What defines uncommon? What defines uncommon? What defines - - PDF document

Unusual Presentations of Unusual Presentations of Common Infectious Diseases in Common Infectious Diseases in Kids Kids Unusual Presentations of Unusual Presentations of Common Infectious Diseases in Common Infectious Diseases in Kids Kids

Denis Denise Bratc Bratcher, DO DO Denis Denise Bratc Bratcher, DO DO Professor, Pediatrics Professor, Pediatrics Professor, Pediatrics Professor, Pediatrics Ped Pediatric In atric Infectious D fectious Diseases seases Ped Pediatric In atric Infectious D fectious Diseases seases Children’s Mercy H ildren’s Mercy Hospitals &

• spitals & Clinics

linics Children’s Mercy H ildren’s Mercy Hospitals &

• spitals & Clinics

linics Kans Kansas City City, MO , MO Kans Kansas City City, MO , MO

What defines uncommon? What defines uncommon? What defines uncommon? What defines uncommon?

• "Uncommon manifestations of

"Uncommon manifestations of common diseases are more common diseases are more common diseases are more common diseases are more common than common common than common manifestations of uncommon manifestations of uncommon diseases." diseases."

• Series will address unusual

Series will address unusual presentations of common pediatric presentations of common pediatric presentations of common pediatric presentations of common pediatric infections infections

Case #1 Case #1 Case #1 Case #1

13-year old previously healthy male presents with right ankle pain X4 presents with right ankle pain X4 days, fever, perioral cyanosis Seen in healthcare facilities X4—last 2 times with fever  symptomatic care Evaluated by team trainer who noted cyanosis & called 911 cyanosis & called 911 Noted to be cyanotic, hypotensive, tachypneic

Case #1: Review of Case #1: Review of Systems Systems Case #1: Review of Case #1: Review of Systems Systems

• Fever X2 days

Fever X2 days

• Fever X2 days

Fever X2 days

• Right ankle pain X4 days

Right ankle pain X4 days

• Perioral cyanosis

Perioral cyanosis

• Hypotension

Hypotension

• Respiratory distress

Respiratory distress

• Respiratory distress

Respiratory distress

Case #1: Past Medical History Case #1: Past Medical History Case #1: Past Medical History Case #1: Past Medical History

• Cleft palate repair

Cleft palate repair infant infant

• Cleft palate repair

Cleft palate repair—infant infant

• Myringotomy tubes

Myringotomy tubes— —toddler toddler

• No history skin/soft tissue infections

No history skin/soft tissue infections

• Family Hx: mother with history of

Family Hx: mother with history of boils; currently healthy boils; currently healthy

• Social Hx: lives with parents & sister,

Social Hx: lives with parents & sister, 2 cats, 2 dogs; plays football, kick 2 cats, 2 dogs; plays football, kick boxes, & unloads trucks boxes, & unloads trucks

Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam

• VS:38.6

VS:38.6°C; HR 120; RR38; BP C; HR 120; RR38; BP VS:38.6 VS:38.6 C; HR 120; RR38; BP C; HR 120; RR38; BP 76/42 76/42

• General:

General: ill ill-

• appearing

appearing, becoming , becoming somnolent somnolent

• HEENT normal

HEENT normal

• Heart rate/rhythm regular, no

Heart rate/rhythm regular, no murmur; murmur; tachycardic; capillary refill tachycardic; capillary refill murmur; murmur; tachycardic; capillary refill tachycardic; capillary refill very delayed very delayed

• Lungs

Lungs poor aeration bilaterally poor aeration bilaterally

Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam

• Abdomen:

Abdomen: full, distended full, distended, no , no Abdomen: Abdomen: full, distended full, distended, no , no HSM/masses HSM/masses

• Extremities:

Extremities: cool, poorly perfused, cool, poorly perfused, distal pulses not palpable; right distal pulses not palpable; right lower ext. tightly edematous with lower ext. tightly edematous with ecchymosis throughout ecchymosis throughout

• Skin:

Skin: Ecchymotic areas over lower Ecchymotic areas over lower Skin: Skin: Ecchymotic areas over lower Ecchymotic areas over lower extremities; bullous lesions over R extremities; bullous lesions over R ankle ankle

• Neuro:

Neuro: somnolent somnolent

Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Evaluation Evaluation Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Evaluation Evaluation

• CBC:

CBC: WBC WBC 1,600 1,600 CBC: CBC: WBC WBC 1,600 1,600

Differential Differential 21S/34B/38L/13M 21S/34B/38L/13M Hemoglobin Hemoglobin 15.5 15.5 Platelets Platelets 150,000 150,000

• Electrolytes:

Electrolytes:

Sodium Sodium 151 151 Sodium Sodium 151 151 Potassium Potassium 3.2 3.2 Chloride Chloride 105 105 Carbon Dioxide Carbon Dioxide 34 34

Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Evaluation Evaluation Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Evaluation Evaluation

• BUN/Cre

BUN/Cre 40/1.8 40/1.8 mg/dL mg/dL

• Lactic Acid

Lactic Acid 6.8 6.8 mmol/L’ mmol/L’

• PT/PTT

PT/PTT 18.4/87.6 18.4/87.6 secs secs

• Fibrinogen

Fibrinogen 499 mg/dL 499 mg/dL

Case #1: What’s the Case #1: What’s the Diagnosis? Diagnosis? Case #1: What’s the Case #1: What’s the Diagnosis? Diagnosis?

• Septic Shock

Septic Shock

• Septic Shock

Septic Shock

• Staphylococcus

Staphylococcus

• Meningococcus

Meningococcus

• Pneumococcus

Pneumococcus

• Pneumonia

Pneumonia

• Osteoarticular infection

Osteoarticular infection

• Endocarditis

Endocarditis

Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation

• Patient was intubated and ultimately

Patient was intubated and ultimately Patient was intubated and ultimately Patient was intubated and ultimately placed on ECMO with cardiopulmonary placed on ECMO with cardiopulmonary failure failure

• Blood cultures repeatedly revealed

Blood cultures repeatedly revealed Methicillin Methicillin-

• resistant

resistant S. aureus

• S. aureus (MRSA)

(MRSA)

• Clindamycin

Clindamycin-

• susceptible; not inducibly

susceptible; not inducibly-

• resistant

resistant

• Echocardiogram: no vegetations or

Echocardiogram: no vegetations or thrombi thrombi

Case #1: Radiologic Evaluation Case #1: Radiologic Evaluation Case #1: Radiologic Evaluation Case #1: Radiologic Evaluation

• CXR: diffuse bilateral alveolar

CXR: diffuse bilateral alveolar

• CXR: diffuse bilateral alveolar

CXR: diffuse bilateral alveolar

• pacities throughout the lungs
• pacities throughout the lungs
• CT Head: no acute intracranial

CT Head: no acute intracranial abnormality abnormality

• Ultrasound:

Ultrasound:

• Right lower extremity: thrombus

Right lower extremity: thrombus within superficial femoral vein to within superficial femoral vein to the popliteal vein level the popliteal vein level

Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation

• Patient

Patient initiallly initiallly managed with managed with i / li d i / i / li d i / illi illi vancomycin/clindamycin/ vancomycin/clindamycin/oxacillin

• xacillin

pending susceptibility confirmation pending susceptibility confirmation

• Vancomycin MIC =1 from outside hospital

Vancomycin MIC =1 from outside hospital

• Blood cultures remained positive

Blood cultures remained positive

• Vanc

Vanc levels optimized; clindamycin levels optimized; clindamycin continued continued

• Rifampin and gentamicin added

Rifampin and gentamicin added

• All lines, except ECMO circuit, changed

All lines, except ECMO circuit, changed

Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation

• Bedside fasciotomies revealed

Bedside fasciotomies revealed

• Bedside fasciotomies revealed

Bedside fasciotomies revealed extensive necrosis of muscles extensive necrosis of muscles throughout entire right lower throughout entire right lower extremity extremity

• Ultimately above

Ultimately above-

• the

the-

• knee

knee amputation required amputation required

• Unable to wean from ECMO

Unable to wean from ECMO support after lengthy course support after lengthy course

Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Clinical Infection--Clinical Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Clinical Infection--Clinical

• MRSA now established as

MRSA now established as

• MRSA now established as

MRSA now established as community pathogen in many community pathogen in many areas worldwide areas worldwide

• Most frequently causes skin &

Most frequently causes skin & soft tissue infections soft tissue infections

• Constitute over 90% of infections

Constitute over 90% of infections caused by community caused by community-

• acquired

acquired MRSA in children MRSA in children

Kaplan SL. Infect Dis Clin N Am. 2005;19:747--57

Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Clinical Infection--Clinical Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Clinical Infection--Clinical

• Increasingly associated with

Increasingly associated with

• Increasingly associated with

Increasingly associated with invasive infections: invasive infections:

• Musculoskeletal infections

Musculoskeletal infections

• Often complicated by venous

Often complicated by venous thrombophlebitis, septic pulmonary thrombophlebitis, septic pulmonary emboli & disseminated staphylococcal emboli & disseminated staphylococcal emboli & disseminated staphylococcal emboli & disseminated staphylococcal disease disease

• Complicated pneumonia with empyema

Complicated pneumonia with empyema

• Endocarditis

Endocarditis

Case #1: Case #1: Disseminated MRSA Disseminated MRSA Infection--Microb Infection--Microbiology

• logy

Case #1: Case #1: Disseminated MRSA Disseminated MRSA Infection--Microb Infection--Microbiology

• logy
• Staphylococci are Gram

Staphylococci are Gram-positive positive Staphylococci are Gram Staphylococci are Gram positive positive cocci that appear as grape cocci that appear as grape-

• like

like clusters clusters

• Ubiquitous in our environment

Ubiquitous in our environment

• S. aureus
• S. aureus has many surface

has many surface proteins that allow it to bind to proteins that allow it to bind to tissue and foreign bodies tissue and foreign bodies tissue and foreign bodies tissue and foreign bodies

• Methicillin resistance is defined by

Methicillin resistance is defined by

• xacillin minimum inhibitory
• xacillin minimum inhibitory

concentration (MIC) of ≥4 mcg/ml concentration (MIC) of ≥4 mcg/ml

Case #1: Case #1: Disseminated MRSA Disseminated MRSA Infection--Epidemiology fection--Epidemiology Case #1: Case #1: Disseminated MRSA Disseminated MRSA Infection--Epidemiology fection--Epidemiology

• Most community

Most community-acquired MRSA acquired MRSA Most community Most community-acquired MRSA acquired MRSA (CA (CA-

• MRSA) strains in the US are

MRSA) strains in the US are USA300 clones USA300 clones

• Capable of spreading rapidly within

Capable of spreading rapidly within communities communities

• Carries SCC

Carries SCCmec mec type IV genotype and type IV genotype and Panton Panton Valentine leukocidin (PVL) Valentine leukocidin (PVL) Panton Panton-Valentine leukocidin (PVL) Valentine leukocidin (PVL)

• PVL implicated as factor in ability of CA

PVL implicated as factor in ability of CA-

• MRSA isolates to cause skin infections

MRSA isolates to cause skin infections and more complicated infections and more complicated infections

Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Diagnosis Infection--Diagnosis Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Diagnosis Infection--Diagnosis

• High index of suspicion

High index of suspicion—trauma alone not trauma alone not High index of suspicion High index of suspicion trauma alone not trauma alone not a cause for fever! a cause for fever!

• Isolation of MRSA from culture of

Isolation of MRSA from culture of

• therwise sterile body fluid is definitive
• therwise sterile body fluid is definitive
• Rapid methods to promptly identify

Rapid methods to promptly identify methicillin methicillin-

• resistance

resistance

• Antimicrobial susceptibility testing to

Antimicrobial susceptibility testing to i l d “D t t” t d t t i l d “D t t” t d t t include “D zone test” to detect include “D zone test” to detect clindamycin clindamycin-

• inducible resistance

inducible resistance

• Heightened attention to vancomycin

Heightened attention to vancomycin susceptibilities susceptibilities

Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Treatment Infection--Treatment Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Treatment Infection--Treatment

• Aggressive drainage of abscesses

Aggressive drainage of abscesses Aggressive drainage of abscesses Aggressive drainage of abscesses

• r other purulent collections is
• r other purulent collections is

crucial to success crucial to success

• MRI allows location of additional

MRI allows location of additional fluid collections for drainage fluid collections for drainage

• Requires close communication of

Requires close communication of q medical, surgical, interventional medical, surgical, interventional radiology, and infectious disease radiology, and infectious disease physicians physicians

Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Treatment Infection--Treatment Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Treatment Infection--Treatment

• Vancomycin = drug of choice

Vancomycin = drug of choice

• Vancomycin = drug of choice

Vancomycin = drug of choice for invasive MRSA infections for invasive MRSA infections

• “MIC creep”

“MIC creep”– – national increases in national increases in median vancomycin MIC median vancomycin MIC

• Has led to recommendations to

Has led to recommendations to i d i d i d i d use increased vancomycin doses use increased vancomycin doses for invasive MRSA infections for invasive MRSA infections— — especially MIC of 1 μg/ml especially MIC of 1 μg/ml

• 60 mg/kg/d divided every 6 hours

60 mg/kg/d divided every 6 hours

Frymoyer A, et al. Pediatr Infect Dis J. 2009;28:398-402

Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Treatment Infection--Treatment Case #1: Disseminated MRSA Case #1: Disseminated MRSA Infection--Treatment Infection--Treatment

• Other treatment considerations:

Other treatment considerations:

• Other treatment considerations:

Other treatment considerations:

• Clindamycin

Clindamycin

• Gentamicin

Gentamicin— —synergy synergy

• Rifampin

Rifampin— —never as monotherapy never as monotherapy

• Linezolid

Linezolid— —for serious infections; for serious infections; limited data for osteoarticular tx limited data for osteoarticular tx

• Daptomycin

Daptomycin— —not efficacious for not efficacious for pulmonary involvement pulmonary involvement

Case #2 Case #2 Case #2 Case #2

22 22-

• month old female presents

month old female presents with 2 with 2-

• day history of fever, rash

day history of fever, rash Eating poorly & acting as if her Eating poorly & acting as if her throat hurts throat hurts More fussy than usual More fussy than usual R h d t iti R h d t iti Rash appeared on extremities, Rash appeared on extremities, buttocks 2 days ago buttocks 2 days ago— —some some “blisters” now scabbing “blisters” now scabbing

Case #2: Review of Case #2: Review of Systems Systems Case #2: Review of Case #2: Review of Systems Systems

• General: fever X2 days fussy

General: fever X2 days fussy

• General: fever X2 days, fussy

General: fever X2 days, fussy

• HEENT: sore throat?

HEENT: sore throat?

• GI: poor appetite; no vomiting,

GI: poor appetite; no vomiting, diarrhea diarrhea

• Skin: rash X2 days

Skin: rash X2 days—began as began as

• Skin: rash X2 days

Skin: rash X2 days—began as began as pink spots, then “blisters”, now pink spots, then “blisters”, now scabs scabs

Case #2: Past Medical History Case #2: Past Medical History Case #2: Past Medical History Case #2: Past Medical History

• No prior hospitalizations/surgeries

No prior hospitalizations/surgeries F il H t ib t F il H t ib t

• Family Hx: noncontributory, no

Family Hx: noncontributory, no

• thers ill
• thers ill
• Social Hx: only child, lives with

Social Hx: only child, lives with parents, attends daycare where parents, attends daycare where

• thers have been sent home with
• thers have been sent home with

fever, rash fever, rash I i ti d i d I i ti d i d

• Immunizations: record reviewed

Immunizations: record reviewed— — up up-

• to

to-

• date per AAP/ACIP

date per AAP/ACIP recommendations recommendations

Case #2: Physical Exam Case #2: Physical Exam Case #2: Physical Exam Case #2: Physical Exam

• Alert but

Alert but fussy fussy female in no female in no Alert but Alert but fussy fussy female in no female in no distress distress

• HEENT:

HEENT: vesicular lesions vesicular lesions on the

• n the

posterior oropharynx posterior oropharynx

• Heart/Lungs/Abdome: benign

Heart/Lungs/Abdome: benign

• Skin:

Skin: multiple brightly multiple brightly Skin: Skin: multiple brightly multiple brightly erythematous, scaly plaque erythematous, scaly plaque-

• like

like lesions with dry, superficial scabs lesions with dry, superficial scabs

• ver legs, face, buttocks, and trunk
• ver legs, face, buttocks, and trunk

Case #2: Further Evaluation Case #2: Further Evaluation Case #2: Further Evaluation Case #2: Further Evaluation Case #2: What’s the Case #2: What’s the Diagnosis? Diagnosis? Case #2: What’s the Case #2: What’s the Diagnosis? Diagnosis?

• Varicella

Varicella

• Varicella

Varicella

• Herpes simplex virus infection

Herpes simplex virus infection

• Enterovirus disease

Enterovirus disease— —hand, hand, foot, & mouth disease foot, & mouth disease

• Poison ivy or other contact

Poison ivy or other contact

• Poison ivy or other contact

Poison ivy or other contact dermatitis dermatitis

• Bullous impetigo

Bullous impetigo

Case #2: Hand, Foot, & Case #2: Hand, Foot, & Mouth Mouth Disease--Clinical Disease--Clinical Case #2: Hand, Foot, & Case #2: Hand, Foot, & Mouth Mouth Disease--Clinical Disease--Clinical

• Common viral illness caused by non

Common viral illness caused by non- Common viral illness caused by non Common viral illness caused by non- polio enteroviruses polio enteroviruses

• Usually accompanied by mild fever,

Usually accompanied by mild fever, rash on palms & soles, oral vesicles rash on palms & soles, oral vesicles

• Primarily affects children <5 years

Primarily affects children <5 years

• Summer & fall outbreaks typically

Summer & fall outbreaks typically yp y yp y

• ccur in the US
• ccur in the US
• Usually associated with serotype

Usually associated with serotype coxsackievirus A16 coxsackievirus A16

Case #2: HFMD— Case #2: HFMD— Microbiology/Epidemiology Microbiology/Epidemiology Case #2: HFMD— Case #2: HFMD— Microbiology/Epidemiology Microbiology/Epidemiology

• Enteroviruses = RNA viruses

Enteroviruses = RNA viruses

• Enteroviruses = RNA viruses

Enteroviruses = RNA viruses

• Members of the family

Members of the family Picornaviridae Picornaviridae

• Over 100 known enterovirus

Over 100 known enterovirus serotypes currently serotypes currently

• Spread by fecal

Spread by fecal-

• oral &
• ral &

respiratory routes respiratory routes

• Fomite spread common

Fomite spread common

Case #2: HFMD—Recent Case #2: HFMD—Recent Epidemiology Epidemiology Case #2: HFMD—Recent Case #2: HFMD—Recent Epidemiology Epidemiology

• Morbidity & Mortality Weekly Report

Morbidity & Mortality Weekly Report— — M h 30 2012 M h 30 2012 March 30, 2012 March 30, 2012

• 63 reports of children & adults with

63 reports of children & adults with signs/symptoms of HFMD with fever & signs/symptoms of HFMD with fever & atypical rash in 4 states atypical rash in 4 states

• 63% <2 years of age; 24% adults

63% <2 years of age; 24% adults

• Rash & fever more severe than typical HFMD

Rash & fever more severe than typical HFMD

• Hospitalization more common (19%)

Hospitalization more common (19%)

• Coxsackievirus A6 identified in 25 (74%)

Coxsackievirus A6 identified in 25 (74%)

• CDC. “Notes from the Field: Severe Hand, Foot & Mouth Disease Associated with Coxsackievirus A6—

Alabama, Connecticut, California, & Nevada, November 2011—February 2012. MMWR. 2012;61:213- 214.

Case #2: HFMD—Recent Case #2: HFMD—Recent Epidemiology Epidemiology Case #2: HFMD—Recent Case #2: HFMD—Recent Epidemiology Epidemiology

• 44 (70%) had daycare/school

44 (70%) had daycare/school 44 (70%) had daycare/school 44 (70%) had daycare/school exposure exposure— —53% of adults had contact 53% of adults had contact with children in daycare with children in daycare

• Clinical signs:

Clinical signs:

• Fever

Fever 76% 76%

• Rash:

Rash: Hand/foot/mouth lesions

Hand/foot/mouth lesions 67% 67% Arms/legs/face/buttocks Arms/legs/face/buttocks 35% 35% Vesicles Vesicles 70% 70% Scabs Scabs 65% 65%

• CDC. “Notes from the Field: Severe Hand, Foot & Mouth Disease Associated with Coxsackievirus

A6—Alabama, Connecticut, California, & Nevada, November 2011—February 2012. MMWR. 2012;61:213-214.

Case #2: HFMD—Recent Case #2: HFMD—Recent Epidemiology Epidemiology Case #2: HFMD—Recent Case #2: HFMD—Recent Epidemiology Epidemiology

• International outbreaks of

International outbreaks of International outbreaks of International outbreaks of coxsackievirus A6 have been reported coxsackievirus A6 have been reported since 2008 since 2008

• Finland, Japan, Singapore, Spain, Taiwan

Finland, Japan, Singapore, Spain, Taiwan

• No previous US outbreaks reported

No previous US outbreaks reported

• No epidemiologic link of US cases to

No epidemiologic link of US cases to

• ther areas
• ther areas
• Reports continue to CDC

Reports continue to CDC— —NE, South, NE, South, Midwest, West regions Midwest, West regions

• CDC. “Notes from the Field: Severe Hand, Foot & Mouth Disease Associated with Coxsackievirus

A6—Alabama, Connecticut, California, & Nevada, November 2011—February 2012. MMWR. 2012;61:213-214.

Case #2: HFMD—Diagnosis, Case #2: HFMD—Diagnosis, Treatment, Prevention Treatment, Prevention Case #2: HFMD—Diagnosis, Case #2: HFMD—Diagnosis, Treatment, Prevention Treatment, Prevention

• Diagnosis made on basis of clinical

Diagnosis made on basis of clinical Diagnosis made on basis of clinical Diagnosis made on basis of clinical features features

• Symptomatic treatment only

Symptomatic treatment only

• Transmission reduced by good hand

Transmission reduced by good hand hygiene, disinfection of surfaces, hygiene, disinfection of surfaces,

• esp. in daycare settings
• esp. in daycare settings
• No vaccines for non

No vaccines for non polio polio

• No vaccines for non

No vaccines for non-polio polio enteroviruses currently available enteroviruses currently available

• Contact state health department if

Contact state health department if case suspected case suspected

Case #2—Outcome Case #2—Outcome Case #2—Outcome Case #2—Outcome

• Respiratory viral culture

Respiratory viral culture

• Respiratory viral culture

Respiratory viral culture

• btained
• btained—

—pending pending

• Symptomatic care provided

Symptomatic care provided

• Parents reassured

Parents reassured— —prevention prevention methods reviewed methods reviewed

• Patient has had full recovery

Patient has had full recovery

Case #3 Case #3 Case #3 Case #3

10 10-

• year old female admitted with

year old female admitted with 5 day history of “low day history of “low grade” grade” 5-day history of “low day history of “low-grade” grade” fever, malaise, fatigue fever, malaise, fatigue Tender, fluctuant, left axillary Tender, fluctuant, left axillary lymph node noted lymph node noted Patient denies cat exposure or Patient denies cat exposure or Patient denies cat exposure or Patient denies cat exposure or

• ther ill exposures
• ther ill exposures

Past medical history and review Past medical history and review

• f systems otherwise negative
• f systems otherwise negative

Case #3: Physical Exam Case #3: Physical Exam Case #3: Physical Exam Case #3: Physical Exam

• General: healthy

General: healthy-appearing female appearing female General: healthy General: healthy-appearing female appearing female

• Heart, Lungs: normal

Heart, Lungs: normal

• Abdomen: soft, nontender, no

Abdomen: soft, nontender, no hepatosplenomegaly hepatosplenomegaly

• Extremities:

Extremities: 4X4 cm left axillary 4X4 cm left axillary lymph node noted with mild, lymph node noted with mild, lymph node noted with mild, lymph node noted with mild,

• verlying erythema & fluctuance;
• verlying erythema & fluctuance;

small papular lesion noted over L small papular lesion noted over L wrist wrist— —healed without erythema healed without erythema

Case #3 Case #3 Case #3 Case #3

Case #3: Further History Case #3: Further History Case #3: Further History Case #3: Further History

• Presumptive diagnosis of

Presumptive diagnosis of Bartonella Bartonella infection made infection made infection made infection made

• Grandmother reports that patient regularly

Grandmother reports that patient regularly feeds stray cats in her neighborhood feeds stray cats in her neighborhood

• Lymph node aspiration revealed

Lymph node aspiration revealed purulent material purulent material

• Nurses report seizure activity as

Nurses report seizure activity as discharge paperwork being completed discharge paperwork being completed

• Patient transferred to PICU for

Patient transferred to PICU for refractory seizure activity refractory seizure activity

Case #3:Laboratory Evaluation Case #3:Laboratory Evaluation Case #3:Laboratory Evaluation Case #3:Laboratory Evaluation

• CBC: unremarkable

CBC: unremarkable CBC: unremarkable CBC: unremarkable

• CSF Exam:

CSF Exam:

WBC WBC 3 3 Differential Differential 55%L/44%M 55%L/44%M RBC RBC Protein/Glucose Protein/Glucose 50/55 50/55

• CSF Enterovirus & HSV PCRs

CSF Enterovirus & HSV PCRs—negative negative CSF Enterovirus & HSV PCRs CSF Enterovirus & HSV PCRs negative negative

• CSF

CSF Bartonella Bartonella PCR PCR— —negative negative

• Bartonella

Bartonella serology serology— —IgG >1:1024 IgG >1:1024 (positive) (positive)

Case #3: Radiologic/EEG Case #3: Radiologic/EEG Evaluations Evaluations Case #3: Radiologic/EEG Case #3: Radiologic/EEG Evaluations Evaluations

• MRI Brain:

MRI Brain:

• MRI Brain:

MRI Brain:

• No focal abnormalities

No focal abnormalities

• Electroencephalogram:

Electroencephalogram:

• Marked diffuse slowing

Marked diffuse slowing

• Multiple, scattered epileptiform

Multiple, scattered epileptiform foci foci

Case #3: Case #3: Bartonella Bartonella--Clinical

• -Clinical

Case #3: Case #3: Bartonella Bartonella--Clinical

• -Clinical
• Predominant manifestation of cat

Predominant manifestation of cat scratch disease is regional adenopathy scratch disease is regional adenopathy scratch disease is regional adenopathy scratch disease is regional adenopathy

• Begins with primary inoculation lesion at

Begins with primary inoculation lesion at site of initial scratch site of initial scratch

• Evolves through vesicular, erythematous,

Evolves through vesicular, erythematous, and papular phases and papular phases

• Enlarged lymph nodes appear proximal to

Enlarged lymph nodes appear proximal to inoculation site about 2 weeks later inoculation site about 2 weeks later

• Most common: axillary, epitrochlear, cervical,

Most common: axillary, epitrochlear, cervical, supraclavicular, submandibular, inguinal supraclavicular, submandibular, inguinal

• May be associated with fever, malaise, fatigue,

May be associated with fever, malaise, fatigue, anorexia anorexia

Case #3: Case #3: Bartonella-- Bartonella--Clinical Clinical Case #3: Case #3: Bartonella-- Bartonella--Clinical Clinical

• Other clinical manifestations:

Other clinical manifestations:

• Other clinical manifestations:

Other clinical manifestations:

• Hepatosplenic disease

Hepatosplenic disease

• Fever of unknown origin

Fever of unknown origin

• Ocular manifestations

Ocular manifestations

• Parinaud oculoglandular syndrome

Parinaud oculoglandular syndrome

• Neurologic manifestations

Neurologic manifestations

• Musculoskeletal manifestations

Musculoskeletal manifestations

• Other atypical manifestations

Other atypical manifestations

Case #3: Case #3: Bartonella Bartonella Encephalitis--Clinical Encephalitis--Clinical Case #3: Case #3: Bartonella Bartonella Encephalitis--Clinical Encephalitis--Clinical

• Encephalopathy

Encephalopathy

• Encephalopathy

Encephalopathy—

• Most common neurologic manifestation

Most common neurologic manifestation— —up up to 5% of patients to 5% of patients

• CT/MRI findings generally normal

CT/MRI findings generally normal

• LP results normal or slight lymphocytic

LP results normal or slight lymphocytic pleocytosis or increased protein pleocytosis or increased protein

• EEG abnormalities typical

EEG abnormalities typical

• EEG abnormalities typical

EEG abnormalities typical

Case #3: Case #3: Bartonella Bartonella— Microbiology/Epidemiology Microbiology/Epidemiology Case #3: Case #3: Bartonella Bartonella— Microbiology/Epidemiology Microbiology/Epidemiology

• Bartonella henselae

Bartonella henselae Bartonella henselae Bartonella henselae

• Fastidious, slow

Fastidious, slow-

• growing Gram

growing Gram-

• negative

negative bacillus bacillus

• Domestic cat = major reservoir and

Domestic cat = major reservoir and vector for vector for B. henselae

• B. henselae transmission

transmission

• Cat

Cat-

• to

to-

• cat transmission via cat flea

cat transmission via cat flea

• Kittens more likely infected than older

Kittens more likely infected than older

• Kittens more likely infected than older

Kittens more likely infected than older cats cats

• Over 90% of patients with cat scratch

Over 90% of patients with cat scratch disease have recent cat contact disease have recent cat contact

Case #3: Case #3: Bartonella-- Bartonella--Diagnosis Diagnosis Case #3: Case #3: Bartonella-- Bartonella--Diagnosis Diagnosis

• Serologic diagnosis usually adequate

Serologic diagnosis usually adequate

• Indirect fluorescence assay (IFA) IgG titer of

Indirect fluorescence assay (IFA) IgG titer of

• Indirect fluorescence assay (IFA) IgG titer of

Indirect fluorescence assay (IFA) IgG titer of ≥1:64 indicates positive test ≥1:64 indicates positive test

• Titers >1:256 strongly suggestive of

Titers >1:256 strongly suggestive of active/recent infection active/recent infection

• Positive IgM suggests acute disease

Positive IgM suggests acute disease— —short short-

• lived

lived

• Culture

Culture--

• -challenging

challenging P l h i ti P l h i ti i ll i ll

• Polymerase chain reaction

Polymerase chain reaction—commercially commercially available but sensitivity limited available but sensitivity limited

• Histopathology

Histopathology— —Warthin Warthin-

• Starry stain, not

Starry stain, not specific specific

Case #3: Case #3: Bartonella Bartonella Treatment Treatment Case #3: Case #3: Bartonella Bartonella Treatment Treatment

• Lymphadenitis

Lymphadenitis— Lymphadenitis Lymphadenitis

• Typically self

Typically self-

• limited over months

limited over months

• Needle aspiration for suppurative nodes

Needle aspiration for suppurative nodes

• One randomized placebo

One randomized placebo-

• controlled

controlled trial trial

• 5-
• day azithromycin course

day azithromycin course  80% decrease 80% decrease in lymph node volume in lymph node volume in lymph node volume in lymph node volume

• Uncontrolled retrospective study

Uncontrolled retrospective study— —

• Shorter duration of illness in patients

Shorter duration of illness in patients treated with ciprofloxacin, gentamicin, treated with ciprofloxacin, gentamicin, rifampin, or TMP rifampin, or TMP-

• SMX

SMX

Case #3: Case #3: Bartonella Bartonella--

• - Treatment

Treatment Case #3: Case #3: Bartonella Bartonella--

• - Treatment

Treatment

• Hepatosplenic disease or neuroretinitis

Hepatosplenic disease or neuroretinitis— — Hepatosplenic disease or neuroretinitis Hepatosplenic disease or neuroretinitis

• Role of antimicrobial therapy unclear

Role of antimicrobial therapy unclear

• Limited data suggest gentamicin or combo

Limited data suggest gentamicin or combo therapy with rifampin + gentamicin or therapy with rifampin + gentamicin or azithromycin azithromycin

• Neurologic disease

Neurologic disease— —

• No studies to guide treatment decisions

No studies to guide treatment decisions No studies to guide treatment decisions No studies to guide treatment decisions

• Some experts suggest combination of

Some experts suggest combination of doxycycline + rifampin for 10 doxycycline + rifampin for 10-

• 14 days;

14 days; azithromycin or TMP azithromycin or TMP-

• SMX + rifampin in

SMX + rifampin in children ≤8 years old children ≤8 years old

Case #: Case #: Bartonell Bartonella--Prevention

• -Prevention

Case #: Case #: Bartonell Bartonella--Prevention

• -Prevention
• Minimize cat/kitten

Minimize cat/kitten

• Minimize cat/kitten

Minimize cat/kitten scratches & scratches & bites bites— —avoid avoid rough play rough play

• Flea control for

Flea control for pets pets pets pets

Case #3--Outcome Case #3--Outcome Case #3--Outcome Case #3--Outcome

• Patient required pentobarbital

Patient required pentobarbital

• Patient required pentobarbital

Patient required pentobarbital coma for seizure control coma for seizure control

• After brief inpatient pediatric

After brief inpatient pediatric rehabilitation services, he rehabilitation services, he regained full strength and regained full strength and neurologic recovery neurologic recovery

Case #4 Case #4 Case #4 Case #4

2-

• year old female presents with

year old female presents with classic varicella classic varicella c ass c a ce a c ass c a ce a

• Lesions in various stages of

Lesions in various stages of evolution evolution—onset 4 days ago

• nset 4 days ago

Fever X2 days with complaints of left Fever X2 days with complaints of left arm pain arm pain ED: noted exquisite left arm ED: noted exquisite left arm tenderness, erythema, and tenderness, erythema, and tenderness, erythema, and tenderness, erythema, and progressive duskiness progressive duskiness Orthopedic Surgery & Infectious Orthopedic Surgery & Infectious Diseases consulted Diseases consulted

Case #4: Review of Case #4: Review of Systems Systems Case #4: Review of Case #4: Review of Systems Systems

• Chickenpox lesions began 4

Chickenpox lesions began 4

• Chickenpox lesions began 4

Chickenpox lesions began 4 days ago days ago

• Fever onset yesterday

Fever onset yesterday

• Significant left arm pain

Significant left arm pain--

• worsening

worsening

Case #4: Case #4: Past Medic Past Medical Hist l History

• ry

Case #4: Case #4: Past Medic Past Medical Hist l History

• ry
• No prior hospitalizations/surgeries

No prior hospitalizations/surgeries

• No prior hospitalizations/surgeries

No prior hospitalizations/surgeries

• Attended “chickenpox party”

Attended “chickenpox party” recently recently

• Family Hx: noncontributory; no

Family Hx: noncontributory; no

• thers ill
• thers ill
• Social Hx: lives with parents, only

Social Hx: lives with parents, only child child

• Immunizations: none

Immunizations: none

Case #4: Physical Exam Case #4: Physical Exam Case #4: Physical Exam Case #4: Physical Exam

• VS:

VS: 39.6 39.6°C.; HR 150 C.; HR 150-

• 160; RR 30’s;

160; RR 30’s; BP 96/56 BP 96/56

• General: alert, anxious female

General: alert, anxious female

• HEENT: pharynx clear; otherwise

HEENT: pharynx clear; otherwise unremarkable unremarkable

• Heart rate/rhythm regular;

Heart rate/rhythm regular; tachycardic; tachycardic; no murmurs/rubs; no murmurs/rubs; capillary refill <2 seconds capillary refill <2 seconds

• Lungs: CTA bilaterally;

Lungs: CTA bilaterally; tachypneic tachypneic

• Abdomen: soft, nondistended; no

Abdomen: soft, nondistended; no hepatosplenomegaly; mildly tender hepatosplenomegaly; mildly tender

Case #4: Physical Exam Case #4: Physical Exam Case #4: Physical Exam Case #4: Physical Exam

• Extremities:

Extremities: exquisite tenderness to exquisite tenderness to superficial touch of left arm; mild superficial touch of left arm; mild erythema noted over lower arm with erythema noted over lower arm with dusky areas of ecchymosis distally; dusky areas of ecchymosis distally; unwilling to move; mild diffuse unwilling to move; mild diffuse edema; no joint edema edema; no joint edema

• Skin:

Skin: multiple varicella lesions multiple varicella lesions in in

• Skin:

Skin: multiple varicella lesions multiple varicella lesions in in various stages of evolution scattered various stages of evolution scattered

• ver body;
• ver body; mild erythema of bases of

mild erythema of bases of lesions lesions

Case #4: Pertinent Laboratory Case #4: Pertinent Laboratory Evaluation Evaluation Case #4: Pertinent Laboratory Case #4: Pertinent Laboratory Evaluation Evaluation

• CBC:

CBC: WBC 17 900 WBC 17 900

• CBC:

CBC: WBC 17,900 WBC 17,900

Differential Differential 50S/32B/17L 50S/32B/17L Hemoglobin Hemoglobin 9.6 9.6 Platelets Platelets 117,000 117,000

• BUN/Cre

BUN/Cre 32/2.1 32/2.1

• Liver Panel

Liver Panel

AST/ALT AST/ALT 190/200 190/200

• ESR

ESR 62 62

Case #4 Case #4 Case #4 Case #4 Case #4: What’s the Case #4: What’s the Diagnosis? Diagnosis? Case #4: What’s the Case #4: What’s the Diagnosis? Diagnosis?

• Bacterial skin/soft tissue

Bacterial skin/soft tissue

• Bacterial skin/soft tissue

Bacterial skin/soft tissue infection infection— —Staphylococcus, Staphylococcus, Streptococcus Streptococcus

• Impetigo

Impetigo

• Cellulitis

Cellulitis

• Necrotizing fasciitis

Necrotizing fasciitis

• Osteoarticular infection

Osteoarticular infection

• Thrombosis

Thrombosis

Case #4: Further Evaluation Case #4: Further Evaluation Case #4: Further Evaluation Case #4: Further Evaluation

• Surgery evaluation raises concern

Surgery evaluation raises concern

• Surgery evaluation raises concern

Surgery evaluation raises concern for necrotizing fasciitis for necrotizing fasciitis

• Emergent operative evaluation

Emergent operative evaluation revealed full thickness necrosis of revealed full thickness necrosis of skin, subcutaneous tissue and fascia skin, subcutaneous tissue and fascia

• Operative tissue cultures revealed

Operative tissue cultures revealed G A G A St t St t Group A Group A Streptococcus Streptococcus (clindamycin susceptible) (clindamycin susceptible)

• Blood culture negative

Blood culture negative

Case #4: Group A Case #4: Group A Strep Strep Necrotizing Fasciitis--Clinical Necrotizing Fasciitis--Clinical Case #4: Group A Case #4: Group A Strep Strep Necrotizing Fasciitis--Clinical Necrotizing Fasciitis--Clinical

• Rapidly progressive, deep

Rapidly progressive, deep-seated seated p y p g , p p y p g , p bacterial infection of the subcutaneous bacterial infection of the subcutaneous soft tissue soft tissue

• Infection spreads in plane between

Infection spreads in plane between subcutaneous tissue and superficial muscle subcutaneous tissue and superficial muscle fascia fascia

• May involve any area of the body

May involve any area of the body

• May follow surgery, trauma, omphalitis,

May follow surgery, trauma, omphalitis, l i ll l i ll

• r commonly varicella
• r commonly varicella
• Often fulminant course

Often fulminant course— —mortality 25 mortality 25-

• 75%

75%

• Associated with toxic shock syndrome

Associated with toxic shock syndrome and multiorgan system failure and multiorgan system failure

Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Clinical Fasciitis--Clinical Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Clinical Fasciitis--Clinical

• Varicella

Varicella-

• associated necrotizing

associated necrotizing f iiti f iiti t i 3 t i 3rd

rd

4th

th d

f d f fasciitis fasciitis—onset in 3

• nset in 3rd

rd or 4

• r 4th

th day of

day of lesions lesions

• Pain out of proportion to initial

Pain out of proportion to initial

• utward signs of infection
• utward signs of infection
• Induration, edema

Induration, edema blistering, blistering, blebs within 24 hours blebs within 24 hours

• Progressive infection results in

Progressive infection results in destruction of fascia & fat destruction of fascia & fat dusky dusky appearance appearance

Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Diagnosis Fasciitis--Diagnosis Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Diagnosis Fasciitis--Diagnosis

• High index of suspicion:

High index of suspicion: g p g p

• Pain out of proportion to external cutaneous

Pain out of proportion to external cutaneous findings = findings = RED FLAG! RED FLAG!

• Labs:

Labs:

• WBC may be elevated

WBC may be elevated— —often with bandemia

• ften with bandemia
• Platelets may be low

Platelets may be low— —DIC may be present DIC may be present

• Multiorgan system involvement may be noted

Multiorgan system involvement may be noted

• Cultures and pathology evaluation of tissue

Cultures and pathology evaluation of tissue p gy p gy

• MRI can reveal evidence of inflammation

MRI can reveal evidence of inflammation along fascial planes & determine along fascial planes & determine compartments and structures involved compartments and structures involved

• Should not delay surgical intervention

Should not delay surgical intervention

Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Treatment Fasciitis--Treatment Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Treatment Fasciitis--Treatment

• Fluid resuscitation & multisystem

Fluid resuscitation & multisystem Fluid resuscitation & multisystem Fluid resuscitation & multisystem

• rgan failure management
• rgan failure management
• Immediate aggressive surgical

Immediate aggressive surgical debridement/biopsy of necrotic tissue = debridement/biopsy of necrotic tissue = treatment of choice treatment of choice

• Antimicrobial therapy:

Antimicrobial therapy:

( )

• IV

IV Penicillin Penicillin (bactericidal cell (bactericidal cell-

• wall inhibitor)

wall inhibitor) + + clindamycin clindamycin (protein synthesis inhibitor to (protein synthesis inhibitor to stop toxin production) stop toxin production)

• IV Immune Globulin

IV Immune Globulin— —if severely ill if severely ill

Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Prevention Fasciitis--Prevention Case #4: GAS Case #4: GAS Necrotizing Necrotizing Fasciitis--Prevention Fasciitis--Prevention

• Varicella vaccine per AAP/ACIP

Varicella vaccine per AAP/ACIP Varicella vaccine per AAP/ACIP Varicella vaccine per AAP/ACIP recommendations recommendations

• Consider targeted

Consider targeted chemoprophylaxis to household chemoprophylaxis to household contacts who are: contacts who are:

• 65 years or older

65 years or older

• HIV

HIV-

• infected

infected

• Varicella

Varicella-

• infected

infected

• Diabetic

Diabetic

Case #4: Outcome Case #4: Outcome Case #4: Outcome Case #4: Outcome

• Extensive debridement of left

Extensive debridement of left

• Extensive debridement of left

Extensive debridement of left arm soft tissues arm soft tissues

• She completed 2 weeks of

She completed 2 weeks of antimicrobial therapy antimicrobial therapy— — transitioned to oral clindamycin transitioned to oral clindamycin

• nce clinically stable
• nce clinically stable
• She required subsequent skin

She required subsequent skin grafting but fully recovered grafting but fully recovered