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Infectious Diseases Case Presentation 18 September 2002 Dr Zakeya Bukhary, Fellow, Infectious Diseases Dr Hail Al-Abdely, Consultant, Infectious Diseases.

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Presentation on theme: "Infectious Diseases Case Presentation 18 September 2002 Dr Zakeya Bukhary, Fellow, Infectious Diseases Dr Hail Al-Abdely, Consultant, Infectious Diseases."— Presentation transcript:

1 Infectious Diseases Case Presentation 18 September 2002 Dr Zakeya Bukhary, Fellow, Infectious Diseases Dr Hail Al-Abdely, Consultant, Infectious Diseases

2 First Case

3 A 19-year-old girl from the Eastern Province, who was completely healthy until May 2001 when started to c/o: –RIF pain and fever associated with constipation and weight loss –The pain was colicky and slowly progressive, moderately severe, non-radiating and not relieved by analgesics History

4 Fever was on and off with no diurnal variation and no night sweating or chills No nausea or vomiting No skin rash or joint pains Systemic review: unremarkable

5 History No Hx of TB or contact with TB patients No previous abdominal surgeries No drug Hx Lives in Dhahran

6 History At the local hospital (DHC), she was found to have ileocecal mass (5/2001) Colonoscopy showed ulcers of the Rt hemicolon and Bx was consistent with acute inflammation. Started empirically on ciprofloxacin + flagyl but without response

7 History Colonic biopsy ? Crohn’s. Started on oral steroids. Has temporary improvement and gained wt. Oct 2001, f/u showed an increase in the mass size clinically and confirmed by CT abdomen.

8 27 Oct 2001, laparatomy (at DHC) showed unresectable mass with intense inflammation involving the Rt. hemicolon Bx showed necrotizing granuloma with broad fungal hyphae. Culture was negative. Treated with ABLC and continued low dose steroid On 11 Nov 2002  referred to KFSH&RC for 2 nd opinion

9 Pt was clinically unwell but not toxic P/E: –T 38.8ºC PR 110/min BP 120/70 RR 20 Wt 49 kgHt 158 cm –Not in distress or jaundiced or cyanosed –Was pale –No LN enlargement –Chest/heart exam  unremarkable

10 Abd Exam Soft, with large, irregular, ill-defined mass extending from the RUQ to RIF and umbilical region; mildly tender and hard. Non-palpable liver or spleen No ascitis B.S. were present

11 Investigation WBC 14.0PMN 80%No bands Lymph 20.0% Eosinophils 1.3% Hb 92MCV 78.8MCH 23.4 Plt 305 ESR 15 Urea 4.9Cr 96 Na 135K+ 3.3 ALT 50ALP 185Bil 4Alb30 PPD skin test –veCXR  N

12 CT abdomen 12 November 2001

13 Differential Diagnosis

14 D. Dx Deep GI mycosis TB Actinomycosis Crohn’s Lymphoma

15 Course Review of histopath slides from DHC – showed moderate chronic colitis, no cryptitis with positive granuloma and fungal hyphae With prominent eosinophilic infiltrate

16 Pathology

17 Pt was spiking high grade Temp 40.0º C Started on Ambisome + Tazocin for possibility of perforation and superadded bacterial infection Pain control, NPO, TPN Surgical opinion confirmed that the mass was non-operable

18 14 Nov 2001 –FNA and True cut Bx to get tissue for microbiological Dx for c/s 17 Nov 2001 –Steroids - methylprednisone 1 mg/kg/d started Course

19 20 Nov 2001 –Dx of GI mycosis confirmed by culture positive Basidiobolus ranarum Basidiobolus ranarum –IV itraconazole was added –Ambisome changed to Ampho B to minimize drug induced hepatitis Course

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21 f/u CT scan Abd (20/11/2001): –showed very impressive response to steroids + antifungal (Ampho B + short course of itraconazole) with regression of the inflammation and dilatation of the Rt. hemicolon which has emptied its content and has partly collapsed. Course

22 Clinically, pt was improving with no fever and no abd pain Started on oral feed 11 Dec 2001  discharged on ketoconazole 600 mg p.o. OD, and steroids on tapering dose In vitro - susceptibility test showed better inhibitory effect of ketoconazole which was started orally

23

24 CT abdomen 8/4/2002 2/9/2002

25 Discussion

26 Basidiobolomycosis Introduction –Classification –Epidemiology –Pathogenesis & Clinical Manifestation –Diagnosis Revision of invasive G.I.B. Rx

27 Zygomycetes Mucorales (Mucormycosis) Entomophthorales (Entomophthoramycosis) Conidiobolus Basidiobolus

28 Basidiobolus species are normal inhabitants of soil throughout the world They have been also isolated from the gut of amphibians and reptiles

29 These fungi cause a chronic inflammatory granulomatous disease (Entomophthoramycosis) reported in healthy inhabitants of tropical and subtropical regions (Africa, Southeast Asia, South America)

30 The mode of transmission of infection to humans remains unknown Inhalation, ingestion, direct inoculation and acquisition secondary to I.M. injection and insect bites have been postulated

31 The disease generally manifested as subcutaneous lesions Visceral involvement and deep invasive infection either primary or secondary to subcutaneous disease, is rare and affects mainly immunocompromised hosts and can be fatal. Nazir et al, Ann Trop Paediatrics 1997;17:161

32 Diagnosis depends on microscopic documentation of tissue invasion and presence of typical hyphae of B. ranarum In contrast with mucormycosis no vascular invasion or tissue infarction or necrosis

33 Lesions produced by B. ranarum are characterized by an acute and/or chronic inflammation in association with broad, irregular, erratically septate hyphae, surrounded by a distinctive eosinophilic sheath

34 Culture of the fungus is the only way to identify correctly the species.

35 Immunodiffusion test has been used in several patients and claims 100% specificity specificity and may have a prognostic value. Kaufman et al, J Clin Microb 1990;28:9:1887

36 The first case described of the infection was in a pt from Indonesia by Joe et al in 1956 Approximately 300 cases (90% cutaneous) have been reported in the World Literature, mostly from Tropical Asia, Africa and South America A majority of cases have been in children under 10 years of age

37 In 1994, a healthy 8-year-old boy reported as a case of invasive retroperitoneal infection due to B. ranarum based on histopath who did not respond to high dose Ampho B but the mass resolved completely in 6/52 in response to K1 saturated solution orally Ann Trop Paediatrics 1997;17:161

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39 The 5 th case was a 49-year-old lady who presented with GIB mimicking Crohn’s disease with no response to mesalamine and steroids Diagnosed histopathologically Responded clinically to oral itraconazole Smilack et al, Gastroenterology 1997;119:250

40 In 1996 B. ranarum involving the rectum was reported from Kuwait, in a 30-year-old man presented with PR-bleed and polypoid mass Dx confirmed by culture Responded to antifungals (Ampho B + ketoconazole) Khan et al CID 1998;26:521

41 Am J Clin Pathol 1999;112:610

42 Lyon et al conducted a case-control study to generate hypotheses about potential risk factors in the reported few cases of GIB in AZ, between 1994 to 1999. According to their results they considered: –Ranitidine –Smoking –Digging earth as of one’s job

43 The length of residence in AZ to be associated significantly with GIB

44 Some factors did not reach statistical significance, including: –Steroids –Use of over-the-counter drugs –Animal contact –Eating unwashed vegetables One of the cases had a Hx of PICA daily for years before the Dx of GIB CID 2001;32:1448

45 Currently, there is no means of preventing this infection or even identifying those at risk for development of this disease Early detection of the disease seems to be the best hope of reducing the serious morbidity and mortality associated with long-standing disease

46 Based on the limited information, it appears that optional treatment of GIB combines surgical and medical methods Pts should undergo resection and debridement of all affected tissues; followed prolonged antifungal Rx CID 2001;32;1448

47 Clinical failures have been described in association with Ampho B Mycopathologia 1986;95:101 Am Trop Paed 1997;17:161 CID 1999;28:1244

48 Ketoconazole has been shown to be effective in both in vitro and in vivo studies AAC 1984;25:413

49 The best choice of antifungal agent is not clear, but itraconazole seems to have the best results Mycopathologia 1986;95:101 Am J Kidney Dis 1997;29:620 Am J Clin Pathol 1999;112:610 CID 1998;27:663 CID 1999;28:1244 CID 2001;32:1448

50 In general Basidiobolus spp displays low MICs of itraconazole 0.25  g/ml, ketoconazole 0.5  g/ml MICs of 0.1 – 1.0  g/ml found to be inhibitory JAC 1999;44:557 Rev Inf Dis 1987;9(Suppl 1):S15

51 End of First Case

52 Second Case

53 History 52Y/O American white female. –Told to have pulmonary nodules on CXR 10/9/01and subsequently on CT chest 21/9/01 in the US. –Totally asymptomatic. –No Intervention –Moved to Saudi Arabia with her husband (work for a Saudi bank) 11/2001

54 History Lived in: –Arkansas- childhood –California (1978-1995) –Scotland (1995-1998) –Poland (1998-2001)

55 History PMH: –Hypertension –Hyperlipidemia –S/P Hysterectomy & salpingo-opherectomy 1996 for large ovarian cyst.

56 Meds Quinapril 20mg QD Indapamide 1.5mg QD Simvastatin 40mg QD

57 History Seen in a private hospital in Riyadh –Clinical evaluation was unremarkable –PPD: negative –CT chest 17/1/02

58 17/1/2002

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60

61

62 Differential Diagnosis What will you do next?

63 Intervention Open-Lung biopsy 6/2/02 –Report “Caseating granuloma”. Sent for TB culture. Start 4 drugs anti TB (4 March 2002) High fever and diffuse skin rash (12 March 2002) Stop anti TB Better

64 Course 20 March 2002 –Further stains showed fungus –Started on fluconazole 400mg QD –Serologies sent for: Cryptococcal serum antigen, negative Coccidioides ab, negative Balstomyces ab, negative Histoplasma ab, could not be determined

65 Pathology

66 11/6/2002

67

68 D/C fluconazole and start itraconazole 400 mg QD Patient did not take it.

69 28/8/2002

70

71 Histoplasmosis Introduction –Pathogenesis –C. Fx –Dx –Rx

72 Histoplasmosis Histoplasma capsulatum was first described in 1905. It is a thermally dimorphic fungus, found in soil enriched by droppings of some birds and bats It can remain viable for years in the soil

73 Histoplasma capsulatum (filamentous phase)

74

75 Pathogenesis Hyphal elements of H. capsulatum, are inhaled into the lungs, where they reach the alveolar spaces and transform into yeasts forms Following pulmonary infection, organisms spread through lymphatics to the regional lymph nodes and hematogenously to other organs

76 In immunocompetent patients resemble tuberculosis, with caseating granulomas and necrosis Granulomas heal with fibrosis and can calcify Reactive arthritis, pericarditis and erythema nodosum can present

77 Clinical The degree of exposure and immune status of the host determines the severity of the disease More than 95% of persons infected are asymptomatic Histoplasmoma: a coin-like lesion in the lungs

78 In symptomatic cases: –Primary pulmonary histoplasmosis Mild self-limiting disease Rarely severe with ARDS –Chronic pulmonary histoplasmosis Occurs in a setting of underlying disease, e.g. COPD Subacute recurrent pneumonia Associated with apical fibrosis and cavitation

79 In symptomatic cases (cont.): –Disseminated disease Most serious form, usually in immunodeficient patients with prolonged fever, hepatosplenomegaly, meningoencephalitis, sepsis, DIC.

80 Dx Tissue Bx stains are highly sensitive Immunodiffusion (more specific less sensitive ) and complement fixation (more sensitive less specific) antibody tests assist in Dx

81 Antigen detection by radioimmunoassays in serum and urine is highly sensitive and specific in disseminated disease In patients with AIDS who have disseminated histoplasmosis, elevated antigen levels are present in the urine in 95% of cases, and in the serum in 80%.

82 Therapy In immunocompetent patients: itraconazole is the drug of choice and it is highly effective Ampho B has a response rate of more than 75% in meningeal and life-threatening histoplasmosis Dismukes et al, Am J Med 1992;93:489

83


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