1 Jacobs Case Studies - UCSF CME Jacobs Case Stu… · • Paraand%retropharyngeal%abscess% ... –...

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Case Studies in Infec3ous Diseases

Richard A. Jacobs, M.D., PhD.

NO DISCLOSURES

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CASE PRESENTATION

•  A 45 year old man awoke the day prior to presenta3on with a sore throat. Throughout the

day the sore throat worsened, and he had difficulty ea3ng dinner because of pain. The next morning he awoke with an even worse sore throat and an elevated temperature of 103.5˚ F. In the office he complained of a severe sore throat, his temperature was 98˚ F and his pharynx had mild

erythema without exudate.

What would you do at this point?

1.  Rapid strep test

2.  An3bio3cs without tes3ng

3.  Observe without an3bio3cs (send home)

4.  Send to ENT 5.  Order head/neck CT

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SORE THROAT DIAGNOSIS NOT TO MISS

•  Epiglo]3s •  Uvuli3s •  Para and retropharyngeal abscess •  Angioedema/anaphylaxis •  Diphtheria •  Foreign Body •  HIV

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When To Suspect Epiglo]3s

•  “Worst sore throat of my life”

– With minimal findings on exam

– Hoarse/muffled voice

– Severe odynophagia

Adult Epiglo]3s

•  Increasing incidence in adults (decreasing in children due to Hib vaccina3on)

•  Adults -‐-‐more indolent (days v hours) and less toxic appearing

•  Dx made by direct visualiza3on –  fiberop3c laryngoscopy less likely to provoke spasm than

mirror exam –  Lateral neck films less sensi3ve than laryngoscopy, but s3ll

good in adults – 77% -‐ 88% sensi3ve (“thumb sign”)

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Adult Epiglo]3s

•  Bacteriology – H. influenzae/parainfluenzae; S. pneumoniae; Gp A strep; S. aureus (MSSA & MRSA)

•  Therapy – An3bio3cs – 3rd genera3on cephalosporin +/-‐ vancomycin (severe sepsis or require intuba3on)

– Airway maintenance—not standard as it is in children

– Steroids—Controversial—generally not given as no clear benefit demonstrated

Case Presenta3on

•  20 year old previously healthy male •  Day 1

•  Onset of sore throat with fever •  Day 2 – Evaluated in office—exuda3ve pharyngi3s with tender anterior cervical adenopathy, h/o fever and no cough (4/4 of Centor Criteria)

– Azithromycin started (within 24 hours of onset of symptoms)

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Diagnosis of Gp A Streptococcal Pharyngi3s

•  IDSA (Infec3ous Disease Society of America) –  Rapid strep test

•  ACP (American College of Physicians) and the AAFP (American Academy of Family Prac3ce) – Modified Centor Criteria

Modified Centor Criteria

Score 3 or 4 —> Rx empirically

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Case Presenta3on

•  20 year old previously healthy male

•  Day 1 – Onset of sore throat with fever

•  Day 2 – Evaluated in office—exuda3ve pharyngi3s with tender anterior cervical adenopathy, h/o fever and no cough (4/4 of Centor Criteria)

– Azithromycin started (within 24 hours of onset of symptoms)

Case Presenta3on

•  Day 3 – PC—not beqer—s3ll with sore throat and fever – Plan—con3nue azithromycin

•  Day 5 – Phone Call—not beqer • Diffuse myalgias, difficulty swallowing, pain on (R) side of neck

– Plan-‐-‐to finish Azithromycin; encourage fluids; ibuprofen for symptom relief; call if not beqer

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Case Presenta3on

•  Day 6 – PC-‐-‐SOB and pleuri3c chest pain – Instructed to go to ED for evalua3on

Case Presenta3on

•  ED evalua3on – WBC—21,400 with 51% PMNs and 42% bands – Plts—16,000 – BUN 80, Cr 4.2 – PTT 50; FDP elevated – pH 7.29 with elevated lac3c acid – CXR, chest CT and BCs obtained

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Case Presenta3on-‐-‐CXR

Case Presenta3on—Chest CT

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Case Presenta3on—Blood Culture

Fusobacterium necrophorum

What Went Wrong?

•  Natural History of GpA Streptococcal Pharyngi3s

– w/o therapy, symptoms beqer in 3-‐4 days

– With early therapy (24 hours) symptoms resolve 24-‐48 hours sooner

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•  Fusobacterium necrophorum – Anaerobic gram-‐nega3ve rod – An important upper respiratory pathogen in ADOLESCENTS AND YOUNG ADULTS (ages 15-‐25) • Can isolate F. necrophorum from 10% with sore throat (equal in frequency to gp A streptococcus) • Peritonsillar abscesses—F. necrophorum isolated in 23% (most in pure culture) c/w gp A streptococcus—17%

2009;151:812-‐815 2009;151;812-‐815

•  Fusobacterium necrophorum

– Complica3on—LEMIERRE’S SYNDROME – Sep3c phlebi3s IJ vein, bacteremia, –  sep3c pulmonary emboli/abscess

•  Es3mated to occur in 1 of 400 cases of F. necrophorum pharyngi3s (more common than Rheuma3c Fever following gp A streptococcal pharyngi3s)

2009;151:812-‐815 2009;151: 812-‐815

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Pharyngi3s in Adolescents

•  Fusobacterium necrophorum – Resistant to azalides and macrolides (azithromycin/clarithromycin)

– Sensi3ve to penicillins, cephalosporins and clindamycin

Take Home Points

•  Pharyngi3s in the adolescent and young adults (ages 15-‐25) can be more complicated than previously thought

•  ALTHOUGH CONTROVERSIAL, SOME HAVE RECOMMENDED –  In pa3ents 15-‐25 years of age, with a Centor score of > 3 and nega3ve diagnos3c tests for gp A strep to treat with penicillin, amoxicillin or a cephalosporin

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Take Home Points

•  WHAT IS NOT CONTROVERSIAL – Remember the natural history of pharyngi3s

–  If pa3ents do not improve as expected think about complica3ons •  Peritonsillar abscess •  Retropharyngeal abscess •  Lemierre’s syndrome

Trivia Ques3on # 1-‐-‐Which President Died of Peritonsillar Abscess?

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100%1.  John Quincy

(Quinsy ?) Adams?

2.  Thomas Jefferson

3.  George Washington

4.  Andrew Jackson

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Case Presenta3on

•  55 y/o woman with a past hx of kidney stones presents to Urgent Care c/o upper mid-‐back pain and pain in the ley shoulder for 2 days. No history of trauma. On PE she is afebrile with normal vital signs and TTP over the ley posterior shoulder.

•  She is treated symptoma3cally and sent home

Case Presenta3on

•  The following day, as instructed, she calls her PCP who orders thoracic and lumbar spine films —> degenera3ve disc disease

•  CBC —> WBCs 14.6 (4-‐11) with 90% PMNs (40-‐80)

•  ESR —> 48 (0-‐15)

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Case Presenta3on

•  Told to go back to Urgent Care b/o elevated WBCs. She c/o pain in the upper back that has been ge]ng progressively worse. Her Temp is 100.6°F and on exam there is tenderness in the thoracic paraspinous area

•  WBC—> 14.5 •  UA—> 10-‐20 WBC’s/HPF; 0-‐2 RBCs; 1+ bacteria

•  ABD CT—> bilateral renal calculi and no hydronephrosis

Your next step?

1.  Analgesics and fluids for renal calculi

2.  Analgesics for musculoskeletal pain

3.  Nitrofurantoin for a UTI

4.  MRI spine 1 2 3 4 5

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Case Presenta3on

•  Told to go back to Urgent Care b/o elevated WBCs. She c/o pain in the upper back that has been ge]ng progressively worse. Her Temp is 100.6°F and on exam there is tenderness in the thoracic paraspinous area

•  WBC—> 14.5

•  UA—> 10-‐20 WBC’s/HPF; 0-‐2 RBCs; 1+ bacteria

•  ABD CT—> bilateral renal calculi and no hydronephrosis

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FEVER AND BACK PAIN

•  Pyelonephri3s w/wo stone and obstruc3on •  Pancrea33s •  Cholecys33s •  PID •  Endocardi3s •  Osteomyeli3s/Disci3s •  Epidural abscess

Take Home Point

•  Fever and back pain is an epidural abscess un3l proven otherwise***

•  Best diagnos3c test is an MRI with contrast

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***

•  BUT ONLY ≈ 50% OF PATIENTS WITH AN EPIDURAL ABSCESS HAVE FEVER ON PRESENTATION

Role of ESR/CRP in Diagnosis •  If there is back pain and a predisposing condi3on for SEA (DM, IVDU, co-‐exis3ng infec3on, recent back surgery, indwelling catheter, immunocompromised)

Obtain an ESR/CRP

If elevated —> obtain MRI (sensi3vity 98% Specificity 70%)

(J Neurosurg Spine 14:765-‐770, 2011)

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Case Presenta3on

•  A 62 y/o man with HTN, hyperlipidemia and CAD presents with new onset of headache. He notes that over the last 2-‐3 weeks he has not been feeling well with intermiqent low-‐grade fevers and decreased appe3te. On PE he is afebrile with a BP of 118/65 and a P of 98. He has a 2/6 SEM at RUS boarder (old) but an otherwise normal exam.

•  A diagnosis of sinusi3s is made —> Augmen3n for 7 days

Case Presenta3on

•  He presents 2 weeks later to the ED with a visual field defect. An CT is done and he is found to have a (R) posterior communica3ng artery infarct. He notes that ini3ally he felt beqer on the an3bio3cs, but when stopped he developed low grade fevers again.

•  CBC —> 14.3 with a normal diff; Hct = 32 •  ESR —> 77

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At this point you would??

1.  MRI of the Brain

2.  CT of the sinuses 3.  Do a temporal artery BX

4.  Obtain BCs

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Blood Cultures– Gram nega3ve rods

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Case Presenta3on

•  HACEK organisms

•  Haemophilus aphrophilus •  Ac3nobacillus ac3nomycetemcomitans (Aggrega3bacter ac3nomycetemcomitans)

•  Cardiobacterium hominus •  Eikenella corrodons •  Kingella kingae

Trivia Ques3on # 2

•  Kingella kingae – named ayer the American bacteriologist Elizabeth O. King

•  Can you name the two other organisms with same genus and species name to honor their discoverer?

•  NOTE—LOA LOA does not qualify – Mongin, a French surgeon was the first to remove the worm from a pa3ent’s eye

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Take Home Points

•  A prolonged fever is NOT a viral syndrome or a self-‐limited bacterial infec3on – Anyone with a prolonged fever should have blood cultures drawn

•  “A central nervous system event, especially in a young, otherwise healthy individual, is endocardi3s un3l proven otherwise”

Case Presenta3on

•  The den3st of your 45 year old female pa3ent with MVP and moderate mitral regurgita3on calls wan3ng to know if she needs an3bio3c prophylaxis for a root canal and which one.

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Should prophylaxis be given?

1. Yes 2. No

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Prophylaxis for Endocardi3s

•  “New” AHA Guidelines from 2007 – Updated from 1997

•  Transient bacteremia occurs in up to 50% of individuals as a result of normal daily ac3vi3es

•  Endocardi3s is much more likely to occur from frequent bacteremias associated with daily ac3vi3es than from bacteremias caused by dental, GI or GU procedures.

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Procedures for Which Endocardi3s Prophylaxis is Recommended

•  DENTAL PROCEDURES that involve manipula3on of gingival 3ssue, periapical region of the tooth or perfora3on of oral mucosa—NOT ROUTINE DENTAL CLEANING

•  RESPIRATORY PROCEDURES with viola3on of the mucosa-‐-‐tonsillectomy/adenoidectomy, bronchoscopy with biopsy, drainage of an infec3on (empyema)

Procedures for Which Endocardi3s Prophylaxis is Recommended

•  GI PROCEDURES likely to cause bacteremia—dila3on of esophageal strictures, treatment of varices, ERCP with obstructed ducts—NOT ROUTINE UPPER ENDOSCOPY, COLONOSCOPY OR SIGMOIDOSCOPY

•  SKIN/MUSCULOSKELETAL PROCEDURES—drainage of abscesses (an3bio3cs ac3ve against S. aureus)

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Recommended Regimens

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Case Presenta3on

•  The den3st of your 65 year old pa3ent who is 9 months s/p total hip arthroplasty calls wan3ng to know if prophylaxis should be given for a root canal

Should Prophylaxis Be Given?

1.  Yes 2. No

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100%

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Dental Prophylaxis for Prosthe3c Joints

•  Area of controversy for years between the ADA, AAOS and IDSA –  2004 AAOS & ADA recommenda3on prophylaxis if joint placed within past 2 years

–  2009 AAOS recommends prophylaxis for all prosthe3c joints regardless of when placed

–  Promise of collabora3on with joint guidelines – GOOD NEWS-‐-‐2013 AAOS & ADA propose new guidelines

Dental Prophylaxis for Prosthe3c Joints

•  BAD NEWS—> Grade of Recommenda3on is Limited:

The prac33oner might consider discon3nuing the prac3ce of rou3nely prescribing prophylac3c an3bio3cs for pa3ents with hip and knee prosthe3c joint implants undergoing dental procedures.

•  Implica3ons: Prac33oners should be cau3ous in deciding whether to follow a recommenda3on classified as Limited

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What TO DO??

•  Disconnect between organisms causing PJIs and mouth flora –  Late infec3ons almost always due to skin flora (S. epi, P. acnes, corynebacterium spp) not streptococci found in the mouth

•  Bacteremias common as a result of everyday ac3vi3es

•  Best study cited in the recommenda3ons: – Clin Infect Dis 2010;50:8-16

Clin Infect Dis 2010;50:8-16

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Risk of PJIs Following Dental Procedures

•  Prospec3ve case control study comparing pa3ents with PJI to pa3ents randomly admiqed to orthopedic floor

•  Dental records obtained and reviewed by DDS •  Variables were high and low risk procedures and whether the pa3ent received an3bio3c prophylaxis

Conclusions

•  Dental procedures do NOT increase risk of PJI •  An3bio3c prophylaxis does NOT decrease the risk of PJI infec3on

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Take Home Points

•  Prophylaxis NOT indicated for pins, plates, fixa3on devices, THA or TKA regardless of when the implant was placed

Case Presenta3on

•  Your 48 y/o female pa3ent pa3ent with asthma, who is on a tapering dose of prednisone (present dose 20 mg) for a recent exacerba3on, is seen over the weekend at an Urgent Care Clinic for a 3 day h/o fever to 102° F, nasal conges3on and facial pain. A diagnosis of ABRS is made and she is placed on amoxicillin-‐clavulanate (Augmen3n) 875/125 BID.

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Case Presenta3on

•  3 days later she comes in to see you saying that she is no beqer on the amoxicillin-‐clavulanate.

At this point you would?

1.  Increase the amoxicillin-‐clavulanate to 2 gm BID

2.  Change to levofloxacin 3.  Do a sinus CT

4.  Refer to ENT

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Pathogenesis of Acute Bacterial Rhinosinusi3s

•  It is almost always a pyogenic complica3on of a viral upper respiratory tract infec3on

•  Viral infec3on causes mucocilliary dysfunc3on, allowing bacteria from the nasopharynx to ascend to the sinuses and invade the mucosa

Risk factors for Acute Fungal Rhinosinusi3s

•  Hematologic malignancies •  Hematopoie3c stem cell transplanta3on

•  Chemotherapy-‐induced neutropenia

•  Solid organ transplanta3on •  Advanced HIV infec3on •  Diabetes mellitus

•  Glucocor3coids

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Endoscopy Was Performed

Take Home Point

•  Maintain a high degree of suspicion in immunocompromised pa3ents who present with sinus complaints, especially those without a preceding viral upper respiratory infec3on

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Trivia Ques3on

•  Can you name the two other organisms with same genus and species name to honor their discoverer?

Trivia Answer

•  Morganella morganii—named ayer the Bri3sh bacteriologist H. de R. Morgan

•  Rickeqsia rickeqsii—named ayer the American pathologist Howard Taylor Rickeqs

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Case Presenta3on

A 22 yr old comes to the office complaining of the acute onset of unilateral weakness of the right side of his face. Your diagnosis is Bell’s Palsy.

What is Your Therapy

1.  Prednisolone 2.  Acyclovir 3.  Prednisolone + acyclovir

4. Nothing

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100%

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E3ology of Facial Nerve Palsy

•  50% are idiopathic (Bell’s Palsy) •  Herpes Simplex/Varicella Zoster •  Lyme disease (most common cause of bilateral FN

palsy) •  Diabetes •  Sarcoid •  Trauma •  Tumors •  Other infec3ons

–  CMV, EBV, HIV

Therapy of Bell’s Palsy

•  Quite controversial •  Because of the associa3on with herpes viruses the use of acyclovir has been felt to be beneficial

•  Two well done prospec3ve, randomized, controlled, blinded studies have been done

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Lancet Neurol 2008;7:993-‐1000


•  839 pa3ents enrolled within 72 hours of onset of symptoms – Placebo + placebo (206) – Prednisilone (60mg X 5 days then reduced by 10 mg/day) + placebo (210)

– Valacyclovir (1000mg TID X 7 Days) + placebo (207)

– Valacyclovir X7 Days + prednisolone X10 Days (206)

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Placebo

Valacyclovir + placebo

Prednisilone

Prednisilone + valacyclovir


•  Case closed on therapy??? NO!! •  Other less powered studies and subgroup analyses suggest that acyclovir might be beneficial in the most severe cases – Minimal or no movement of facial muscles and inability to close the eye

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Take Home Points

•  Early treatment (within 72 hours of onset) recommended

•  For most cases prednisolone for 10 days is adequate

•  For severe cases (complete or near complete paralysis) prednisolone for 10 days + valacyclovir for 7 days is recommended

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