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ID Case Conference

ID Case Conference. September 4, 2007 Yvonne L. Ballard. Case. CC: right foot pain HPI: 44yo WF with DM presented to vascular surgery clinic with right foot pain, at first metatarsal

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ID Case Conference

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  1. ID Case Conference September 4, 2007 Yvonne L. Ballard

  2. Case • CC: right foot pain • HPI: • 44yo WF with DM presented to vascular surgery clinic with right foot pain, at first metatarsal • Original injury in 04/07, when pt’s toe got stuck on a fringe in carpet, causing a fall…pt developed ulcer of right first toe, which progressively got worse

  3. PMH: Diabetes Mellitus Hypertension CHF Morbid Obesity Medications Glucophage Insulin 70/30 Lasix Lisinopril Neurontin Spironolactone Zocor Celexa Aspirin SocHx: Smokes 1ppd No Etoh, illicits No pets No recent travel NKDA FamHx: CAD

  4. Sequence of Events • 6/28/07: Pt reports increasing pain to right first MTP, with associated color changes of the toe • 7/5/07: Seen in Vasc Surg clinic, and admitted to hospital • Xray: Osteomyelitis of first great toe, and grossly displaced calcaneal cuboid joint • Arterial duplex: ABIs of 0.49 and 0.59 in the anterior and posterior tibial arteries • 7/9: Angiography and stenting of R SFA • 7/10: Repeat Xray showed multiple displaced fractures at the mid foot level, and 3rd and 4th metatarsals

  5. 7/6: bedside debridement (resection of superficial necrotic skin only in the region of the first toe) • 7/11: Discharged home on IV antibiotics: Vancomycin, Zosyn • (stop date of 8/15/07) • 7/24: Amputation of first right toe • 8/16: re-admitted for new black eschar in middle of her wound, with increased drainage • 8/16: wound debridement (down to bone) and biopsy sent to Micro

  6. Physical Exam, 8/21 • Vitals: Tm 36.1, BP 107/62, P 56 • Physical Exam: • Gen: NAD • CV: RRR • Resp: CTA B/L • Ext: large surgical wound on right foot, wound from amputation shows small black area at base without purulence

  7. WBC 10.3 Hct 36.5 Plt 137 LFTs WNL Coags WNL BUN/Cr: 20/1.5 ESR 45 Labs, 8/21

  8. 8/21: Discharged home with IV Abx: • Vancomycin • Ertapenem • Posaconazole

  9. Discussion…

  10. 8/16 Biopsy Results: • 4+ Candida parapsilosis • HOWEVER…There was a “significant amount of mould” growing UNDER the Candida on the plate

  11. Alternaria alternata • One of the causative agents of phaeohyphomycosis • Emerging opportunistic pathogen in immunosuppressed patients • Is ubiquitous – common laboratory contaminant

  12. Immunocompetent Cutaneous Subcutaneous Brain abcesses Sinusitis Immunocompromised Fungemia Disseminated disease Other Described Cases Meningitis Pneumonia Prosthetic valve endocarditis Peritoneal dialysis catheter infection Osteomyelitis Septic Arthritis Phaeohyphomycosis

  13. Alternaria alternata • A fungus commonly isolated from plants, soil, food, and indoor air environment • Produces a melanin-like pigment • A. alternata is the most common species of >50 species in the Alternaria genus • Colonizes the paranasal sinuses, leading to chronic hypertrophic sinusitis

  14. Alternaria alternata • Onychomycosis • Sinusitis • Ulcerated cutaneous infections • Keratitis • Visceral infections • Osteomyelitis

  15. Patient Characteristics See table in: Lyke KE, Miller NS, Towne L, Merz WG. A case of cutaneous ulcerative alternariosis: rare association with diabetes mellitus and unusual failure of itraconazole treatment. Clin Infect Dis. 2001 Apr 15;32(8) 1178-87. Review

  16. Other species • A. chartarum • A. dianthicola • A. geophilia • A. infectoria • A. stemphyloides • A. teunissima

  17. Images To view images of the fungus, go to Doctor Fungus at: http://www.doctorfungus.org/index.htm

  18. Macroscopic Features • Grows rapidly on potato glucose agar (at 25 °C) • Colony flat, downy/woolly • Covered by grayish, short aerial hyphae • Initially greyish white, later turns greenish black or olive brown with light border

  19. Microscopic Features • Septate brown hyphae • Simple or branched large conidia, with transverse and longitudinal septations • May produce germ tubes • Ovoid, darkly pigmented, smooth or roughened • End is round, tapers at apex (beak-like appearance)

  20. Histopathologic Features • H&E stain • Dark colored filamentous hyphae • Fontana-Masson silver stain • Specific to melanin

  21. Susceptibilities • No standardized in vitro susceptibility testing • Caspofungin shown to be active in vitro • Voriconazole • Generated lower MICs than Itraconazole

  22. Treatment – Case Reports • Systemic -azoles • Intralesional Ampho B and surgical excision • Immunotherapy

  23. Search PubMed • Alternaria alternata infections • Case reports • Reviews • Differential Diagnosis • Drug Therapy

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