Necrotising pneumonia

Transcription

1 Necrotising pneumonia TASNIM HASAN INFECTIOUS DISEASE ADVANCE TRAINEE 29 TH SEPTEMBER 2017

2 Background 57 year old male Background Rheumatoid arthritis On adalimumab and methotrexate Ischaemic heart disease CABG 2011 Works as a truck driver Caucasian Nil travel Nil pets Gardener

3 HPI January 2017 Flu like symptoms, decreased oral intake, dyspnoea, productive cough (yellow phlegm) OE Temp 34.7, sats 98%, HR 120, BP 67 systolic Diaphoretic, looks unwell and moved to resus Chest reduced air entry right, no added sounds HSDNM, abdo snt, nil rash, peripheries cool

4 Initial Ix

5 Differential diagnosis?

6 Differential diagnosis Sepsis/septic shock -?source Pneumonia Bacterial Viral Opportunistic pathogens Non-infectious causes (less likely) AMI, PE

7 TNF-alpha inhibitors and infection risk TNF-alpha is important for macrophage activation, phagosome activation, differentiation of monocytes into macrophages, recruitment of neutrophils and macrophages, and granuloma formation and function Infections primarily occur in the first 6-12 months per 1000 patients per year suffer a serious infection 3% end up hospitalised Serious infections associated with TNF-alpha inhibitors include: Bacterial: Septic arthritis, Listeriosis, Legionella pneumonia, Other (Mycobacterial, NTM, Nocardia) Viral: Hep B, Herpes zoster,?cmv/hsv Fungal: Dissseminated histoplasmosis, coccidioides, blastocystomycosis and other IFI (risk factor endemic travel),?cryptococcus,?aspergillus,?pjp Hard to quantify exact risk given multiple confounders

8 Further investigations CXR

9 Provisional diagnosis Community Acquired Pneumonia Potential pathogens?

10 P Charles et al. CID. 2008

11 Initial Abx?

12 Management Commenced on ceftriaxone and azithromycin Methotrexate and adalimumab ceased Intubated

13 Further test results Blood cultures - negative Respiratory virus PCR - negative Sputum MCS - negative Pneumocystis PCR negative (BAL) Urinary Pneumococcal Ag - negative Urinary Legionella Ag - negative

14 Further test results BAL Aspergillus PCR (serum) and galactomannan negative CMV PCR Q fever negative Mycoplasma IgM negative Adenovirus serology negative Influenza serology negative Legionella serology negative Hepatitis screen negative HIV negative Vasculitic screen CCP elevated 371 All else negative

15 More results BAL 1/2 Legionella longbeachae Serology results: Legionella longbeachae <128 30/1/17 (acute) /2/17 (convalescent)

16 L. longbeachae First isolated from a patient in Long Beach, California, 1980 Common in Australia, New Zealand and Japan Most common source thought to be commercial potting mix and decomposing materials Outbreaks in spring and autumn Cause community acquires lobar pneumonia Fewer deaths

17 From: Diagnosis of Legionella Infection Clin Infect Dis. 2003;36(1): doi: / Date of download: 2/6/ by the Infectious Diseases Society of America

18 Management Ciprofloxacin Azithromycin

19 Dual therapy for legionella -?evidence

20

21 Progress Subsequent imaging confirmed a broncho-pulmonary fistula Endo-bronchial valves inserted into the anterior and posterior segments of right upper lobe in March. Tracheostomy at same time Isolation of his right lung and preferential left lung ventilation Also had recurrent pneumothoraces Transferred to Westmead for Cardiothoracic input

22

23 VAP In ICU for almost two months, single lung ventilation Spike in temperature, increased inflammatory markers, hypotension Cultures (Sputum, BAL) Pseudomonas aeruginosa

24 P. aeruginosa susceptibilities Lavage 13/4/17 S gent, R mero, taz, ceftaz, I cipro (MIC 0.5) 26/4/17 S gent, R mero, taz, ceftaz, cipro 28/4/17 S gent, R mero, taz, ceftaz, cipro

25 Antimicrobial management

26 4 months on

27 Post treatment cessation

28 Summary Community acquired pneumonia, investigations and management Pitfalls of diagnostic techniques in Legionella Urinary Ag only detects L. pneumophila serogroup 1; serology usually not useful in acute setting; fastidious organism culture results are often delayed Management of complicated Legionella pneumonia Challenges of antimicrobial resistance and antimicrobial stewardship; Importance of source control

29 References Danza A, Ruiz-Irastorza G (2013). Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus 22: Dixon WG, Watson K, Lunt M, Hyrich KL, Silman AJ, Symmons DP (2006). Rates of serious infection, including sitespecific and bacterial intracellular infection, in rheumatoid arthritis patients receiving anti-tumor necrosis factor therapy: results from the Briticsh Society for Rheumatology Biologics Register Arthritis and rheumatism. 54(8): Bongartz T, Sutton AJ, Sweeting MJ, Buchan I, Matteson EL, Montori V (2006). Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systemic review and meta-analysis of rare harmful effects in randomized controlled trails. JAMA 295(19): Smith CH, Anstey AV, Barker JNWN, Burden AD, Chalmers RJG et al (2009). British association of dermatologists guidelines for biological interventions for psoriasis British Journal of Dermatology 161: Curtis JR, Xi J, Patkar N, Xie A, Saag K, Martin C (2007). Drug-specific and time-dependent risks of bacterial infection among patients with rheumatoid arthritis who were exposed to tumor necrosis factor a antagonists. Arthritis and rheumatism 56: Whiley H, Bentham R. Legionella longbeachae and Legionellosis (2011). Emerging Infectious Diseases 17(4):