Katrina Booth Dr. Pursell March 4,, 2011 ` ` A 68-year-old man is evaluated in the hospital for daily fevers, with temperatures as high as 39.6 °C (103.2 °F) for the past 3 days, day history of cough productive of thick days and a 2 2-day tan sputum that was not responsive to vancomycin and cefepime therapy. He also has acute myeloid leukemia for which he has been receiving g induction chemotherapy. py His absolute neutrophil count has been less than 100/µL (0.10 × 109/L) for 12 days. Chest radiographs g p reveal a dense right g upper pp lobe infiltrate. CT scan of the chest shows cavitation and three other small densities in the right middle and lower lobes. Bronchoscopy with bronchoalveolar lavage yields washings with mostly lymphocytes and macrophages and no organisms on Gram stain, acid-fast bacilli testing, and fungal stains. Empiric therapy with voriconazole is initiated. After several days, the f fungal l cultures lt appear to t be b growing i a mold. ld ` ` ` ` ` ` Which of the following organisms is the most likely cause off this lesions? hi patient’s i ’ pulmonary l l i ? 1. Aspergillus fumigatus 2 Candida lusitaniae 2. 3. Histoplasma capsulatum 4. Nocardia asteroides 5. Pseudallescheria boydii 1. 2. 3. 4. 5. Aspergillus fumigatus f Candida lusitaniae Histoplasma capsulatum Nocardia d asteroides d Pseudallescheria b dii boydii 20% 1 20% 20% 2 3 20% 4 20% 5 ` ` ` ` ` The cause of his lesions is Aspergillus fumigatus because BAL fluid yielded no bacteria, but fungal cultures grew a mold. Statistically, the most likely organism is Aspergillus. Other fungi such as Pseudallescheria, Mucor, or others fungi, others, may also occur in this setting. The major manifestation of invasive aspergillosis pulmonary infection is fever in the setting of neutropenia and broad broadspectrum antibiotic therapy. Common symptoms include chest pain, cough, and hemoptysis. Findings on CXR are variable and include nodules,, p patchy y infiltrates,, or cavities. Candida species rarely cause a primary pneumonia, and these species grow with smooth colonies disease in patients with H. capsulatum infection would be slower than that demonstrated in this patient. Nocardia asteroides may cause cavitary pulmonary disease and multiple lesions, but it does not resemble a mold on 66 yo M s/p OHT and Renal Txp c/b rejection now on HD presenting with L eye y swelling g and forehead sore ` ROS Positive for: ◦ ◦ ◦ ◦ ` N/V x 2 episodes Facial numbness Occ headache Occ. Decreased vision in left eye ROS Negative for: ◦ Neck stiffness ◦ Cough ◦ Other skin lesions ` ` ` PMHx ◦ s/p OHTxp 2005 ◦ s/p Renal Txp 2005 c/b rejection, now on HD ◦ Pulmonary nocardia 1 year ago ◦ IDDM ◦ Cataracts ◦ Prostate ostate Ca PSurgHx ◦ Heart/kidney txp ◦ L AV fistula Meds ◦ Lantus ◦ Novolog ◦ ◦ ◦ ◦ ◦ ◦ Myfortic Prograf Prednisone Hydralazine Pravachol Cli d (for Clinda (f last l 10 d days)) ` Social Hx ` Fam Hx ` Allg: Watermelon ◦ Previous tob, occ EtOH ◦ NC ` ` ` ` ` ` VS: T 37.4 BP 146/75 HR 111 RR 18 RA Sat 97% Gen: NAD CV: tachy, no murmurs, no S3, no edema Lungs: CTAB Abd: benign HEENT: ok dentition, no oral lesions, no lymphadenopathy TMs clear lymphadenopathy, clear. Superficial 1x1 1x1.5 5 cm ulcer in mid forehead without drainage. Bilateral injected conjunctiva. L periorbital edema present, no tracking cellulitis ` ` Neuro: Ptosis of L eyelid, L pupil fixed and dilated, only able to see light from L eye, unable to move L eye medially, decreased sensation L face from nose to top of head. Right upper and lower facial f droop. Strength intact, no meningismal signs. Other CNs intact Psych: Fidgety, odd affect ` CN 3 supplies muscles that adduct, depress, and elevate eye and constricts pupil ` Track begins in midbrain, passes through the lateral wall of the cavernous sinus, divides into superior and inferior branches and enters orbital fissure Location of lesion Assoc. signs Causes Nucleus Contralateral ptosis Infarction, hemorrhage, tumor Fascicles Contralateral Infarction, hemiparesis or tremor, hemorrhage, tumor ipsilateral ataxia S b Subarachnoid h d space Isolated l d llesion, headache Ischemia, h aneurysm, tumor, meningitis, trauma Cavernous sinus CN IV IV, VI, VI V1, V1 V2, V2 pain Tumor, ischemia, Tumor ischemia thrombosis, AV fistula Orbital apex Ptosis, visual loss, pain, CN IV, VI, V1, V2 Trauma, tumor, inflammation, infection 144 3.7 90 44 37 12.3 LFTs normal ESR 51 CRP 63 8.4 87 2.0 7.1 1.7 11.0 231 N31L40M26 ANC 530 CT Head: patchy hypoattenuation in cerebral white matter is nonspecific. L maxillary sinus disease CXR-no acute cardiopulmonary findings, no evidence of infection ` ` Refused initial LP, derm biopsy or ENT evaluation, but later consented Started on vancomycin, augmentin, and cipro LP results: Opening pressure: 21 cm Clear fluid Tube 1: WBC 20 (N1, L 86, M13), RBC 93 Tube 4: WBC 16 (N4, E1, L76, M19), RBC 84 Glucose 80 Protein 50 No organisms on gram stain How do you change your abx coverage? Condition Appearance Pressure WBC/type Gluc Protein Normal Clear 9-18 0-5/lymphs 50-75 15-40 Bacterial Cloudy 18-30 10010,000/polys <45 100-1000 TB Cloudy y 18-30 <500/lymphs /y p <45 100-200 Fungal Cloudy 18-30 <300/lymphs <45 40-300 Aseptic Clear 9-18 <300/lymphs 50-100 50-100 ` ` ` ` ` Viral-enterovirus, HIV, HSV, CMV, EBV Rickettsial, syphilis Ri k tt i l spirochetal-lyme, i h t l l hili Medications-NSAIDS, bactrim Neoplasm Rheumatologic-Lupus, sarcoid ` ` ` MRI brain: No abnormal b i N b l mass, lleft ft maxillary ill sinus disease, moderate small vessel ischemic disease CT angio head: no vascular aneurysm or thrombus ENT scope and lavage-no evidence of fungal invasion, no purulence to send for culture ` Normal population: viral>bacterial ◦ Outpt population: 2% are bacterial ` Hospitalized patients: GNR GNR, some GPC ◦ Acute sinusitis in 1-8%, presents as FUO ` Immunocompromised: fungal ◦ mucor, rhizopus, aspergillus ` Diagnosis ◦ CT better than plain films ◦ ENT eval for endoscopy for immunocompromised or nosocomial sinusitis ` Endoscopy: endoscopically guided meatal cultures correlated with cultures performed during maxillary antrostomy in 86% of patients in one study. For fungal sinusitis, look for signs of dusky or pale mucosa (black is late stage), lack of bleeding, decreased sensation to pain. ` ` Study from 2001 looking at incidence of rhinosinusitis after transplantation. transplantation Rate was as high as 11.5%. Study from 2005 looking at mortality in liver transplant pts with chronic rhinosinusitis. ◦ Of 996 pts who received liver transplant, 28 had pretransplant rhinosinusitis. ◦ Of these, 5 were treated medically, 1 had surgery and 22 had no treatment. was ◦ Untreated rhinosinusitis before transplantation p associated with aggravated rhinosinusitis after transplantation but did not contribue to an increase in infection mortality or overall mortality. ` ` ` ` ` Orbital cellulitis: posterior to orbital septum and involves fat and muscles Preseptal cellulitis: anterior to orbital septum Sinusitis most common risk factor in orbital cellulitis Can have swelling and pain in both, but orbital cellulitis will cause chemosis (redness and discharge), limitation in eye movement, ision loss vision PO abx for preseptal cellulitis, IV abx initially for orbital cellulitis ` ` ` ` ` Started on augmentin, cipro, voriconazole (later changed to posaconazole), and acyclovir for presumed orbital cellulitis and possible HSV meningitis Myfortic dose decreased with improvement in neutrophil count F Forehead h d llesion i bi biopsy: negative ti ffor ffungi, i and mycobacteria and bacteria. HSV 1/2 stain faintly positive Final diagnosis TBD Eye exam improving slightly ` ` ` ` ` Post-transplant timeline and infectious risk Causes of CN 3 palsy LP results in meningitis; causes of aseptic meningitis i ii Sinus disease in hospitalized and immunocompromised patients Distinguishing preseptal and orbital cellulitis ` ` ` ` ` ` Gram positive branching rod found f d in i soil il Can cause localized or systemic disease and can relapse despite appropriate therapy Common sites: pulmonary, CNS, cutaneous In pulmonary pulmonary, can mimic TB (weakly acid acid-fast fast and can cavitate) Many y isolates with varying y g susceptibilities, p , bactrim usually first line tx After initial treatment, need oral abx for at least 1 year