relich indiana cases - scacm

10/15/2019

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Infectious Diseases in the Hoosier StateClinical Microbiology Case Studies from Indiana

Ryan F. Relich, PhD, D(ABMM), MLS(ASCP)SMAssistant Professor, Pathology and Laboratory Medicine

Indiana University School of Medicine

Section Director, Clinical Microbiology and Serology (Eskenazi Health)Section Director, Clinical Virology and Serology (IU Health)

Medical Director, Special Pathogens Unit Laboratory (IU Health)Associate Medical Director, Division of Clinical Microbiology (IU Health)Associate Medical Director, Division of Molecular Pathology (IU Health)

Indianapolis, IN USA

Disclosures and disclaimer

• Research funding/support

• Abbott, BD Diagnostics, Beckman Coulter, BioFire

Diagnostics / bioMerieux, Cepheid, Luminex

Corporation, Roche, Sekisui, STAT-Diagnostica

Objectives

• Interpret morphological clues relevant to the identification

of parasitic and nonparasitic arthropods, rarely encountered microorganisms, and viruses associated with

cytopathic changes in diseased tissues;

• Discuss clinical features, including case presentations and

disease signs/symptoms, associated with the presented cases; and

• Discuss treatments and/or preventive measures for the

presented disease cases.

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Case 1You’re getting under my skin!

Case 1

• An elderly female from southcentral Indiana presented to an IU Health ED in acute respiratory distress

• History of hypertension, COPD, mental status change, and a potpourri of other issues

• No recent travel outside of Indiana, she has a pet dog that she walks 5 – 10 times per week, and she hasn’t had contact with farm animals or wildlife

Case 1

• She was admitted to the general inpatient ward for overnight observation

• On the day following admission, a care provider noticed a small “pimple” on the patient’s chest…

…and it contained something that was moving!!!

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Case 1

• The following object was removed with forceps and was submitted to the IU Health Division of Clinical Microbiology for identification

Dimensions and General Comments:

Size: 2.0 X 0.7 mmOther: black spines present

Case 1

Anterior End Posterior End

MandiblesPeritreme

Case 1

• What can we say about this?

• This “object” is an early-instar fly larva

• With the help of a colleague at ARUP Laboratories, we

identified it as a Cuterebra sp., 2nd-instar larva

• Cuterebra spp. are uncommon causes of myiasis in

humans

• This type of presentation is called furuncular myiasis

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Case 1

• Furuncular myiasis

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Dermatology Atlas

Case 1

• Cuterebra spp.

• Rodent or rabbit botflies

• Dogs, cats, and other

companion or livestock

animals can also be

hosts

• Several species exist in North America

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BugGuide.net

Case 1

• Identification of larvae associated with myiasis

• Morphology and anatomy

• Mouthparts

• Shape, number, etc. of spiracles (slits) on anterior and posterior ends

• Cuticular spines

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Case 1

• Follow up

• No other larvae were found

• The patient was discharged after 5 days of inpatient care

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Case 1

• References

• Centers for Disease Control and Prevention DPDxWebsite - https://www.cdc.gov/dpdx/index.html

• Mathison BA, Pritt BS. 2014. Laboratory identification of

arthropod ectoparasites. Clin Microbiol Rev 27:48-67

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Case 2A bad headache and a stiff neck

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Case 2

• A 21-year-old male university student presented to an IU Health ED complaining of a stiff neck, low-grade fever, slight photosensitivity, and general malaise

• An LP was performed

• Physical description: clear, colorless

• Protein: 56 mg / dL (elevated)

• Glucose: 49 mg / dL (normal)

• Cellularity: 283 nucleated cells / µµµµL (80% lymphocytes)

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Case 2

• Additional tests

• CSF culture and Gram stain

• Viral culture

• Cryptococcal antigen lateral-flow test

• HSV-1/2 PCR

• Enterovirus PCR

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Case 2


• CSF culture and Gram stain

• Gram stain: no organisms seen

• Bacterial culture: no growth

• Cryptococcal antigen

• Not detected

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Case 2


• HSV and enterovirus PCR

• Not detected

• Viral culture

• POSITIVE!

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Case 2

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Primary rhesus macaque kidney cells(Prior to inoculation)

Primary rhesus macaque kidney cells(3 days post-inoculation)

Case 2

• Cytopathic effect (CPE) was evident after 72 h of incubation

• Syncytium formation

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CPE – Syncytia in RhMK or LLC-MK2

Perform hemadsorption (HAD) assay (Guinea pig RBCs)

Stain for HPIV-1, 2, 3, and 4 and mumps virus

Stain for RSV and measles virus

( - ) ( + )

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Case 2

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Hemadsorption assay(Negative control)

Hemadsorption assay(Patient’s culture)

Case 2

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Culture immunofluorescence

Mumps VirusHuman Parainfluenza Viruses

HPIV-1 HPIV-2

HPIV-3 HPIV-4

Case 2

• Mumps virus (MuV)

• Mumps orthorubulavirus, a paramyxovirus

• (-)ssRNA genome

• Enveloped particles

• 12 genotypes (A – N)

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CDC Public Health Image Library

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Case 2


• Etiologic agent of mumps

• Transmitted through contact with upper respiratory tract secretions (saliva, respiratory droplets)

• Fomites (e.g., sharing a water bottle, placing contaminated hands in mouth)

• Kissing and other direct secretion exposure

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Case 2


• Signs and symptoms begin 12 – 25 days after infection

• Fever

• Muscle aches

• Malaise

• Loss of appetite

• Parotitis

• CNS infection is rare

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CDC Public Health Image Library

Case 2

• Follow up

• Patient was observed on the general inpatient floor for 2 days

• His symptoms spontaneously resolved and he was well

enough to leave the hospital

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Case 3This yeast is a beast!

Case 3

• A male in his early 30s who sustained 3rd-degree burns on part of his body was transferred from South Africa to the U.S.

• He was a bush pilot who was in a plane crash; crawled from the wreckage and was later found alive

• He was transported to South Africa

• He later ended up at the Eskenazi Health Burn Center for care

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Case 3

• Upon hospitalization, surveillance cultures for drug-resistant pathogens were obtained from various anatomical sites

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Case 3

• One isolate obtained from a surveillance swab of the patient’s burn wound…

• Growth of yeast after 48 h of

incubation at 35℃

• VITEK 2 YST ID card identified

the isolate as Candida haemulonii

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Case 3

• This identification prompted us to pursue additional testing

• MALDI-TOF MS, submission to ISDH Laboratories

• Bruker MALDI Biotyper RUO � Candida auris

• ISDH (and CDC) Laboratories � Candida auris

• AST

• Sensititre™ YeastOne ™ YO9 panel

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Case 3

• AST results

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Drug MIC (µµµµg ml-1) CDC Breakpoint (µµµµg ml-1)

Anidulafungin 0.25 ≥4

Amphotericin B 1 ≥2

Micafungin 0.12 ≥4

Caspofungin 0.25 ≥2

5-Flucytosine 0.25 N/A

Posaconazole 0.25 N/A

Voriconazole 4 N/A

Itraconazole 0.5 N/A

Fluconazole ≥256 ≥32

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Case 3

• Candida auris

• “auris” = L. gen. f. n., isolated from the ear of a human patient

• Species description in 2009; isolated from the ear discharge of a Japanese patient*

• Now that we know it’s a thing, it’s been detected all over

the world…including Indianapolis

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*Satoh et al. 2009. Microbiol Immunol.

Case 3

• Turns out, we were expecting this

• The patient was diagnosed with C. auris while in South Africa

• Also isolated were…

• an OXA-48-like-expressing Klebsiella pneumoniae

• a pan-drug-resistant Pseudomonas aeruginosa

• a multi-drug-resistant Acinetobacter sp.

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Case 3

• Phenotypic misidentification of C. auris

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ID Method Organism misidentified as

VITEK 2 YST Candida haemuloniiCandida duobushaemulonii

API 20C Candida sakeRhodotorula glutinis*

BD Phoenix Candida haemuloniiCandida catenulate

MicroScan Candida famataCandida guilliermondii**

Candida lusitaniae**Candida parapsilosis**

*Characteristic color not present**No hyphae/pseudohyphae on cornmeal agar

Adapted from: https://www.in.gov/isdh/27706.htm

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Case 3

• Follow up

• The patient was discharged from the burn center without subsequent spread of C. auris to other patients

• The patient recovered and returned home

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Case 4An unwelcome passenger

Case 4

• A 36-year-old Burmese male was transferred from an OSH to an IU Health hospital with fever, a rash that blanched when pressed, petechiae, acute liver failure, and pulmonary failure

• Serum biochemical results at the time of admission were remarkably out of whack

• ALT – 3,963 U/L (nl, 0 - 35 U/L)

• AST - >35,000 U/L (nl, 7 – 52 U/L)

• LDH – 14,020 U/L (nl, 140 - 271 U/L)

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Case 4

• He was transferred to the MICU and was intubated secondary to respiratory collapse

• He received 3 units of platelets and 1 unit of cryoprecipiatate within 24 h of admission

• A review of the patient’s history revealed the following

• Alcoholic cirrhosis with ascites

• Chronic hepatitis B

• Recent travel to Burma and Thailand

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Case 4

• Blood, BAL fluid, urine, pleural fluid, and stool were submitted to the IU Health Division of Clinical Microbiology for testing

• No pathogens were detected in any of the specimens

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Case 4

• Over the course of a 22-day MICU stay

• He developed recurrent abdominal compartment syndrome

• Developed numerous bleeds that required surgical

intervention to remove hematomas and attempt to stop bleeding

• Blood oozed continuously and pooled/clotted without

identifiable sources

• He developed hemothorax secondary to bleeding in the

chest

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Case 4

• Over the course of a 22-day MICU stay

• Serological testing for arthropod-borne viruses detected dengue virus infection

• This patient was diagnosed with dengue hemorrhagic fever

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Case 4

• Dengue fever and dengue hemorrhagic fever (DHF)

• Caused by dengue virus, a mosquito-borne pathogen

• Dengue is probably the most widespread arbovirus on the

planet

• ~400 million infections and ~96 million illnesses per year

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Case 4

CDC

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Case 4

• Dengue fever and dengue hemorrhagic fever (DHF)

• Caused by dengue virus, a mosquito-borne pathogen

• Dengue is probably the most widespread arbovirus on the

planet

• ~400 million infections and ~96 million illnesses per year

• Primary infections leading to illness often cause “breakbone fever,” that is typified by fever, rash, and

excruciating joint and muscle pain, vomiting, nausea, and

pain behind the eyes

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Case 4

• Dengue fever and dengue hemorrhagic fever

• Dengue virus

• Genus, Flavivirus; family, Flaviviridae

• Non-segmented (+)ssRNA

genome

• Enveloped particles

• 5 serotypes

• Dengue 1 – 5

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Protein Data Bank Japan

Case 4


• DHF

• Can occur upon secondary, tertiary, or quaternary infection with a different dengue virus serotype

• Patients present with typical dengue fever symptoms, but

progress to develop bleeding

• Nose bleeds

• Gingival bleeds

• Conjunctival suffusion

• GI bleeds

• Organ hemorrhage

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Case 4


• Dengue shock syndrome

• Results from severe hypotension resulting from fluid

dyshomeostasis

• Dengue patients require close monitoring during

intravenous fluid replacement

• Patients are at risk for fluid overload

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Case 4

• Follow up

• On day 22 of hospital admission, the patient developed severe hypotension (dengue shock syndrome) and

coded

• He was successfully resuscitated

• The patient coded a second time a short while later, and

the family decided to withdraw care

• The patient died shortly afterward

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Case 4

• Follow up

• Dengue outbreak in Thailand

• Over 25,000 cases reported since the beginning of

2019

• In the Philippines, over 150,000 cases have been reported in 2019

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Case 5“Fever in the morning’, fever all

through the night”

Case 5

• A 5-year-old male presented to an IU Health ED mid-summer with a 3-day history of a macular rash, migratory polyarthralgia, trouble walking, fevers (39 –41⁰C), and chills

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Case 5

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Case 5

• A 5-year-old male presented to an IU Health ED mid-summer with a 3-day history of a macular rash, migratory polyarthralgia, trouble walking, fevers (39 –41⁰C), and chills

• The patient was seen at urgent care centers a couple of times during the weeks preceding this presentation

• Prescribed azithromycin and doxycycline for suspected respiratory infection and tick-borne illness

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Case 5

• Antibiotic therapy temporarily resolved the signs and symptoms, but they returned after completion of the second course of antibiotics

• The patient lived with his bio-mom, bio-dad, and pets (a dog, a fish, and rats)

• Blood cultures and blood for arbovirus and tick-borne pathogens were collected

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Case 5

• Arbovirus testing

• Negative

• Tick-borne pathogen testing

• Negative

• Blood cultures

• POSITIVE!

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Case 5

• After 48 h of incubation, the following organism was detected in the aerobic bottles from both sets of blood cultures

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Bar, 10 µm

Case 5

• Subculture (BAP, 96-h post-inoculation, incubated in 5% CO2)

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Case 5

• Isolate biochemical profile

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Biochemical test Result

Catalase Negative

Oxidase Negative

Indole Negative

Nitrate reduction Negative

Arginine hydrolysis Positive

Gelatinase production Negative

Esculin hydrolysis Positive

Glucose fermentation Positive

Lactose fermentation Negative

Sucrose fermentation Negative

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Case 5

• Bruker MALDI Biotyper RUO

• Streptobacillus moniliformis (score value >2.00)

• One of two etiologic agents of rat-bite fever

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Case 5

• S. moniliformis

• Non-motile, often pleomorphic GNRs arranged in chains

• Wall-less cells are often produced

• Colonies adopt variable morphologies

• Fried-egg colonies are frequently noted

• Largely biochemically inert (save Arg and esculin hydrolysis)

• Penicillins, cephalosporins, and doxycycline are the mainstays of treatment

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Case 5

• Follow up

• Patient was treated with oral penicillin V for 14 days

• Patient made a full recovery

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Case 6That’s a bad cough – you should get

that checked out.

Case 6

• A 68-year-old male presented to the Richard A. Roudebush VA Medical Center with an influenza-like illness

• Past medical history includes multiple myeloma and thrombocytopenia

• Admitted for diagnostic workup and treatment

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Case 6

• Chest X-ray: left lower-lobe infiltrates

• Computed tomography: right-sided filling defect of heart

• He was diagnosed with pulmonary embolus, pulmonary abscess, and left-lobe pneumonia

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Case 6

• BAL performed to determine etiology of pulmonary symptoms

• Influenza A PCR � POSITIVE

• Routine bacterial and Legionella spp. cultures were also performed

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Case 6

• BAL fluid Gram stain - few WBCs, no organisms seen

• Routine bacterial cultures grew 1+ mixed upper respiratory microbiota

• No growth of Legionella on day 3 of inpatient stay

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Case 6

• Follow up

• Broad-spectrum antimicrobial treatment resolved pneumonia

• Patient recovered after a couple of days following admission and treatment

• Discharged on inpatient day 3

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Case 6

• But wait…there’s a twist!

• On the last day of observation, the following isolate was observed on the selective BCYE agar plate

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Case 6

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Case 6


• Gram stain

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Bar, 10 µm

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Case 6


• Legionella pneumophila DFA � NEGATIVE

• MALDI-TOF MS (Bruker, RUO) � NO ID

• 16S rRNA gene sequencing � NO ID

• Closest match (<96.7% identity): Legionella hackeliae

• THIS WAS A NEVER-BEFORE-DESCRIBED SPECIES!!!

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Case 6

• Legionella indianapolisensis, sp. nov.

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Case 6

• If you’d like to learn more about it…

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• Clinical laboratory team members• IU Health Division of Clinical Microbiology

• Eskenazi Health Clinical Microbiology and Serology Laboratories

• Blaine Mathison, M(ASCP)• ARUP Laboratories

• ISDH Clinical Microbiology Laboratory

• Jyl Madlem, MS, MT(AMT)

• SCACM and all of you!

Thank you!!!

relich indiana cases - scacm

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