Friday August 21 2020 Joseph P Myers MD Case No 1 55 yo man with DJD and prior left TKA who presents with 34 days history of severe left knee pain and slight redness No injuries ID: 1038087
Download Presentation The PPT/PDF document "Infectious Disease Case Conference" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Infectious Disease Case ConferenceFriday, August 21, 2020Joseph P. Myers, M.D.
2. Case No. 155 y.o. man with DJD and prior left TKA who presents with 3-4 days history of severe left knee pain and slight redness.No injuriesNo new tattoos No piercingsNo dental workNo IDU (Injection Drug Use)Minimal alcohol (2 beers/week)Past Medical History:2019 – Left TKA (January)2006 – Mitral Valve Repair (CCF)2019 – Bovine AVR (bicuspid AV)+ smoking (1 ppd x 30 yrs)Exam: Afebrile and all else negative except for left knee with effusion and tenderness to palpation everywhere around knee and minimal erythema (pinkish)
3. Case No. 16/12/2020 – Aspirate of Knee in Office:WBC = 10,771 with 95% PMNNegative crystal examination Negative Gram stainEventual negative culture6/15/20 – Re-Aspiration of Knee in Office:WBC = 22,237 with 93% PMNNegative crystal examinationNegative Gram stainEventual negative culture6/15/20 – Admitted emergently and taken to OR early next morning (6/16/20)
4. Case No. 16/16/20 – Operative drainage and polyethylene exchange ~ 30 cc of bloody material in joint but very stable implants proximally and distallyCulture sent from OR eventually remained negative Blood cultures from 6/15/20: (20 minutes apart by chart) Late on 6/16/Both positive for a Gram variable rodCardiobacterium hominis in BOTH setsTEE normally seated and functioning bioprosthetic aortic valve (27 mm) and NO VEGETATIONS on any structureRx: 6 wks of IV Ceftriaxone
5.
6. Cardiobacterium hominis Septic Arthritis: 2 cases found in Google Scholar™ Search82 yo ♀ with a remote bioprosthetic MV who presented with: native left knee pain with 65,000 WBC on joint aspirationnegative joint culturepositive blood cultures for C. hominisTEE perforation of bioprosthetic mitral valve and mitral regurgitationRx: CTX x 6 weeks and lifetime suppressive therapy with cefixime [Diagn Microbiol Infect Dis 2002; 42:79-81]64 yo ♂ with remote bioprosthetic AV (20 yrs ago) who presented with:3 month history neck painMRI C4-C5 discitispositive blood cultures for C. hominis (2 of 3 sets)TEE normal bioprosthetic AVRx: amoxicillin IV x 6 weeks (Europe)[Med et Malad Infect 2014; 44:128-133]
7.
8. Case No. 262 yo ♂ presented to his Orthopedic Surgeon with 24h hx of bilateral knee pain, R >> L. PMH + for partial right knee medial menisectomy 9 months previously without complications+ for known Aortic Stenosis due to bicuspid aortic valve (not critical on echo)Exam with R knee effusion with tenderness to palpation; no heart murmur or peripheral signs of endocarditisAdmitted for Workup and I&D of knee
9. Case No. 2Laboratory Data:WBC = 15,700; CRP = 87.1; ESR = 14Knee aspirated: see next slideBlood cultures obtainedJoint fluid 14,225 WBC with 95% PMNJoint fluid Positive String Test (see slide); Negative Crystals; Gram-stain NOSScheduled for OR the following morning
10. Right Knee Aspirate – cloudy fluid
11. String Test of Synovial Fluid: It should do this.
12. Synovial Fluid “String Test”Normal joint fluid b. Inflamed joint fluid (very viscous) (reduction of viscosity)
13. Microbiologic String Test
14. Case No. 2Joint fluid aspirate and OR cultures eventually negative2 of 2 sets of blood cultures positive for a Gram-variable bacillus (rod)Identified as Capnocytophaga speciesTEE negative for vegetations on AV or elsewhere4 weeks of OPAT
15. Case No. 2Capnocytophaga species other than “canimorsus” cause disease2013 review showed 18 cases of bone/joint infection caused by Capnocytophaga species:Mouth organism in humans Most common predisposition seemed to be alcoholism2020 review in immunocompetent humans59% of infections gave history of dog bites or dog contact (lick, petting, etc.)75% were males5/128 were spondylitis or septic arthritisBottom line: You don’t have to be asplenic to get severe infection with Capnocytophaga species
16. Characteristics of Synovial FluidAdapted from Harris ED, Budd RC, Genovese MC, et al, editors: Kelley's textbook of rheumatology , ed 7, Philadelphia, 2005, Elsevier.
17. Case No. 2References:Piau C, Arvieux C Mallet M et al. Int J Antimicrob Ag 2013; 41:509-515Mader N, Luhrs F, Langenbeck M et al. Infect Dis 2020; 52(2):65-74Parenti DM, Snydman DR. J Infect Dis 1985; 151(1):140-147Lion C, Escande F, Burdin. Eur J Epidem 1996; 12:521-533
18.
19. Case No. 379 yo man with end-stage COPD on oxygen at home presented with 3 days of worsening SOBPMH:DVT on CoumadinCOPD on Oxygen at homeAbdominal AAA repair 2013Carotid artery endarterectomy ExaminationAfebrileWBC = 7800Bloody sputum on tissue Bilateral rhonchi and rales throughout lung fieldsSputum Gram stain:PMN’sMany Gram-negative rods
20. Chest X-ray (AP) View:
21. CT Scan of Lungs (following day)Upper LungLower Lung
22. Sputum Culture Results:
23.
24.
25. Case No. 4History of Present Illness:64 yo woman to ED from group home for hip pain and fallsReports mechanical fall onto her hip in bathroom at group homePain is “achy” left hip and buttocksPMH with CCF stay with severe anemia and MSSA bacteremia 2 months previouslyDenies fever, chills, chest pain, abdominal pain, n, v, dNo sexual contacts, travel, animal contact, injection drug useLives in group home in MogadorePhysical Exam:Positive for tachycardia (112)Positive for tenderness of lateral left hip and left buttocksLaboratory:WBC = 30.2K with 95% neutrophilsBun/Creat are normal
26. Chest X-Ray
27. Radiographic Findings: Hip and Pelvis
28. Radiographic Findings:
29. Procedure On 3rd hospital day, Interventional Radiology placed a 10Fr pigtail catheter in retroperitoneal spacePurulent material was obtainedGram stained smear of material Many PMNs and No Organsisms SeenCulture was significant for a single organism: ???
30. Pasteurella multocida
31.
32.
33. Case No. 5I received a call on my cell phone from Dr. Brad Martin who asked me if I knew what wine decanting was. After I started to tell him, he quickly stopped me and said “human wine decanting”? He then told me about the following patient who he was seeing at the then Medina General Hospital (now Cleveland Clinic Medina Hospital).23 y.o. man (MSM) who was being seen in the ICU at MGH for bacteremic E coli pyelonephritis and septic shock.Detailed history by the Critical Care physician revealed that the patient performed “human wine decanting.”
34. Case No. 5This was described by the patient as the process by which, at a party for MSM, he would:go to a back roomself-catheterize his own urinary bladderdrain out all of the urinefill his bladder with wineremove the catheterthen return to the partyfill guests’ empty wine glasses from his penis with the wine sequestered in his bladderRepeat this process over and over throughout the night for extremely LARGE cash tipsA few days after this party, he was admitted with the E coli bacteremic pyelonephritis.So . . . Take a detailed and accurate history, always.