Came with a Bang.......

Dr Neelam DoshiConsultant MicrobiologistWythenshawe Hospital

University Hospitals South Manchester Foundation Trust

Occupational Zoonoses 9 July 2009

Points to cover

Case history, diagnosis and management

Diagnostic dilemma Adverse incident Event meeting Lessons learnt Disease update

Case History

22 y Kurdish immigrant male, EM SRFT April 2007 9 pm

Acute severe right testicular pain un able to walk and sleep Chills, nausea , increased urinary frequency for 2 mo. No trauma, penile discharge, not sexually active No significant past history, drug allergy, fit ‘n’ well Smokes 10 cig/d , social drinker

Shares a house with friends

Diagnosis

Vitals T 37.7° C P 107 /min BP 93/52 mm Hg RR 18

G/E, CVS, RS, P/A : NAD

Local ExaminationTender, swollen right testis, normal appearance

Provisional Diagnosis

1. Testicular torsion2. Urinary tract infection3. Calculi

Management Hb: 12 g/dl WCC : 10.5(Nφ=7.9)/cmm CRP: 28 , Urine dipstick: traces nitrates and protein Blood culture and MSU sent

Plan: 1am To theatres for testicular exploration and orchiopexy

On table: testis bit dusky but no torsion, epididymo-orchitis+

Discharged next day :Scrotal support ,pain killers and oral ciprofloxacillin for

2/52 , though stilll febrile 38 ° C

Re admission 5 days later calls 999, EM in agony Swollen testis, unable to walk, vomiting ,fever with

chills Pain score : 8, T: 38 ° C WCC : 9.6, CRP 55, ECG normal, Blood cultures done . No English, needs interpreter

Diagnosis ?Post operative haematoma ?Infection IV gent 5 mg/kg and to Urology, ciprofloxacin

continued

Diagnostic conundrum

Microbiology lab phones a gram negative cocco-baccilli in b/c taken on first EM admission i.e. 8 days before

Lab dilemma Aerobic growth only Very slow to grow on chocolate plates @Co2, 37 ° C ?Haemophilus spp , ?others Plates left on the bench pending senior BMS review,

several biochemical test put up for id ( open bench) Day 6 of 2nd admission , aerobic bottle from a new b/c set

shows a similar gn-cocccobaccili In the light of clinical diagnosis of epididymo-orchitis and

the gram stain , medics thought ,?Brucella spp.

Blood culture Gram’s stain

More history

Microbiologists and the clinician in the presence of the friend, at the ward Recent long trip in Europe on foot and back

of lorries in un-sanitary conditions In UK for last 2 mo. Worked with cattle's/camels/sheep in past

(3 years ago) in country of origin.

Panic......

Isolate sent to the Reference lab at Liverpool All cultures and tests moved to Cat 3 lab Expert ID opinion Prof Beeching sought . Clinicians contacted to rationalize Rx to oral

doxycycline 100 mg bd and rifampicin 600 mg bd for 6 weeks and to r/o deep seated infection .To send serum for antibodies .

Difficult traceability of patient as illegal immigrant, no GP, had a friends contact no in PAS. Needs Kurdish interpreter.

Now began the real panic!........

Adverse event meeting Urgent meeting :Lab/Medics/OH/HSE Event summarized

All work done on open bench( aerosols), 6 staff exposed, including me and one in first trimester!

OH – letters to the staff about the incident, serum as base line and repeat at 3 and 6 mo , the warning s/s and wait till id confirmed .

How things could have been done differently.

Actions

Future procedures and precautions To process all small gram negative cocco-baccilli

and those with clinical information suggesting high risk pathogens , in safety cabinet .

To raise awareness through lectures/plate rounds Update SOP on how to deal with high risk

pathogens, stick it on all benches High light high risk spp. by usage of yellow

stickers by clinicians Internal lab transfer of cultures of this organism

Bang.......... the news Call from VLA Confirmed B melitensis 3 Situation more worse

Two staff reported flu like symptoms and lassitude , repeat bloods/sera taken, Doxycycline and rifampicin treatment dose prescribed

Mental trauma and Fear !!

Settled only when sera results negative and recovered from- what was just a flu!! None started the antibiotics! OH NHS records for 30 yrs.

Follow Up : 15 days later and 2 mo laterAbsolutely well , no complications, 6 w Rx completed,

Registered with a GP, Disease notified with HPUAll contacts well till date.

Brucellosis Romanian skeletal remains Florence Nightingale and her doctor colleague-Crimean

fever, spondylitis, and neurobrucellosis 1886 Bruce discovered the organism Bang Pathologist-aborted fetuses of animals

Intracellular small, poorly staining ,gram negative bacilli 6 spp.( host and pathogenicity)-melitensis-sheep/cattle Highly infective : Infective dose10 organisms only.

UK: free as vaccinate animals 1991, test /slaughter scheme, animal movement tracing.

The disease

Acute or insidious 1-2 mo Intermittent fever (undulating), headache,

weight loss, tiredness, depression. Sequelae: OM/ Spondylitis /Epididymo-orchitis,

psychoneurosis, endocarditis, abortion Endemic areas: Middle east/Mediterranean

S. & Central America, Asia, Africa, Caribbean.

Diagnosis

Culture: slow growth : B/C, Bone marrow, aspirates, poorly staining gram, oxidase and urease +,CLED no growth, no X and V ,non motile.

4 fold rise in sera titer False positive Y enterocolitica / E coli o157

Routes: respiratory/ sexual/ GI /LAI /bioterrorism High risk activities: vets/abattoirs/farmers, lambing. Treatment

Conclusions Sufficient clinical information

D/D of scrotal pathologies in immigrants where Brucella is endemic.

Safe working practices Protocols for hazardous organisms , Risk assessment Senior review in difficult isolates Training and communication-good

Due concerns for the fear within staff- drug side effects, chronic sequelae, pregnant staff.

Bio terrorism weapon Imported infection.

References and websites

Pappas et al. Brucellosis. N Eng J Med. 2005; 352(22): 2325 - 2336. Clinical Microbiology Letter Jan 1 2006, Vol 28 (1).

Laboratory Acquired infections :Are microbiologists at risk? Young, EJ.An overview of human brucellosis. Clinical Infect. Disease

1995 21:283-290 Yurdakul T et al. Epididymo-orchitis as a complication of brucellosis

.Review of 84 cases.Urologia Internationalis, 1995, vol. /is. 55/3(141-142), 0042-1138.

Health Protection Agency, Colindale ,London http://www.hpa.org.uk Guidelines for Investigation of Zoonotic diseases April 2009

CDC website. http://svmweb.vetmed.wisc.edu/pbs/zoonoses/-University of

Wisconsin

Thanks…….