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One case of sepsis

One case of sepsis. Chisa Yamada, M.D. Montefiore Medical Center. Case. 45 y/o male CC: fever, chills, nausea, vomiting, dizziness

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One case of sepsis

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  1. One case of sepsis Chisa Yamada, M.D. Montefiore Medical Center

  2. Case • 45 y/o male • CC: fever, chills, nausea, vomiting, dizziness • HPI: Patient who has cirrhosis came to ER for one day history of CC. He stated that he hit in his head at work by a box one week prior and got bitten by cat in left hand three days prior to admission. He denied palpitation, SOB. Patient had one episode of melena and coffee ground epistaxis in ER.

  3. Case • PH: ethanol abuse, cirrhosis ( varices, status post TIPS x 2. Chronic thrombocytopenia), HTN, hepatitis C • Allergies: NKA

  4. Case Physical exams • Vitals: T 98.0 (~104), BP 74/44, P 122, R 24, PO2 96.3 • Neurological: awake, alert oriented • Cardiac: regular rhythm, tachycardia, no chest pain • Respiratory: clear sound, no SOB, no cough • Abdomen: soft, no pain • Neck: supple • HEENT: PERRL, ecchymosis, nose and gum bleeding • Skin: fair, left hand with cat bite ( no inflammation) • Extremities: no edema

  5. Case Labs • Gas: 7.301/45.5/90.1/21.8/96.3 • CBC: RBC 2.54, WBC 11.8(polys 67, bands 31, lympho 2, eos 0), Hb 8.4, Hct 25.1, Plt 42.0, PT/PTT 16.2/38.5, INR 1.6, D-dimer 1.0 • Chem: Na 134, Cl 101, K 4.2, Ca 7.5, Glu 155, BUN 43, Creatinine 1.7, SGOT 157, SGPT 34, ALP 82, T-Bil 14.7, D-Bil 5.5, LDH 440, Amylase 82, Lypase 32, CPK 127 • UA: orange color, turbid appearance, pH 1.024, protein 100, glu negative, ketone trace, occult blood large, bilirubin large, nitrite negative, WBC 29, RBC 30-35, bacteria 2+

  6. Case Images • CXR: mild CHF • CT: Head - (R)maxillary sinus hemorrhage Abd - Diffuse thickening of small bowel and colon, gastric varices, ground glass opacity at the base of left lung • KUB: bowel distended • Abdominal sono: sludge in gallbladder • Duplex abdominal sono: decrease of flow velocity

  7. Case Cultures • Blood : Gram negative bacillus – Pasteurella pneumotropica identified by Vitek (Penicillin sensitive, Vanco resistant) • Urine : negative • Sputum : moderate candida albicans

  8. Case Hospital course • Patient was diagnosed as septic shock leading to ARF and ARDS. Patient was intubated at ER and transferred to MICU. FFP, RBC, platelets were transfused. Hydration, Gentamicin, Vasopressin treatment were started. Since Penicillin sensitive Pasteurella pneumotropica had isolated, Gentamicin was changed to Penicillin. Although, WBC has been increased and fever still spikes and patient’s condition is unchanged. Patient is now treated by Imipenem and Vanco and under observation.

  9. Pasteurella Species • Pasturella. multocida subsp. multocida subsp. septica subsp. gallicida • Pasturella. canis • Pasturella. stomatis • Pasturella. dagmatis Rare opportunistic human pathogen • Pasturella. pneumotropica • Pasturella. hemolytica • Pasturella. aerogenes • Pasturella. caballi • Pasturella. bettyae

  10. Pasteurella Species • Inhabit the oral cavity and GI tract of many animals causing septicemia and pneumonia dog, cat, mice, rat,, hamster, guinea pig, rabbit • Human infection by dog (25%) and cat (75%) bites Hx of household or domesticated animal contact Cat bites – Pasteurella Dog bites – S. aureus, Staphylococcus, Pasteurella Host

  11. Pasteurella Species • Toxin production Leukotoxin – toxic to leukocytes and impair cellular response and stimulate the inflammatory response • Produce polysaccharide capsules Antiphagocytic and aids in the resistance to intracellular killing by neutrophils • Binding of transferrin Supply iron necessary for growth Pathogenesis

  12. Pasteurella Species Clinical manifestations • Skin and soft tissue infections – fever, cellulitis • Bone and joint infections – septic arthritis, osteomyelitis, combined both • Central nervous system infection – meningitis, brain abscess, subdural empyema • Septicemia and endocarditis • Respiratory tract infections – pneumonia, empyema, sinusitis, bronchitis • Intra abdominal infections – peritonitis, apendicitis • Others – genitourinary tract, endophthalmitis

  13. Pasteurella Pneumotropica • Household pets • Sometimes reported in the respiratory floras of persons who have pets, specially if these individuals have some underlying disease such as cirrhosis, or a neoplasm. Clinical cases

  14. Pasteurella Pneumotropica • Only several cases reported - two septicemia one septicemia reported with chemo for leukemia one septicemia reported with no underlying disease • Treatment – generally susceptible to penicillin, ampicillin, cephalosporins, piperacillin, tetracycline, erythromycin, chloramphenicol, ceprofloxacin, aminoglycosides, trimethoprim-sulfamethoxazole Clinical cases

  15. Pasteurella Pneumotropica • Portal hypertention splenomegaly thrombo or pancytopenia varices • Decreased production of clotting factors in liver bleeding • Decreased production of complements in liver opsonins, chemoattractants, anaphylatoxins complement cascade (AgAb complex, Membrane attack complex) susceptible to bacterial infection, especially bacterias that have polysaccharides, lipopolysaccharide of cell wall in G(-) organism and that produce endotoxins Cirrhosis and complications in this patient

  16. Pasteurella Pneumotropica • Gram negative coccobacillus • Aerobic and facultative anaerobic, non-motile, • Grow on blood agar – smooth, convex, nonhemolytic, 0.5-1mm in diameter • Variable grow on MacConkey agar • Oxidase, catalase, urease, indole, ornithine decarboxylase – positive • Acid production positive - glucose, maltose, galactose negative – mannitol, sorbitol • Reduce nitrates to nitrites Microbiological features

  17. Pasteurella Pneumotropica Differential diagnosis by biochemical reaction

  18. Pasteurella Pneumotropica Differential diagnosis by biochemical reaction

  19. Pasteurella Pneumotropica • Culture • Biochemical reaction • Vitek identification • Enzyme-linked immunosorbent assay • PCR – primer 16S rRNA Diagnosis

  20. References • Frebourg NB. Berthelot G, Hocq R, Chibani A. Lemeland JF. Septicemia due to Pasteurella pneumotropica: 16S rRNA sequencing for diagnosis confirmation.J Clin Microbiol. 2002 Feb; 40(2): 687-9 • Nozu R. Goto K, Ohashi H, Takakura A, Itoh T. Evaluation of PCR as a means of identification of Pasteurella pneumotropica.Exp Anim. 1999 Jan; 48(1): 51-4 • Cuodorado-Gomez LM, Arranz-Cazo JA. Pasteurella pneumotropica pneumonia in a patient with AIDS.Clin Infect Dis. 1995 Aug; 21(2): 445-6 • Holst E, Rollof J, Larsson L, Nielsen JP. Characterizaion and distribution of Pasteurella species recovered from infected humans. J Clin. Micro. 1992 Nov; 30(11): 2984-2987 • HA Riview of Pasteurella pneumotropica, Charles River Laboratories, Spring 1991 • Principles and Practice of Infectious Diseases • Color Atlas and Textbook of Diagnostic Microbiology • Harrison’s Principles of internal Medicine • Medical Microbiology & Immunology

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