia. The symptoms progressed during that time despite
an IM injection of ceftriaxone followed by 4 days of doxycycline (he was seen by
his PCP c/o urgency and frequency of urination initially).
Physical
◦ Temp 101.3 vital signs otherwise normal. Alert and oriented x 4
◦ Pt. c/o diplopia with lateral gaze bilaterally, right facial droop with drooling,
prominent nystagmus; greater with left lateral gaze than right. He could not
cough. He was somewhat ataxic. 3/5 strength of right arm and leg, 5/5
strength of left arm and leg. Reflexes were brisk.
Lab
◦ WBC 6030, segs-68, lymphs-8, monos-13, eos-1; Hgb 10.7, Platelets 397K, U/A
15-20 WBC, Sodium 131, ALP 256; CMP o/w normal.
◦ CT head without contrast “negative”
◦ Lumbar puncture was clear and colorless
◦ WBC-28 (segs-25 lymph-63 monos-12)
◦ Gram Stain-few WBCs, No organisms seen
RBC-86
Protein-119
Glucose-41 (blood glucose 111)
Case #1
More History
◦ He had actually not felt well for 4 months. He had c/o back pain for one month then
presented to the VH-ED 2 months PTA c/o 7-10 day history of fevers, chills, cough,
nausea, vomiting, and diarrhea. His liver enzymes were elevated and an U/S
revealed a thick-wall GB with pericholecystic fluid. There was also a hepatic flexure
“complex cyst”. He was treated with Moxifloxacin and was discharged home form
the ED.
◦ After that he continued to have malaise, easy fatigability and a 10 pound weight loss.
He continue to work (construction worker) but returned to his PCP when his
headache worsened and he began to have frequency of urination 4 days PTA.
Other
◦ He lives on a farm and raises pigs
◦ He was bitten in the hand by a Black Snake 10 months PTA
◦ He killed the snake and fed it to his pigs.
Treatment and Diagnostic Studies
◦ He was initially started on IV Vancomycin, Rocephin, and Acyclovir
◦ Neurology and Infectious Diseases consultation
◦ MRI of the Brain ordered
Case #1
MRI of the brain with contrast
◦ Multiple well-circumscibed ring-enhancing lesions throughout the
parenchyma of the cerebrum and cerebellum, as well as the pons
and brainstem. No significant peripheral edema is identified. No
mass effect. The findings are suspicious for microabscesses, which
could be of infectious origin. “Appearance is most suggestive of
somebody who is immune suppressed”.
Case #1
CT of the abdomen/pelvis/chest
◦ Nonspecific nodular opacities in the lung with upper lobe
predominance, a few appear cavitary. 2.1 x 1.8 cm areas
adjacent to the right psoas muscle.
◦ Interventional radiology aspirate yielded 30cc of pus that was
sent for analysis (and stained acid-fast)
Case #1
Treatment and clinical course
◦ Isoniazid, Ethambutol, Rifampin, Pyrazinamide, and Decadron were
initiated.
◦ Most of his neurologic deficits resolved in the first 3 days of
treatment (likely initially due to the Decadron).
◦ Mycobacterium tuberculosis was isolated from the right psoas pus. It
was not identified in the CSF. He tested HIV negative.
Final diagnosis: Tuberculous Meningitis widespread
tuberculomas in brain, lung, pelvic and mediastinal lymph
nodes.
◦ 10 weeks into treatment he remains asymptomatic. Repeat MRI
2/2/14 still shows innumerable ring-enhanced lesions throughout the
CNS but most are smaller in size.
◦ He will likely need 18 -24 months of treatment with slow tapering of
the Decadron.
Case #2
Presentation
◦ A 10 year old boy was admitted to the hospital with a 2 day history of fever,
headache and malaise. He was brought to the ED when his fever reached 105F
and he became “confused”
Physical exam
◦ Alert, but hyperactive and anxious appearing. Temp 104.5, HR 120
◦ No nuchal rigidity. No conjunctivitis, oral lesions. Lungs clear. Abdomen soft
and nontender. No focal neurologic deficits.
Labs
◦ WBC 14,000 with 45% segs, 50% lymphs, 5% monos. CXR negative. Blood
cultures drawn. CT of the head without contrast was “negative”
Admitting Diagnosis: Viral syndrome. IV fluids and
antipyretics initiated.
Case #2
Hospital Course
◦ Over the next 48 hours he remained highly febrile (again up to 105F) and
agitated. His parents became increasingly concerned. He began to “talk
nonsense”
◦ The attending ordered a repeat CT of the head, now with contrast.
◦ Blood and urine cultures remained no growth.
◦ As a result of the CT findings; ID consult was requested and antibiotics
were initiated.
◦ A lumbar puncture was performed
CSF analysis
◦ Clear, slightly xanthochromic
◦ WBC (38; segs 25, lymphs 75) RBC-525
Protein-90
Glucose-84
◦ Cryptococcal antigen: negative
◦ Gram stain: Mononuclear cells, No organisms
Case #2
Initial treatment? Intravenous Acyclovir
ID evaluation
◦ Dazed and babbling incoherently
◦ IV Acyclovir had already been started for suspected HSV encephalitis
◦ Patient immediately transferred to Pediatric ICU at a nearby tertiary
care center.
◦ He arrested enroute and had to be brought back for intubation. He
subsequently was transported to the tertiary care center and
improved over the next 72 hours. He was extubated and was alert
and communicative.
◦ Two hours later he rapidly decompensated, “blew his pupils”, became
comatose and expired
◦ CSF PCR testing confirmed HSV Encephalitis
Case #3
Presentation
◦ A 57 year old male with a history of COPD due to a 60+ pack year history of cigarette
smoking was referred to the ID clinic by his pulmonologist for evaluation of “yeast”
found in a BAL specimen. The bronchoscopy was performed to evaluate a left
lingular mass that had been noted on CXR. He had complained of a cough with low
grade fever for “months” and more recently had developed a severe headache.
Physical Exam
◦ He was lying on his side on the examining table, holding his head, curled up in a ball.
He was afebrile.
◦ He was thin and cachectic. Alert and oriented, but in severe distress due to his
headache
◦ He could not hear out of his left ear and he had dysconjugate eye movement.
◦ No other neurologic deficits. The rest of the exam was unremarkable.
Diagnostic Studies
◦ CT scan of the head without contrast was negative
◦ A lumbar puncture revealed very high opening pressure and his headache was
relieved within minutes of the procedure
Case #3
History
◦ He lives in a rural area and raises chickens. He regularly sweeps out
the chicken coop.
◦ He takes no corticosteroids or any immunosuppressive drugs.
◦ He has had “lazy eye” since childhood but now clarifies that he can’t
see out of his right eye or hear very well out of either ear.
Labs
◦ WBC 13,400 with 62% PMNs, 34% lymphs, CRP 1.5
◦ HIV antibody negative
◦ CSF was Clear and colorless:
◦ Protein 156
◦ Glucose 24
◦ WBC 38 (60% PMNs and 40% lymphs)
Case #3
His serum and CSF cryptococcal antigen
was positive at a titer of 1:1024,
signifying Cryptococcal meningitis.
The CSF culture grew Cryptococcus
neoformans (and stained with India ink)
He received 14 days of Liposomal
Amphotericin B plus 5-flucytosine
(induction) and was sent home on high
dose Fluconazole orally.
Case #4
Presentation
◦ A 23 year old male from Columbia (SA not SC) presented to the
ED unresponsive and febrile. His friends could not wake him up
that morning and called EMS. They related that he was fine the
previous night but that he had lost a lot of weight over the last 6
months. He could not be aroused by the ED staff, UDS was
negative. A stat CT of the head revealed a left hemispheric mass
with a midline shift and early herniation. Decadron and
mannitol were initiated and the neurosurgeon was consulted.
Physical exam
◦ Physical exam revealed him to be unarousable but moaning. He
was restless but would not move his right side. He appeared
thin and somewhat cachectic. Oral thrush was noted.
Blood work was remarkable for the following:
◦ WBC 2,100 with 75% PMNs, 6% lymphs, 18% monos, 1% eos
◦ Hemoglobin was 9.5, platelets 65,000.
◦ Liver enzymes were mildly elevated, serum creatinine was
normal
Case #4
Rapid HIV test was positive
◦ Calculated absolute lymphocyte count was 126
Decadron, Ceftriaxone, Metronidazole,
Sulfadiazine, Pyrimethamine, and Praziquantel
were initiated.
His CD4 count was 12, Toxoplasmosis IgG positive,
Taenia solium antibodies negative.
Within 48 hours he was alert and oriented, able to
move all 4 extremities.
◦ It was decided that cerebral toxoplasmosis was the most
likely pathogen so treatment for that alone was continued.
Case #5
Presentation
◦ 57 year old WM c/o a 1 week history of “eye irritation”, the L>R. His PCP sent him to a
ophthalmologist who noted “bilateral retinitis”, L>R. The patient considered himself
healthy and had not seen a doctor for 5 years. He took no medications. No history of
DM, HTN, Liver disease or kidney disease. No prior episodes of retinitis.
Social History
◦ He is married. No children. Works as an accountant. No tobacco, alcohol, or illicit drugs.
Initial Labs
◦
◦
◦
◦
WBC 6,350 with segs/57, lymphs/36, mono/4, eos/2, baso/1
Hemoglobin 13.9, platelets 194K, creatinine 0.95, Glucose 134
ALP 162, AST/ALT/T.bilirubin normal. Serum protein 9.2
UDS negative
Lumbar puncture: CSF findings
◦
◦
◦
◦
Normal opening pressure
WBC 20 (55% segs/ 45% lymphs)
Cryptococcal antigen negative
VDRL nonreactive
Protein 100
Glucose 80
Case #5
Other Labs
◦
◦
◦
◦
◦
HIV antibody positive
CD4 count 545
CMV IgG positive/IgM negative
CMV DNA by PCR <200
Serum protein electrophoresis: benign monoclonal gammopathy
RPR reactive at 1:512 titer and FTAabs reactive
The diagnosis of neurosyphilis in a HIV positive patient
presenting with bilaterally retinitis was made.
Aqueous Penicillin G 24 million unit/day was initiated. A PICC
line was placed and he was discharged home after 7 days of
treatment to complete the balance of 14 total days of treatment.
At the time of discharge his vision had improved dramatically as
did his eye exam.
Case #6
Presentation
◦ 49 year black female with a 2 day history of left ear ache and a
one day history of AMS. Her daughter brought her to the ED,
she was aphasic and lethargic on arrival. She was afebrile but
her WBC was 21,900. A stat CT of the head showed maxillary
sinusitis and left mastoiditis.
Physical Exam
◦ She was lethargic but arousable. Nuchal rigidity was present
and she had tenderness over the left mastoid. Her left tympanic
membrane was perforated with purulent drainage noted in the
ear canal.
Case #6
Additional history
◦ History of Migraine headaches, hypothyroidism, hypertension, hyperlipidemia
◦ No ETOH abuse, illicit drugs, head trauma
Lumbar puncture: CSF results
◦ Straw colored and cloudy
◦ WBC 16620 (99%PMNs/1% lymphs) RBCs 585 Protein >300 Glucose <5
Gram stain: Gram-positive diplococci and chains of cocci
Growth on BAP:
Case #6
She was initially started on
Vancomycin, Rocephin, and
Decadron.
The Streptococcus pneumonia MICs
◦
◦
◦
◦
Vancomycin 0.5
Ceftriaxone
Penicillin-G
Levofloxacin 1.0
<=0.12
<=0.06
Vancomycin was discontinued and Ceftriaxone was given
for 14 days. She recovered completely with no neurologic
sequelae
Diagnosis: Pneumococcal meningitis with left mastoiditis
and maxillary sinusitis