Infections without borders

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1 Session number CS07 Infections without borders Jeannette Guarner, MD Department of Pathology and Laboratory Medicine Emory University

2 Conflicts: none Disclosures: Paid by The Emory Clinic Worked at CDC , now guest researcher Brought up in Mexico, thus funny accent Husband, at Emory University, Chair of Global Health Images, own and from CDC: In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.

3 LUNG NODULES

4 Case 1 45 year old woman Severe persistent cough and shortness of breath, no fever pack tobacco use Worked up for a lung mass Radiology: right lung cavitary lesion

5 PPD negative Bronchoscopy with biopsies negative for neoplasia Wedge resection Operative report describes a large cavitary lesion and purulent material Material sent to pathology and microbiology

7 QUESTION: What is your diagnosis? 1. Cryptococcus 2. Coccidioides 3. Blastomyces 4. Histoplasma 5. Yeasts not further specified

8 When broad-based budding is seen in pathology, what have cultures shown: High percent of cultures are overgrown with Candida. Retrospective study, 53 patients: Blastomyces recovered in 67% Coccidioides immitis, Candida albicans or Aspergillus from 4 (10%) Thus, not all broad based-budding yeasts in the 8 to 15 micron size range are Blastomyces. Lemos LB, et al. Ann Diagn Pathol. 2000;4: Patel AJ, et al Am J Surg Pathol. 2010;34:

9 Review of more slides:

Description: Spherules with multiple endospores (10 to 100µ in size).

Differential diagnosis: Rhinosporidium seeberi which has sporangia with endospores but is much larger.

Diagnosis: Broad-based budding yeasts Comment: The morphology is consistent with Blastomyces but other yeast can

10 Description: Spherules with multiple endospores (10 to 100µ in size). Diagnosis: Spherules with multiple endospores. Comment: The morphology is consistent with Coccidioides spp. Differential diagnosis: Rhinosporidium seeberi which has sporangia with endospores but is much larger. Description: Yeast ranging in size from 10 to 20µ with broad-based budding. Diagnosis: Broad-based budding yeasts Comment: The morphology is consistent with Blastomyces but other yeast can present with this morphology including Histoplasma, Candida, Pneumocystis, Coccidiodes and others. Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Micro Rev 2011; 24:247-80

11 QUESTION: Which is the usual epidemiologic setting of coccidioidomycosis? 1. Having lived in Mississippi 2. Being a migrant from Vietnam 3. Building a house in the outskirts of the Sonoran Desert 4. Going camping during the summer in the Colorado Rockies

12 Epidemiology: Blastomycosis Blastomyces is isolated from soil with high content of organic compounds.

13 Blastomycosis

14 Epidemiology: Coccidioidomycosis TN Kirkland, J Fierer. Coccidioidomycosis: A Reemerging Infectious Disease. Emerg Infect Dis. 1996:2:

Infectious diseases elicited history in our patient Born in Los Angeles and lived there until 2000. Moved to Chihuahua.

16 Infectious diseases elicited history in our patient Born in Los Angeles and lived there until Moved to Chihuahua. In 2005, had a pneumonia on the right side, for which she was treated with an unknown intravenous antibiotic and azithromycin. Patient moved to GA in 2009.

17 Immunoassay in urine for blastomycosis. Bd, B. dermatitidis; Hc, H. capsulatum; Pb, P. brasiliensis; Pm, P. marneffei; Ci, C. immitis; Af, A. fumigatus; Ca, C. albicans; NI, controles. Durkin M et al. J Clin Microbiol 2004; 42:4873

18 Coccidioidomycosis: Alternative diagnostic methods IgM and IgG measured using EIA and/or immunodiffusion False negative serology in up to 38% of patients with hematogenous infection and 46% of fatal cases Urine antigens using EIA present in 71% of patients Cross-reaction in 10% of patients with other endemic mycosis

19 Mycology laboratory Grows easily in the laboratory (93% sensitivity)

Sporothrix Large (>10 µ) Blastomyces Coccidioides

20 Yeasts Size Grouping Epidemiology Small (2-10 µ) Histoplasma Cryptococcus Candida glabrata Pneuumocystis Talaromyces Sporothrix Large (>10 µ) Blastomyces Coccidioides Paracoccidioides Chrysosporium Parasites: Toxoplasma, Leishmania, Trypanosome

21 Small yeasts

22 Large yeasts

24 Case 2 A 35 years old a farm worker originally from Central America presented with fever and was found to have a lung nodule in a Chest X ray. A PPD was placed.

25 His first sputum AFB smears shows:

26 QUESTION: How many AFB organisms need to be present in 1 µl of sputum so as to have a positive smear? , , ,000 Siddiqi K et al. Clinical diagnosis of smear-negative pulmonary tuberculosis in low-income countries: the current evidence. Lancet Infect Dise 2003;3:288

27 QUESTION: The sputum culture exposed to light grew the following colonies within 1 week, how would you classify this mycobacteria? 1. Rapid grower 2. A photochromogen 3. A scotochromogen 4. Not in the Runyon classification

28 Runyon classification Not in the classification: M. tuberculosis, M. bovis

29 Molecular methods Xpert MTB/RIF at the Black Lion Hospital in Addis Ababa, Ethiopia

30 Histopathology More frequently

31 End of case The patient took his treatment which included isoniazid, ethambutol, rifampin, pyrazinamide, and vitamin B6. At 2 months he started treatment he started feeling weak and having nausea. He went to a physician and his liver function tests were markedly elevated. Even though isoniazid was discontinued the patient went into liver failure and he has been placed in the waiting list for a liver transplant.

33 SKIN NODULES

34 Case 3 41 year old male. One month history of indurated, erythematous, paineless lesions that started in scalp and have spread. Had visited friends in New Orleans for Mardi Gras. Treated unsuccessfully with Bactrim. As part of the work up an HIV test is ordered.

35 Sequence of HIV test positivity Infection Nucleic acid detection Fourth generation (Ag/Ab) IA Rapid Ag/Ab Third generation (IgG/IgM) IA Rapid differential HIV-1 & HIV-2 Rapid tests Western Blot Days after infection Ag/Ab= antigen and antibody; IA= immunoassays Masciotra et al, J Clin Virol 2011

36 New algorithm Western Blot

37 Case continues Negative viral, bacterial and fungal cultures Negative special stains in the biopsy for AFB, fungi and syphilis. RPR reactive with a titer of 1:4 (patient had been treated for syphilis one year before) HIV positive with a CD4 cell count of 243

38 QUESTION: How long does it take for the RPR to become negative? 1. Two years 2. Five years 3. Never as it measures IgG 4. Depends on the stage

39 Non treponemal tests Positives in: 80-90% primary syphilis, 100% secondary syphilis, ~70% late syphilis Converts to non reactive after: 1 year in primary syphilis, 2 years in secondary syphilis, 5 years in late syphilis Chronic persisters: usually biological false reaction. In HIV positive patients, >1:4 titter may indicate active persistent infection or reinfection.

40 Treponemal tests Usually positive for life as they detect IgG against the spirochettes. Do not detect recent infections, become positive 2-3 weeks after initial infection. Include: FTA-ABS: fluorescent label TP-PA: agglutination ELISA

41 Usual sequence of serologic syphilis diagnosis RPR + Proceed to titer & perform confirmatory test Confirmatory tests include: TP-PA, FTA- ABS or syphilis IgG ELISA Diagnosis of syphilis unlikely Diagnosis of syphilis, present

42 Reverse sequence of serologic syphilis diagnosis IgG using instrumentation 140,176 specimens + - RPR 3.4% % Patient does not have syphilis Diagnosis of syphilis, proceed to titer Perform another confirmatory test: TP-PA or FTA-ABS + - Diagnosis of syphilis, past or present 31.6% Diagnosis of syphilis unlikely MMWR, February 11, 2011 / 60(05);

43 Case continues Other tests negative a biopsy was obtained IHC

45 Primary and secondary syphilis rates by state in 2010

47 Case 2 34 yoga instructor and avid gardener. Noticed insect bites after she went on a trip to southern Italy. Within 3 weeks, a nonpruritic, raised and erythematous lesion in the lower leg gradually enlarged and ulcerated. She has no lymphadenopathy.

48 QUESTION: What is your diagnosis? A. Sporothrichosis B. Sarcoidosis C. Leishmaniasis D. Hypersensitivity to insect bite

50 QUESTION: Which is the vector of Leishmania? A. Phlebotomus B. Triatoma C. Simulium D. Glossina

52 Species 21 of 30 species infect humans. L. donovani complex with 3 species; L. mexicana complex with 3 main species; L. tropica; and others. Indistinguishable morphologically, but can be differentiated by isoenzyme analysis, molecular methods, or monoclonal antibodies.

53 90 percent of the world's cases of visceral leishmaniasis are in India, Bangladesh, Nepal, Sudan, and Brazil.

54 Clinical forms: Cutaneous Skin lesions where sandflies fed. One or more sores which can change in size and appearance over time. Painless or painful. Some swollen lymph nodes.

55 Clinical forms: Visceral (kala-azar) Fever, weight loss, lymphadenopathy and hepatosplenomegaly (spleen usually more enlarged than the liver). Abnormal CBC: anemia, neutropenia, and thrombocytopenia. Some patients develop post kala-azar dermal leishmaniasis. HIV opportunistic infection.

56 Diagnosis: Microscopy In tissue specimens, only amastigotes are seen using Giemsa or H&E. Differential diagnosis Histoplasma (no kinetoplast) and Trypanosoma cruzi (seen in muscle rather than macrophages).

57 QUESTION: What is a kinetoplast? A. Aggregate of ribosomes B. DNA-containing granule C. Lysosome with ingested RNA D. Calcified mitochondrion

58 kinetoplast undulating membrane flagellum

59 Diagnosis Isoenzyme analysis: after isolation using the biphasic medium (solid blood agar base with defribinated rabbit blood). Serology: useful in visceral leishmaniasis but is of limited value in cutaneous disease; cross reactivity with Trypanosoma. Molecular: potential to be more sensitive and rapid. Amplify a segment of the rrna internal transcribed spacer 2 (ITS2) from multiple Leishmania species.

60 Treatment Pentavalent antimonial Liposomal amphotericin B Miltefosin Paromomycin

61 In the 10 th century, Avicenna gave detailed descriptions of cutaneous leishmaniasis (Balkh sore).

62 Case A 19 year old woman that camped with friends in Costa Rica presents with a paiful nodule in her back. Some yellow white material is observed on top of the nodule. She has expressed the material and wants you to look at it.

63 Using a magnifying glass you see:

64 QUESTION: What is your diagnosis? A. Tungasis B. Myiasis C. Pediculosis

67 Geographic distribution Mexico to South America: Dermatobia hominis and Cochliomyia hominovorax. Africa south of the Sahara: Auchmeromyia luteola and Cordylobia anthropophaga. Mediterranean basin, Near East, and Central and Eastern Europe: Wohlfahrtia magnifica. United States and Canada: W. vigil. In the New World: Cuterebra species. Where sheep are tended: Oestrus ovis

69 Case 34 year old woman comes for a routine physical exam and nodule in her right arm is noted by her primary care provider. She is a missionary that has spent several months in rural Mexico. She is referred to dermatology and a biopsy is obtained.

72 QUESTION: Which bacteria has been found to be an endosymbiont with filarial nematodes? A. Deinococcus B. Salinibacter C. Bdellovibrio D. Wolbachia

74 Brugia malayi Wuchereria bancrofti Anterior and posterior ends of microfilariae found in humans. A, Wuchereria bancrofti. B, Brugia malayi. C, Loa loa. D, Onchocerca volvulus. E, Mansonella perstans. F, Mansonella streptocerca. G, Mansonella ozzardi. Mansonella

75 Diagnosis Sample: venous blood Periodicity Loa loa midday (10 AM to 2 PM) Brugia or Wuchereria at night, after 8 PM Mansonella any time Onchocerca any time

77 Case A 27 year old man presented with a nodular lesion in the right thigh that occurred after he sustained a cut while snorkeling in the Caribbean. There were no systemic symptoms such as fever or malaise. The nodule was resected.

79 QUESTION: What is your diagnosis? A. Fungus B. Protozoan C. Algae D. Parasite egg

81 Prototheca Only algae known to be a pathogen in humans. Spherical, unicellular organisms 3 to 20 um in diameter. Reproduction is asexual during cell maturation the cytoplasm undergoes a process of cleavage to form 2 to 20 endospores (morula). The sporangia (mother cells) break under pressure from the enlarging endospores; release of spores is passive.

83 LIVER NODULE

84 Case 5 21 year old man from New Zealand. Came to US to get a masters in epidemiology. Presents with fevers, headache and abdominal pain that have been going on for 3 days. Temp 38.9 C; BP 105/54 Exam: tenderness to palpation in LUQ Labs: WBC 14.1 (normal ); platelets 104,000; ALT 200 (normal <45); AST 172 (normal 15-41); ALP (97 (normal 32-91)

85 Differential diagnosis Sepsis Abdominal MRI demonstrated a 12x9x9 cm septated left liver lobe mass: Echinococcosis Amebiasis Pyogenic liver abscess Neoplasia

86 QUESTION: Which of the following is the definitive host of echinococci? A. Dog B. Horse C. Sheep D. Cow

87 Echinococcosis

88 Echinococcosis

89 Echinococcus: radiology M Stojkovic et al: PLOS Neglected Tropical Diseases. 2012

90 Echinococcus: cytology & histology

91 Echinococcus: laboratory diagnosis Antibody detection: False-positive reactions may occur in persons with other helminthic infections, cancer, and chronic immune disorders. Negative results do not rule out echinococcosis. Methods: Indirect hemagglutination (IHA), indirect fluorescent antibody (IFA) tests, and enzyme immunoassays (EIA).

92 Amebiasis Entamoeba dispar and E. histolytica are morphologically identical. E. histolytica: wide disease spectrum: asymptomatic, dysentery, liver abscess

93 Tests Serology

94 Back to our case

95 Arginine Streptococcus anginosus VP

96 Streptococcus anginosus group The group includes: S. constellatus, S. anginosus and S intermedius. (previously called milleri). Produce acetoin from glucose (characteristic buttery odor --Voges-Proskauer test), ferment lactose, trehalose, salicin, and sucrose, and hydrolyze esculin and arginine. Produce pyogenic abscess.

Fungal Diseases of the Respiratory System

Fungal Diseases of the Respiratory System Histoplasmosis(cave disease) Dr. Hala Al Daghistani Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. Histoplasma capsulatum, is usually