A Hunter s Infection Federation of Infection Societies Annual Conference 2013

Transcription

1 A Hunter s Infection Federation of Infection Societies Annual Conference 2013 Dr Philip Asquith (CMT2) Dr Cecilia Jukka (Consultant Medical Microbiologist) Dr John Horsley (Consultant Physician) Southport and Ormskirk NHS Trust

2 Background Autumn year old gentleman, previously fit and well, attends local Emergency Department feeling generally unwell with a two week history of: Pyrexia Myalgia Arthralgia And: abdominal pain, nausea and vomiting for one day Had attended GP surgery one week earlier

3 No history of cough, dysuria, diarrhoea, headaches Observations on admission Pyrexia- temperature 40.8 o C Tachycardia- heart rate 126 bpm Tachypnoea- respiratory rate 22 Relative hypoxia- oxygen saturation 93% on air

4 Examination in AED: Chest clear, heart sounds normal, abdomen generally tender but no guarding or organomegaly No focal neurological signs No cervical, axillary or inguinal lymphadenopathy palpable

5 Initial Investigations White cell count 12.5 x10 9 /litre (neutrophils 10.5 x10 9 /litre ) C-Reactive Protein (CRP) 217 mg/litre Renal and Liver Function Tests normal Amylase 39, Lactate 2.1 u/litre Corrected Calcium 2.07 mmol/litre INR 1.2 Urine dipstick- trace of protein and blood Blood and urine specimens for culture taken

6 Chest X-ray on admission

7 Initial social history Non-smoker Truck driver who occasionally works in forests Many tick and mosquito bites No recent foreign travel

8 Clinical Course Sepsis?source - IV Cefuroxime 1.5g TDS commenced Persistently hypotensive and pyrexial overnightgiven stat dose of Gentamicin Improved during day, febrile again by evening Antibiotics changed to IV Tazocin 4.5g TDS and IV Gentamicin continued

9 Further history elicited: Patient travels extensively throughout the UK for pheasant shooting Trains gun dogs for a living Had been staying in Scotland during recent Legionella outbreak (A red herring travel was 2 months earlier!!)

10 Day 2 Continued deterioration Delirium, visual and auditory hallucinations Increasing oxygen demands Persistent tachycardia Urgent CT head requested - normal Lumbar puncture performed normal opening pressure (<20cmH 2 0), no increased cells, no organisms seen, normal protein and glucose

11 Day 3 Developed dry cough -coarse crackles to mid-zones bilaterally on chest auscultation CRP>300mg/litre Some symptomatic improvement following doses of Gentamicin. IV Clarithromycin commenced High resolution CT chest requested

12 HRCT findings

13 Significant negative results Three sets of blood cultures - 09/10/12 th Nov (prolonged incubation) Mid-stream specimen of urine Urinary Legionella antigen Coxiella serology Brucella serology Borrelia serology Paul Bunnell test HIV 1 and 2 antibody testing

14 Significant negative results Avian IgG precipitins to parrot/pigeon/budgerigar Respiratory Viral PCR panel: Influenza A/B RSV Parainfluenza 1/2/3 Adenovirus Rhinovirus Human metapneumovirus

15 Vasculitic screen (all negative) Anti SSa/SSb Anti-centromere Anti-Scl 70 Anti-Jo1 Anti-GBM canca/panca Double stranded DNA Immunoglobulins (IgA/IgG/IgM)- within normal range

16 Day 4... Reviewed by Consultant Physician and Consultant Microbiologist Tell us more about this hunting

17 Pigeons, lots and lots of pigeons

18 Pigeons, lots and lots of pigeons 3 month history of using trapped pigeons for hunting practice Regularly in contact with faecal matter and feathers No protective clothing used

19 Day 4 continued IV Tazocin and IV Clarithromycin stopped Oral Doxycycline 100mg BD commenced Hunting partner visits patient Partner now unwell also with fever and dry cough Advised to attend Emergency Department Attends two days later so as not to miss big hunt in South of England!

20 Temperature chart *Doxycycline commenced Temperature * 5 6 Days since admission

21 Outcome 10 days following admission the patient was well enough to be discharged (CRP 13, WCC normal) Gentamicin stopped after 7 days Doxycycline continued for a further 3 weeks Hunting partner improved after 5-day hospital stay. Also treated with long duration oral Doxycycline (plus IV Amoxicillin for 1 st two days of admission)

22 Follow-up Reviewed in outpatient clinic 6 weeks later Rising CFT titres to Chlamydophila group from 12 to 64 on acute and convalescent serology specimens Specific fluorescent antibody titres to Chlyamdophila psittaci on acute and convalescent specimens confirmed diagnosis (1024 rising to 4096) Complete resolution of symptoms and returned to training hunting dogs

23 Now wearing protective overalls (and using wild pigenons and using wild pigeons

24 Learning Points Psittacosis 1 Chlamydophila psittaci Typically found in parrots, parakeets, budgerigars May also be found in pigeons, turkeys and doves Transmitted through inhalation of infected avian material (respiratory secretions, faecal matter or dust) or direct contact with plumage of infected birds

25 Learning Points Around 50 cases reported in England and Wales per annum (Public Health England) 1 Typical incubation period 5-19 days following exposure 2 Common symptoms 3 : Fever Dry cough Myalgia Headache Less commonly: Gastrointestinal disturbance Polyarthralgia Horder spots (facial rash)

26 Potential complications include: Severe pneumonia requiring HDU/ITU support, endocarditis, glomerulonephritis, meningoencephalitis, hepatitis, pancreatitis, disseminated intravascular coagulation Untreated Psittacosis has a high mortality (15-20%) 4 Serological diagnosis is performed by PHE Reference Laboratory, Bristol PCR restricted (only available following discussion on tissue or broncho-alveolar lavage specimens)

27 Learning Points An accurate and thorough social history can help aid diagnosis If patient s condition deteriorates despite conventional antibiotic therapy, consider atypical organisms Close collaboration with Infection Specialists is essential in cases of unusual presentations or failure to respond to empirical therapy

28 References 1. Background information on Psittacosis. Public Health England. Z/Psittacosis/GeneralInformation/psiBackgroundInformation/ 2. Psittacosis. Centers for Disease Prevention and Control. htm 3. Psittacosis Centers for Disease Control and Prevention Compendium of measures to control Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis), MMWR Recomm Rep. 2000;49(RR-8):3 17.

29 References Clip Art images from Microsoft Office Powerpoint 2010 Springer spaniel el.jpg.jpg Pheasant Pigeons Chlamydophila psittaci

30 References The Simpsons produced by Gracie Films in association with 20 th Century Fox, created by Matt Groening Breaking Bad produced by High Bridge Productions with Gran Via Productions and Sony Pictures Television for American Movie Classics (AMC)

31 Acknowledgements and Thanks Many thanks to the patient for allowing us to share his story Radiology Department at Southport DGH for help acquiring CT/Radiograph images Public Health England Reference Laboratory, Bristol (especially Dr David Carrington for discussion regarding results) Thank you for listening