Infectious Disease, week #2

Day #6:

A person with a history of E. coli sepsis (blood infection) who now has findings on a brain scan suspicious for abscess, but could also represent tumor. Abscess is more likely, so we will treat with antibiotics for 4 weeks, scan their head again, and see if there has been any response.

A person with an infection of the skull bone behind the ear on the right side, recovered, had a stroke, had a portion of skull removed to accomodate swelling, had the skull replaced and now appears to have developed an infection of the skull bone behind the left ear. Cultured the drainage and tested the susceptibility of the bacteria. Antibiotics recommended, person is recovering.

Day #7:

A person who had their hip replaced, had an infection in that hip, had the replacement removed and a new one inserted, had another infection, had the second replacement removed, now has no hip on that side and is undergoing treatment to clear... infection. They fell and now their knee is swollen too - blood from the fall, blood clot, or spreading infection? Likely from the fall. Continue antibiotics, check inflammatory markers and use ultrasound to rule out clot.

A person on dialysis with endocarditis and known brain abscesses. We helped identify the organism, choose antibiotics and he is undergoing pre-surgical workup. Kinda grumpy.

Day #8:

A Chinese immigrant who is coughing up blood. They have a lung disorder that can cause episodic blood, but there is also concern for tuberculosis (which is endemic in China). More likely to be their underlying condition (based on physical exam) - testing confirms. We set them up with pulmonary follow-up.

Day #9:

A person who arrived in liver failure due to purposeful overdose who continued to have fevers despite antibiotics. Given chest x-ray, more likely drug fever or chemical pneumonitis, but will treat with a short course of antibiotics to rule out aspiration given their altered mental status and vomiting on admission.

Day #10:

A person who has cancer and no immune cells due to chemotherapy now has a fever and trouble breathing. Chest imaging is suspicious for fungus. Lots of antibiotics started until we can clarify the nature of the infection.

A person with multiple antibiotic allergies who has an infection of the inside of the nose. There is always a concern that if inadequately treated, an infection like this will spread backwards to the brain. Broad antibiotics were started until we can grow the bug in culture and narrow them.

Still following:

The endocarditis patient from last week who has vegetations on their pacer leads. They went to surgery and had their pacemaker removed. Labs are still negative, so a 4-6 weeks course of broad spectrum antibiotics before a new device can be placed. Still unclear what their lung findings are: septic emboli vs pneumonia.

The patient with ulcerative colitis who had a blood infection and a clot in their arm... the clot was not surgically removed and they cleared the bacteria from their blood. Was discharged to complete antibiotics at home.

Jargon

Every profession has its own language that tends to make it indecipherable to outsiders. I love the medical language; it's succinct and exquisitely precise. But then, I speak doctor, fluently. In my previous post, I left out lots of details because explaining them in everyday English would have made the post three times as long. But for the curious and the fluent out there, here's the untranslated version:

Day #1:

XX year old (gender) intubated and transfered to the unit secondary to AMS and hypercarbic respiratory failure c/b ARF while being treated for LLE L2 dermatome VZV. Concern for dissemination given RLE vesicles. DFA on RLE (-). Unlikely to represent dissemination, however AMS could be VZV encephalitis. LP not possible due to L2 vesicles and body habitus. Treat empirically for 21 days.

XX year old (gender) with recurrent hospitalizations for HA, n/v. Serial LP with pleocytosis, however HSV/VZV(-). Concern for chronic meningitis. Latest LP wnl. Unlikely to be chronic infectious due to lack of exposure history. Recommend steroids and rheum workup. d/c abx.

Day #2:

XX year old (gender) with newly dx UC refractory to steroids, now on Remicade. Blood cx with GPC in clusters, PICC tip cx w/MSSA. RUE DVT from previous PIV. May d/c vanc, start cefazolin. Blood cx remain (+), RUE U/S with abscess. Now dx of septic thrombophlebitis. I&D on RUE performed, cx remain (+). Recommend thrombectomy.

Day #3:

XX year old (gender) with Waldenstroms and chronic cough x 18mo. BAL in Jan (-) on AFB smear. Now (+) for M. gordonae. Febrile to 39.1 after second chemo infusion. BAL result likely contaminant; triple therapy not benign so recommend no tx unless sx. Cough dry, not consistent with mycobacterium. Fever likely transfusion rxn.

Day #4:

XX year old (gender) hospitalised in Jan for pna/chf, transferred due to vegetations on TV and RV pacer lead. Likely cx (-) endocarditis due to abx use. Continue vanc/zosyn and call EP for lead removal. Call CT surg for valve consult. Possible that pna was actually septic emboli 2/2 large TV veggie.

Infectious Disease, week #1

For my last clinical (in-hospital) month of medical school, I have registered for an infectious diseases consult month. First I will describe what a consult service is, after that we get to the cases I saw during the first week.

Consult Service (n) - a group of physicians called by the treating doctors to answer a specific diagnostic or treatment question because of their subject-specific expertise.

It's not really different from consulting in business. You are posed a specific conundrum, you gather data, make recommendations, but have no power or authority to directly enact your plan. From a logistics standpoint, your workflow is also opposite

to a primary team. You see all your new patients in the morning and round in the afternoon.

Day #1:

A person who had altered mental status and shingles. New lesions were appearing and the primary team was worried the shingles was spreading and had become systemic (usually it's limited to a small part of the body). I decided no (lab testing confirmed), however the change in mental status made the idea of it causing an infection in her head possible. We couldn't confirm because the shingles was covering the part of the body we would use to do a lumbar puncture.

A person was admitted to the hospital three times in two months for headache, nausea and vomiting. All tests looking for infection in the head were negative each time. We were asked to weigh in on the likelihood this was a chronic infection we simply couldn't detect in the lab. While those infections exist, it was more likely this represented a manifestation of her not-fully diagnosed auto-immune disorder. Steroids, not antibiotics, were more likely to be helpful.

Day #2:

A person who was taking immunosuppressive therapy who now had bacteria in the blood. Initially appeared to be a standard line infection (bacteria grow on an IV or central line), however turned in to a septic thrombophlebitis (blood clot with bacteria in it) with an abscess. Despite being surgically drained, the person continued to have bacteria in the blood. More to come.

Day #3:

A person on chemotherapy with a chronic cough who had his sputum cultured one month ago. It just turned positive for mycobacterium gordonae; contaminant or infection to be treated? I decided contaminant and we did not treat.

Day #4:

A person with two recent hospitalizations for pneumonia who now is found to have growths (vegetations) on one of their heart valves and on a lead of their pacemaker. No detectable bacteria in the blood. I decide to cover with antibiotics and have the pacemaker removed. Also talk to the surgeons about whether they need to operate on the valve, given how big the vegetations are. I don't think it was pneumonia, I think the person is sending bits of clot into their lungs.

Day #5:

No new patients, just followed up on existing ones.

?! #492

I was reading a NYT article on hospital compliance with hand-washing when I came across this gem of a comment:

"I'm confused. I thought the only way hand washing would kill bacteria is if the water was boiling hot."

Um, have you heard of SOAP?

PIckled penis

One of my preceptors recently taught me about a physical exam that was commonly done in the late 1980s: androscopy. It's an exam aimed at finding and treating HPV warts on the male genitalia. It is analogous to a (cervical) colposcopy in women.

The male is undressed from the waist down and lies on the exam table with feet in stirrups - similar to a woman undergoing a pelvic exam. The genitals (penis, scrotum, perineum) are wrapped gauze soaked with vinegar for five minutes and then inspected with the naked eye and with the colposcope (a special microscope). Lesions, if present, may be excised, cauterized (acid or freezing), or laser vapourized.

Interestingly, a pub med search has revealed that 51-65% of men who were clinically asymptomatic had lesions on their genitals when viewed under the microscope. However, up to 20% would continue to be seropositive for HPV even with negative follow-up colposcope exams; suggesting that androscopy was not eradicating the disease from the male population. For that reason, and because penile cancer is a very rare complication of male HPV, the exam was largely abandoned as routine practice.

It may come back into favour for the rectum, however, as anal cancer rates increase. Just as we now recommend screening anal pap smears for persons practicing anal intercourse, a vinegar anoscopy of the anus would be a logical follow up exam for a positive result.

For the men out there - yes, they put vinegar on the cervix for a colposcopy.

Who knew?

The reservoir for leprosy in the USA is armadillos.

Scorpion stings can cause acute pancreatitis.

Prion power

I have never been allowed to donate blood in the United States. Having lived in England during the "mad cow years", I'm permanently banned from donating for fear of spreading prion disease. I've never really understood this because in order to get Creutzfeldt-Jacob disease you need to ingest contaminated brain matter (since that's where the prions are located).

A quick aside for those unfamiliar with infectious particles: there are bacteria (alive), viruses (not alive) and prions (also not alive). Bacteria are whole cells, viruses are essentially a little pod of either DNA or RNA and prions are naked proteins. These proteins are misfolded, however, and have a knack for causing normal proteins to also misfold and create aggregates in central nervous system neurons. Since prions live only in neurons, they cannot be transmitted by blood or air or droplets (coughing) like viruses and bacteria.

So basically, the US government is concerned that I am contaminated from prions but haven't shown disease yet and that somehow I will spread this via blood donation. Recent research is now showing - lucky me - that prions may actually be adaptive and develop drug resistance. This is alarming (for the obvious reasons) although currently Creutzfeldt-Jacob is a death sentence (within months) and to my knowledge we didn't think we had effective drugs.

There are several human prion diseases (no, CJD is not the only one) and all are fatal. Worse, standard sterilization procedures do not eliminate prions so it's a good thing they aren't easily transmitted. Adding drug resistance to their virulence is almost superfluous.

Are you smarter than a first year?

A 33yo woman comes to your clinic with bilateral cervical lymph node swelling and fatigue.

Examination: Afebrile. Several bilateral 1-2cm cervial lymph nodes that were soft, non-tender and freely movable. No other lymphadenopathy. Her chest was clear, heart sounds normal, but she had mild tenderness at the right costal margin on deep inspiration.

Lab studies: Hct 37% WBC 5,200/uL, ALT 75 units, AST 70 units, AlkPhos 140 units. UA nml.

What is the (infectious) differential? What testing do you want?

Watch where you're mowing

We recently had a lecture on bioterrorism within our infectious diseases sequence. One of the potential diseases that could be used as a weapon is Tularemia, a not-too-deadily infection caused by Francisella tularensis. It has a low infective dose, does not spread human-human, but you would feel like crap for a while. The Soviets were accused of using it and the US even researched its use as a weapon in the '50s.

Anyway, what I think is much more interesting is the outbreak that occurred in Martha's Vineyard in 2000. The CDC documented cases of people getting sick from lawn-mowing. Apparently, they mowed over nests of infected rabbits, aerosolizing the infected rabbits and inhaling the bug. That's right. The people of Martha's vineyard got sick from aerosolized bunnies.

It was then published in the Journal of Clinical Microbiology.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1233993