ACCME/Disclosures 4/13/2016 IDPB

Transcription

1 ACCME/Disclosures The USCAP requires that anyone in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Dr. Sherif Zaki declares he has no conflict(s) of interest to disclose. IDPB year old man from MA History of EtOH abuse, IVDU, and mitral valve replacement Presented in acute respiratory distress Reported progressive dyspnea, weakness, diaphoresis, diarrhea, and anorexia TTE showed mitral valve vegetation Biopsy report described acute endocarditis w/ abundant cocci on and MSS Blood cultures negative 1

2 Rat Bite Fever Causative agents Differentia diagnosis Streptobacillus moniliformis- more common in North America Broad! Includes both infection and non-infectious etiologies Spirillum minus (sodoku)- more common in Asia Pleomorphic and gram-negative bacterium Difficult to isolate on culture Bacterial agents: S. pyogenes, S. aureus, N. gonorrhoeae, N. meningitides, B. burgdorferi, Ehrlichia species, SFG Rickettsia spp, Brucella spp, Leptospira spp, and T. pallidum 16S paneubacteria PCR showed 100% homology w/ Streptobacillus moniliformis Symptoms started after bite from pet rat Symptoms started after bite from pet rat ISH Streptobacillus moniliformis Requires enriched media and microaerophilic conditions Transmission Bite or scratch from infected rodent 30% of cases no history of rat bite Common clinical signs Fever, headache, chills, vomiting, pharyngitis, polyarthralgia, & maculopapular, petechial or purpuric rash (esp on palms & soles) Less commonly: endocarditis, vasculitis, meningitis, abscesses & septicemia Viral agents: EPV, parvovirus B19, coxsackieviruses, hantavirus and other viral hemorrhagic fevers Mortality rate If untreated mortality ranges from 7-13% Diagnosis: Culture, PCR and ISH No validated serologic tests Additional Cases: Case 1 ( ) Additional Cases: Case 2 ( ) 52 year-old patient Bitten by rat in pet shop Developed severe anemia and thrombocytopenia. Died after a rapid clinical course with generalized maculopapular rash. PCR on isolate subculture was positive for Streptobacillus moniliformis. Autopsy was not performed because of biosafety concerns. 19 year old female with no significant PMH presented DOA to ED Reported 3 day history of fever, nausea, malaise, headache, myalgia & weakness that progressed to dyspnea, chest pain, anxiety and confusion on the day of death Blood and tissue culture negative; serology for leptospirosis, EPV, CMV, viral hepatitis negative for recent infection Decedent owned 9 pet rats & worked at a pet store; no known bites in 2 weeks prior to death Submitted as a Hantavirus pulmonary syndrome rule out. 2

3 ISH 16S paneubacteria PCR showed 100% homology w/ Streptobacillus moniliformis Heart with intravascular bacteria & fibrin thrombi Liver with filamentous bacteria in the central vein ISH ISH 3

4 Infective Endocarditis IDPB Endocarditis can be classified in three categories: Native valve endocarditis Endocarditis in intravenous drug abusers Prosthetic valve endocarditis These categories have different infecting microorganisms and run different courses. Endocarditis can also be classified as: Acute S. aureus most common cause and occurs on normal valves Subacute Viridans streptococci most common cause occurs in damaged valves 62 year old man from GA Hx of mitral valve regurgitation surgery in 1992 Reported recent hx of fatigue, palpitations, lower extremity swelling, and shoulder pain TTE confirmed severe mitral valve regurgitation Mitral valve leaflets positive by and PCR for Streptococcus mutans IDPB year old male from SC Hx of severe mitral regurgitation Had culture negative endocarditis Underwent aortic and mitral valve replacement 4

5 Aortic valve leaflet positive by and PCR for Streptococcus mutans IDPB year old man from NM IVDU w/ hx of gout chronic neck and back pain Presented to ED w/ back pain and severe weakness Dx with acute kidney injury and passed away Autopsy found ruptured aortic valve and chronic hepatitis PAS Aortic valve positive by and PCR for Enterococcus faecalis IDPB year old man from FL Biopsy of Tricuspid valve w/ vegetation Surgical Culture found abundant S. aureus 5

6 Aortic valve positive by and PCR for Staphylococcus aureus IDPB year old man from MA IVDA w/ hx of endocarditis Underwent tricuspid valve replacement Tissue cultures negative but blood culture grew gram negative rods IDPB year old woman from GA Aortic root repair for pseudoaneurysm Purulent lesion intraoperatively Cultures negative Prescribed ceftriaxone and vancomycin Tricuspid valve positive by and PCR for Staphylococcus aureus 6

7 IDPB year old man from GA Hx of bicuspid valve disease, aortic valve disease, head/neck/prostate cancer, and COPD Received prosthetic aortic valve in 2013 Recent hx of fever, chills, constitutional symptoms, and malaise Cardiac evaluation showed endocarditis Prosthetic aortic valve positive by PCR for Haemophilus influenzae HACEK IDPB PAS 59 year old man from TN Suspected marantic endocarditis Hx of embolic strokes Vegetation noted on mitral valve leaflet Initially did not suspect infectious agent Prosthetic aortic valve positive by and PCR for Propionibacterium acnes 7

8 IDPB year old man from GA Hx of ANCA vasculitis and endocarditis Presented w/ dehiscence of prosthetic valve PAS Cultures grew enterococcus and serology showed Q fever EM Mitral valve leaflet vegetation positve by and PCR for Tropheryma whipplei Conclusions: Infective Endocarditis Clinical and laboratory findings Course: Acute or subacute Underlying valve defects IVDU Genitourinary tract manipulation, trauma or disease Laboratory manifestations: Anemia, leukocytosis, proteinuria, hematuria, circulating immune complexes Culture Pathology Special stains:,, and PAS 16 S rrna and specific PCRs (staphylococcus, coxiella, Tropheryma whipplei) Prosthetic aortic leaflet positive by for Coxiella burnettii 8

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