Hospital of the University of Pennsylvania The Importance of Coughing Patient History 76 year old female was admitted to the pulmonary unit in the hospital due to shortness of breath recurrent cough fatigue and weight loss ID: 913127
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Slide1
Stephanie Mitchell, Ph.D.Hospital of the University of Pennsylvania
The Importance of Coughing
Slide2Patient History76 year old female was admitted to the pulmonary unit in the hospital due to shortness of breath, recurrent cough, fatigue and weight loss.
She has a past medical history of persistent cough, excess phlegm or sputum (bronchiectasis), a condition where the lung airways become damaged and unable to efficiently clear mucus.
A chest x-ray and CT scan were performed.
In addition, a bronchoalveolar lavage (BAL) was obtained for bacterial culturesBAL is a medical procedure where fluid is injected deep into the lungs and is retrieved for laboratory testing
BAL sent to laboratory
Photo Credit:
Stephanie Mitchell, Ph.D
)
Slide3Infectious Causes of BronchiectasisSevere pneumonia (bacterial, viral)
Bacterial:
S.
pneumoniae, H. influenza, Legionella pneumophila
Viral: Adenovirus, Influenza AWhooping cough (caused by the bacteria,
Bordetella pertussis)
Tuberculosis (caused by the bacteria,
Mycobacterium tuberculosis
)
Fungal infections- molds (Aspergillus species, Histoplasmosis)
Adenovirus
Gram-negative rod, Mycobacterium tuberculosis Aspergillus fumigatus
J Virol. 2004 Nov; 78(22): 12320–12332.
like
B. pertussis
Slide4Laboratory Processing of BAL for Bacterial Pathogens
Chocolate
Blood
MacConkey
Middlebrook
BAL is sent to the microbiology laboratory.
BAL is plated onto selective media for bacterial and fungal pathogens inside a biosafety hood.
7H11
Fastidious
bacteria
Most bacteria
Gram-negative
bacteria
Mycobacteria
H.
influenzae
S.
pneumoniae
E. coli
M. tuberculosis
Example
Organism
What grows?
Photo Credit:
Stephanie Mitchell,
Ph.D
Slide5Laboratory ResultsAll cultures were negative from the Chocolate, Blood and
MacConkey
plates.
However, growth was observed on the Middlebrook 7H11 plates after approximately 2 weeks. Colonies were smooth, white to buff and creamyUpon microscopic observation, the colonies had a “fried egg” appearance
Smooth, creamy, white
“Fried egg”
ASM MicrobeLibrary.org
Photo Credit:
Stephanie Mitchell,
Ph.D
Slide6Identification and DiagnosisMycobacterium avium
intracellulare
complex (MAI) - “Gram-positive” rod, typically having a beaded appearance, due to the mycolic acids in the cell wall
- Positive when stained with Kinyoun
, an acid-fast bacillus specific stain,
which specifically binds the mycolic acids
- MAI is actually a group of non-tuberculosis mycobacterium,
including
M. avium
and M. intracellulare
- can have a variety of colony morphologies: white/smooth/ creamy, white/dry/raised or yellow/creamy
Beaded Gram-positive rod on Gram Stain
Kinyoun Stain
(pink rods)
Photo Credit:
Stephanie Mitchell, Ph.D
Slide7MAIMAI are commonly found in the environment, such as in soil and water.
Infection with MAI typically present as lung, skin or soft tissue infections.
Patients who have predisposing medical diseases which destroy, damage or obstruct the pulmonary airways, such as bronchiectasis, are at a higher risk of acquiring MAI infection.
Interestingly, MAI infection has been seen in elderly women who appear to have no predisposing conditions. This is referred to as Lady Windermere’s Syndrome.
Slide8Lady Windermere’s SyndromeNamed after a main character in the Oscar Wilde play, “Lady Windermere’s Fan”, who had the habit of voluntarily suppressing her cough.
This condition is thought to occur in “well-mannered” elderly women who are tall, lean, tend to have scoliosis and suppress their cough out of politeness.
This cough suppression is thought to allow secretions to collect in the airways, providing a happy environment for bacteria, such as MAI, to grow.
“To account for the distinctive features of this syndrome, we offer the hypothesis that habitual voluntary suppression of cough may have led to the development of nonspecific inflammatory processes in these poorly draining lung regions, upon which [MAI infection occurred]. We offer the term, Lady Windermere's syndrome, to describe this pattern among elderly women and to suggest that their fastidiousness may be its root cause.”
Reich, J and RE Johnson; Chest. 1992 Jun;101(6):1605-9.
Slide9Patient OutcomeThe most likely cause of this patient’s MAI infection was her history of bronchiectasis, although it is unclear if she had a history of voluntarily suppressing her cough.
Patient was administered three antibiotics daily for 3 months
Azithromycin, ethambutol, and rifampin
Some improvement was seen, so she was transitioned to taking these antibiotics three times per week for continuous, prolonged therapy, which is required for adequate treatment of this infection.
Slide10Stephanie Mitchell, Ph.D.Dr. Mitchell is a Clinical Microbiology Fellow at the Hospital of the University of Pennsylvania in the Department of Pathology and Laboratory Medicine. Her areas of research focus are in the development and implementation of novel methodologies, particularly molecular technologies, for the rapid detection of infectious pathogens.
Photo Credit:
Stephanie Mitchell,
Ph.D