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Morning Report

Morning Report. Dr. Doktor PGY-2 December 6, 2010. The patient. 62yoF Found down in house by neighbor Lying prone, was covered in feces & urine At OSH, brain imaging : edema and mass effect in L basal ganglia w/shift to the right, w/small lesions in L frontal area & R parietal convexity

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Morning Report

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  1. Morning Report Dr. Doktor PGY-2 December 6, 2010

  2. The patient • 62yoF • Found down in house by neighbor • Lying prone, was covered in feces & urine • At OSH, brain imaging: edema and mass effect in L basal ganglia w/shift to the right, w/small lesions in L frontal area & R parietal convexity • Transferred to CUH because serious care starts here • But seriously, for NeuroSx eval

  3. 62yoF • PMHx • HTN, HPL, hypothyroidism, h/o diverticulitis ‘09 • Early Oct had fever/chills, cough. Tx’d for flu, given azithromycin & tylenol w/codeine for cough • PSurgHx • tooth extraction in early October • S/p chole • FHx • Breast CA (mother) • Social Hx • denies tobacco/EtOH

  4. 62yoF: pertinent positives • Head: ecchymosis L face • Neuro: Able to state name only, decreased sensorium, dysphasic, inattentive, cooperative • PERRL • Right-sided CN defects, R facial droop, R-sided weakness/hemiparesis • Toes upward going • Lungs: rhonchi bibasilar • @ OSH: WBC 25.1, Tm 101.6, (+) myoglobinuria

  5. 62yoF S. intermedius (+) liver aspirate: • Ceftriaxone & metronidazole (also phenytoin) • Developed fevers & leukopenia/neutropenia • Abx changed to vancomycin and metronidazole • Counts recovered • Also w/Episode of Candiduria (C. albicans) tx’d w/fluconazole • MRSA in stool

  6. Abscesses in liver & brain • Streptococcus intermedius • Entamoeba histolytica • Aggregatibacter paraphrophilus • Klebsiella pneumoniae, esp in SE Asia Invasive liver-abscess syndrome • Nocardia

  7. Member of S. anginosus/milleri group S. anginosus S. intermedius S. constellatus w/2 subspecies Streptococcus intermedius

  8. Streptococcus intermedius

  9. Streptococcus intermedius

  10. Streptococcus intermedius

  11. Streptococcus intermedius

  12. CNS infections by S. intermedius • Life-threatening • Abscesses: • Brain, epidural, subdural spaces • Meningitis • Lateral or cavernous sinus thrombosis • Source: s/p oral, dental or GI source or abscess from other site

  13. Streptococcus intermedius Viridans strep • Non-hemolytic, catalase-negative • Non-motile, facultative anaerobe • Member of S. anginosus/milleri group • S. anginosus • S. intermedius • S. constellatus w/2 subspecies

  14. Streptococcus intermedius

  15. Streptococcus intermedius vs S. angiosus and S. constellatus

  16. So what’s with the abscesses? • uniquely produces intermedilysin • a cytolytic toxin specific for human cells • a virulence factor for liver and other deep-seated abscesses • hydrolytic enzymes (hyaluronidase) • Spreads through tissues • Liquefaction of pus • Interaction of this group w/PMNs

  17. Abx • -Lactams • Brain abscesses: 3rd gen ceph • PCN resistance rare, but due to PBPs • More likely in S. angoisus or S. intermedius • Vanco for PCN-allergic • Metronidazole for anaerobic coverage • But NOT: • Fluoroquinolones (easily become resistant) • Sulfonamides (have no activity) • Aminoglycosides (most are resistant) • Macrolides (emerging resistance)

  18. 62yoF: Repeat imaging • MRI brain: mild obstructive hydrocephalus in 3rd & lateral ventricles w/increase in proteinaceous material in L lateral ventricle. Interval decrease in multiple brain abscesses • CT A/P: stable appearance of wedge-shaped hypoattenuation in posterior dome of liver: combo of resolving liver abscesses w/altered perfusion 2/2 hepatic venous thrombosis. • Small focus of gas in uterus, endometrial or less likely intramyometrium. Cystic foci w/a few foci of gas in R adnexa ? Of colo-adenxal fistula

  19. 62yoF: New issues T 100.8 Rash Tachy Hypotensive WBC 19.0 In a pt who is already on Gram (+) & anaerobic coverage for brain & liver abscesses

  20. Multiple BCx NGTD UA neg LE/N Ucx NGTD PICC placed 12/3 Lactate 1.7 INR 5.7 (not on coumadin) CXR unchanged Med List Keppra 1500 mg bid Vanco 750mg daily Flagyl Robitussen Levothyroxine Ocean spray (nares) Albuterol neb prn 62yoF: New Issues

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