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ID Case Conference 10-10-07

ID Case Conference 10-10-07. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases. CC: Foot Ulcer. 52 yo woman w/ DM and Charcot foot who presents with worsening swelling and redness around diabetic foot ulcer.

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ID Case Conference 10-10-07

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  1. ID Case Conference 10-10-07 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

  2. CC: Foot Ulcer • 52 yo woman w/ DM and Charcot foot who presents with worsening swelling and redness around diabetic foot ulcer. • Patient reports that her foot ulcer had been present for several years, but that it changed about 1 week ago. She denies any known history of trauma. • Her daughter was the one to notice that the ulcer on the bottom of her left foot was red and swollen, smelled horribly, and had a black area with white splotches. • The patient claims she feels no pain in the area but has had decreased sensation in that foot from neuropathy.

  3. ABX Course • Patient was initially started on Zosyn, received 4 days of therapy then lost IV access and got levaquin/clinda x 1 dose until IV access could be secured. • ID was consulted for assistance with ABX

  4. PMH • CVA '03 - short term memory deficits per daughter HTN DM TYPE 2 HYPERLIPIDEMIA OBESITY CHF

  5. PMH (Cont) • Soc Hx - Lives in Burlington, and she hasn't worked since her stroke in '03. Denies any etoh, tobacco, or illict drug use. No recent travel. No contact with dogs or birds. Has a cat – h/o bites to the hand but no bites or licks on the foot. • Fam Hx - Aunt with Breast CA, Cousin with Breast CA, FH of DM, HTN, Hyperlipidemia.

  6. Medications • NKDA • ASA 81MG ONCE DAILY • EFFEXOR XR 225 MG ONCE DAILY • ENALAPRIL MALEATE 20MG TWO TIMES A DAY • FUROSEMIDE 60MG ONCE DAILY • HYDROCHLOROTHIAZIDE 25MG ONCE DAILY • METFORMIN HCL 1000MG TWO TIMES A DAY • NORVASC 10 MG ONCE DAILY • PLAVIX 75MG ONCE DAILY • SIMVASTATIN 80 MG ONCE DAILY • TOPROL XL 150MG ONCE DAILY

  7. ROS • She admits to polyuria/polyphasia. She denies any fevers or chills, but reports nausea and vomitting this am, where she vomitted water x3 this morning and couldn't keep her medications down. Patient denies any increased swelling in her legs.

  8. BP 147/86 HR 90 RR 20 T 37.0 97% RA NAD, alert/oriented x3, appropriate EOMI, PERRLA MMM, OP clear no palpable cervical nodes no carotid bruits RRR, no m/r/g CTAB, nonlabored soft, nontender, + bowel sounds, obese FROM CN 2-12 Grossly Intact moves all 4 extre's well LE exam – next slide Physical Exam

  9. Foot Exam • 2x2 cm wound over plantar surface of Left foot; moderate purulent drainage; moderate erythema & swelling. Area of fluctuance present over ulcer • 2-3+ pitting edema of lower extremities and feet. Well circumscribed area of erythema and heat on left lower leg and left foot. no clubbing, cyanosis.

  10. 10.3 42 130 95 13.5 304 27 1.9 4.4 29.1 255 Labs CRP >45 ESR 140 Ferritin 462 Hgb A1C 7.0 N-12.4 L-0.2 M-0.5 E-0.1 B-0.0

  11. Diagnostic Studies • X-ray of foot on admission demonstrated presence of cortical bone effacement, concerning for osteomyelitis.

  12. xray

  13. MRI • Subtle enhancement seen within the distal cuboid overlying the large skin ulcer as above may represent osteitis. Early osteomyelitis cannot be fully excluded and follow-up plain radiographs in 7 to 10 days is advised to assess for interval progression. • Diffuse cellulitis and/or edema of left foot and ankle. • Small joint effusion. A septic joint cannot be fully excluded; however, no signal abnormalities in the adjacent bones are seen to suggest this diagnosis. • Abnormal enhancement at the base of the metatarsals are most likely secondary to advanced neuropathic arthropathy.

  14. Discussion

  15. Blood Culture Results • 3/3 blood cultures positive for • Pasteurella multocida 3+ • Oxacillin Susceptible Staphylococcus aureus 3+ • 2007-07-24PENICILLINR • 2007-07-24OXACILLINS • 2007-07-24GENTAMICINS • 2007-07-24VANCOMYCIN MIC2S • 2007-07-24ERYTHROMYCINR • 2007-07-24CLINDAMYCINS • 2007-07-24TRIMETH/SULFAMETS • 2007-07-24DOXYCYCLINES • Streptococcus species 3+

  16. Polymicrobial Bacteremia including pasteurella multocida

  17. Microbiology • Zoonotic (related to animal sources) • Short, encapsulated gram negative coccobacilli • Aerobic, facultatively anaerobic • Small, gray, shining colonies on blood agar • Grow well on sheep blood, chocolate, MHA • Growth uncommon on MacConkey • Resistance associated with degree of encapsulation

  18. Epidemiolgy • Found worldwide • Commensals in the upper respiratory tract of fowl and mammals • Carrier rate 55% in dogs and 60-90% of cats • Causes a variety of disease in animals • Fowl cholera • mastitis

  19. Epidemiology (cont.) • 0.6-1.8 cases of P. multocida infection per 100,000 per year • Most commonly transmitted to humans through bites (cat, dog, other felines, horses, pigs, rats, rabbits, wolves) • Isolated from 50% of dog and 75% of cat bites • Infections not related to bites probably stem from contact with animal secretions

  20. Clinical Manifestations • Soft tissue, bone, and joint infection (usuallly following animal bites/scratches) • Oral and respiratory infections • Serious invasive infection

  21. Soft tissue infection • Rapid development of intense inflammatory response, often within hours of bite • Purulent drainage in 40%, lymphangitis in 20%, regional adenopathy in 10% • Necrotizing fascitis can occur

  22. Image • See UpToDate • Available online at UNC Health Sciences Library [on campus only]

  23. Septic arthritis • Septic arthritis most commonly involves a single joint, usually the knee. Predilection for joints already damaged (RA, DJD, prostheses). Bite usually distal to involved joint without direct penetration. • NOT preceded by a bite or scratch in 1/3 of cases (hematogenous spread) • More than 50% of patients with septic arthritis are immunosuppressed.

  24. Osteomyelitis • Local extension of soft-tissue infection or direct innoculation • Cat bites > dog bites because of the sharp little teeth that go down to bone • Treatment requires at least 4 weeks of IV antibiotics followed by oral antibiotics • 50% of patients experience slow healing, nonunion, joint fusion, limitations of motion, or residual deformity • Poor functional outcome in hand infections

  25. Respiratory infections • Usually have underlying COPD (37%), bronchiectasis (21%), malignancy (15%), cirrhosis (8%) • Pneumonia, pharyngitis, sinusitis, lung abscesses

  26. Other infections • Endocarditis: 15 case reports • Meningitis: 50% of cases infants < 1 year, 30% adults > 60 years • Peritonitis: usually associated with peritoneal dialysis (cat had punctured dialysis tubing in 65%) • Endophthalmitis

  27. Bacteremia • Bacteremia • Most are immunocompromised (cirrhosis, malignancy/chemotherapy) • Mortality approximately 30% • Commonly accompanies a localized infection • Often seen with liver dysfunction

  28. Fun fact –pasteurella bacteremia at UNC is associated with Shaughnessy exposure (no causation. all patients had positive blood cultures prior to exposure. I promise I wash my hands!) Bacteremia (cont) • Very rare • In the past 5 years, we’ve had 4 positive pasteurella multocida isolates from blood at UNC

  29. Association with liver disease • Cirrhosis of any etiology, hepatitis, infiltrating tumors • Impairment of reticuloendothelial system makes patient prone to infection with encapsulated organisms

  30. Treatment • Penicillin is drug of choice • If PCN allergic, quinolone, doxycycline, 1st generation cephalosporin, septra • In cases of septic arthritis, IV abx and serial joint aspirations

  31. Our Patient • Pip/tazo chosen for good coverage of pasteurella, OSSA, and anaerobes/pseudomonas (given diabetic foot ulcer) • Intensive debriedments and IV abx x 2 months showed only mild clinical improvement, no change in ESR • Repeat wound culture confirmed OSSA, no further positive cultures for pasteurella. All repeat blood cultures negative to date. • Currently getting hyperbaric oxygen therapy via our vascular surgery colleagues • Continuing IV Abx – trying to save the foot

  32. Sources • Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine, 15th edition. • Book available online via the UNC-CH Libraries • Tseng, Su, Liu, & Lee. Pasteurella multocida bacteremia due to non-bite animal exposure in cirrhotic patients: report of two cases. Journal of Microbiology, Immunology, and Infection. 2001; 34: 293-296. • Morris MJ, Mcallister CK. Bacteremia Due to Pasteurella multocida. • Talan, Citron, Abrahamian, Moran, Goldstein. Bacteriologic Analysis of Infected Dog and Cat Bites. The New England Journal of Medicine. Vol 340, number 2. 1999.

  33. Sources (continued) • Levinson, Jawetz. Medical Microbiology and Board Review. McGraw-Hill, 1998. Pgs 133-134. • UpToDate [available online at UNC HSL – on campus only] • Mandell’s Principles and Practices of Infectious Disease, 6th Ed. • Book available online via the UNC-CH Libraries • Weber, DJ, Wolfson, JS, Swartz, MN, Hooper, DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984; 63:133. • Weber, DJ, Hansen, AR. Infections resulting from animal bites. Infect Dis Clin North Am 1991; 5:663. • Search by journal title in E-Journals to find copy of full-text article

  34. Search PubMed • Pasteurella Multocida • Case Reports • Reviews • Differential Diagnosis • Drug Therapy

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