“tales from the west”: interesting cases from a county
TRANSCRIPT
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“Tales from the West”: Interesting Cases from a County Hospital
Susan Butler-Wu, Ph.D., D(ABMM), SM(ASCP)
Associate Professor, Keck School of Medicine of USC
Director, Clinical Microbiology Laboratory, LAC+USC
Medical Center
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Case 1: Things are not always what
they seem…
• 45 yo incarcerated male in Los Angeles, CA presented to jail ED with difficulty walking & confusion – ESRD, hypertension, CHF
• Several months prior had a VP shunt placed for unclear reasons
• Patient became more agitated, had started vomiting and was transferred to LAC+USC for care
VP-CSF Values Ref. Range
WBC 79 0-5 cells/µl
• PMN • 67%
• Lymphocytes • 20%
• Monocytes • 13%
Glucose 31 mg/dL 50-80 mg/dL
Protein 29 mg/dL 20-50 mg/dL
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Gram Stain of CSF
Name that bug!
Growth on SAB at 3 days
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Answer
• Coccidioides spp.
Hagman HM et al. Clin Infect Dis. 2000. 30:349-355 Schuetz AN et al. Diagn Cytopathol. 2012. 40(2):163-7
Fine needle aspirate
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• 16 year old Male with arthrogryposis and short stature presented with 3
weeks history of worsening back pain
– dull and mainly localized to the upper back, increased to 9/10 with touch
– no fall or trauma to back; no other joint pain
• Denied any chest pain, however, did say that he had been a little out of
breath over the past few weeks
• Also endorsed vague history of occasional night sweats and a fever of
101°F over the past few weeks
• US born, no travel history. Frequent family visits by relatives from Mexico
frequently but no known sick contacts
• On exam, the pt was febrile (38.2°C - Tmax 39.2°C) and tachycardic (HR:
126)
• 3-4/6 systolic murmur was appreciated on exam that was best heard
over LSB
• Scoliotic spine, approximately 7 cm x 7cm very tender and fluctuant mass
in the right lower thoracic region with faint overlying erythema
• WBC 22.2 (78% N), CRP 255 ESR 108
Dr. Elham Rahmati
Case 2: Lumpy-Bumpy
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Chest CT Key Findings: RLL consolidation. 4.5x
9.3x15.5 cm mass extending through tissue
boundaries involving pleura, communicating
with a large fluid collection within the right
paraspinal musculature.
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• Fine Needle Aspirate
• Growth on BAP, CHOC
• NG on MAC
• Oxidase-neg
• Catalase-pos
• Indole-neg
• Anaerobic culture grew
Fusobacterium spp.
H&E
Name that bug!
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Answer
• Aggregatibacter actinomycecomitans
(formerly Actinobacillus actinomycecomitans)
Based on the pathology
findings, what other
organism do you suspect is
present?
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Answer
• Actinomyces spp
GMS
Gram-positive rods observed
with Brown & Brenn stain
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• 26 yo male with no significant PMH
• Brought into OSH ED by his sister for AMS & HA after she had difficulty arousing him – headache began one week PTA
– pt was seen at OSH discharged, with Norco
• Throbbing HA, as well as all over body pain – no photophobia or neck stiffness
– per family had polyuria/polydipsia in last few days
• Became agitated and combative in ED
• Pt stated that he was born in US
• Works as cook in a Guatemalan restaurant
• Denies travel outside of CA
Case 3: “My head is killing me”
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Case continued
• Underwent lumbar puncture – opening
pressure of 55
CSF
RBC 10
WBC 99
%PMN 72%
%Lymph 20%
% Mono 8%
Glucose 39
Protein 120
• Became febrile over the course
of his hospitalization (Tmax
38.3°C)
• Developed hydrocephalus
• EVD placed
• Progressive de-compensation
Dengue IgG 5.73
Dengue IgM 1.25
Serum WNV IgG 4.48
Serum WNV IgM neg
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The following colonies were observed after 14
days of incubation of the CSF culture
Name that bug!
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Answer
• Mycobacterium tuberculosis complex
• MTBC is capable of growth on routine
bacterial culture media
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What aspect of how this
culture was performed
led to isolation of this
organism?
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Answer
• Extended culture incubation for CSF from shunt specimens over concern for Propionibacterium spp (Cutibacterium)
• No published data examining utility of extended culture incubation for shunt specimens
• Unpublished data: 69/70 CSF shunt samples positive for Propionibacterium spp positive within 7 days (Dr. Lori Bourassa, University of Washington)
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• 52 yo Laotian male was diagnosed ALL
– underwent two rounds of hyperCVAD (chemotherapy)
– generalized pruritus (itching) and urticaria after first
round – stopped TMP/SMX
– pruritis persisted
• Presented to OSH with back pain & nausea 6 days
after having begun chemo
– sx improved after IVF, opioids & he was discharged
• 2 days later, presented to UWMC with abdominal
pain, nausea, emesis & chills
– thought to be due to regimen-related toxicity/colitis
Case 4: Creepy Crawly
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• CT of abdomen & pelvis
• colitis involving cecum and ascending colon
• ground-glass opacities and nodules in lung bases
• Pt became hypoxic, CT chest:
– diffuse nodular ground-glass opacities
• Intubated and underwent bronchoscopy
BAL Gram Stain
BAL culture was negative for bacteria,
fungi, AFB What is the diagnosis?
http://parasitewonders.blogspot.com/2010_10_01
_archive.html
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Answer
• Strongyloides stercoralis hyperinfection
syndrome
Image: CDC DPDx
True or False: Patients
with hyperinfection
syndrome usually have
an elevated eosinophil
count
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False: Absence of eosinophilia does not rule out
Strongyloidiasis
• Diagnosis requires a high degree of clinical
suspicion • 50% of chronically infected patients are asymptomatic, 50% with only minimal
or intermittent GI symptoms
• 9% of US-trained MD’s recognize case presentation of a person needing screening for Strongyloides vs. 56% of foreign-trained physicians
Boulware DR. Am J Med. 2007.120:545
Roxby AC et al.CID. 2009. 49(9):1411-23
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• 64 yo homeless man presents to LAC+USC ED c/o
2 weeks of productive cough, exertional SOB,
decreased appetite and fatigue for the last 5 days
– subjective fevers and night sweats
– yellow sputum
– no nausea, vomiting or diarrhea
• Patient was born in Mexico, moved to the U.S. 28
years ago
• No travel, no substance abuse (including IDU)
• Patient also complains of intermittent left sided
chest pain “all around my heart” – no radiation of pain
Case 5: Itchy itchy, scratch scratch
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Case continued…
• Recent history of staying in a homeless shelter and body lice were discovered on the patient
• CXR showed questionable cavitation – MTB PCR neg x2, AFB smear-neg x3
• Afebrile & normal WBC noted
• Admitted for diuresis, TB r/o and CAP – started on ceftriaxone & azithromycin
• TEE to evaluate cardiac function revealed EF 35% and a 1.6x1.4 aortic vegetation on non-coronary cusp
• Blood cultures were negative x3 sets
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• The patient had positive serologies for this organism (IgG 1:1024)
• Patient underwent valve replacement
• H&E staining showed acute and chronic inflammatory changes
• Warthin Starry staining of the excised valve was performed…
Name that bug!
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Answer
• Bartonella spp.
• B. quintana IgM-neg, IgG 1:512
• B. henselae IgM-neg, IgG 1:1024
Pediculus humanus corporis
Foucault et al. Emerg. Inf. Dis. 2006.
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Names two other
important causes of
culture-negative
endocarditis that cannot
be grown in vitro but
can be visualized by the
Warthin Starry stain?
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Answer
• Coxiella burnettii & Tropheryma whipplei
• T. whipplei was the most common cause of
culture-negative endocarditis in one study
from Europe (6.3% of endocarditis cases)
• Outbreaks of C. burnettii e.g. Netherlands
Geissdörfer et al. JCM. 2012 50(2):216-22
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• 52 yo M presented to LAC+USC ED
• 1 week of AMS after physical altercation
• Pt was tachycardic, hypotensive and had leukocytosis (WBC 14.0)
• Pt has a hx of polysubstance abuse
• Blood cultures positive after 2 days of incubation
2/2 blood culture sets positive –
growth in anaerobic bottle only (i.e.
2/4 bottles positive)
Case 6: Death-spiral
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More information
• Organism did not grow at 35°C in 5% CO2
• Growth observed after incubation in microaerobic atmosphere
• Growth observed after anaerobic incubation (more “spready”)
Oxidase-negative, Catalase-negative
Name that bug!
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Answer
• Anerobiospirillium succiniciproducens
• Identified by both MALDI-TOF Mass
Spectrometry (Bruker Biotyper) & 16S rDNA
sequencing
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What two antibiotics is this organism frequently
resistant to?
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Answer
• Metronidazole and clindamycin
• Generally susceptible to combined beta-
lactam and beta-lactamase inhibitors, 2nd, 3rd
and 4th generation
cephalosporins,
carbapenems, &
fluoroquinolones
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• 52 yo male presents with a 10-day history of fevers and headache after having returned from a 3-week trip to Chiang Mai, Thailand
– pt is US born of Pakistani origin; had not been to Pakistan in over 15 years
• He received the recommended vaccinations prior to travel and took appropriate malaria prophylaxis
• On exam, the patient was noted to be febrile to 38.9°C
• The patient also noted that he had been experiencing diffuse myalgia for the last two days
• On exam, a 1cm x 1.5cm area of discoloration was noted on the patients leg
• WBC 3.2 (leukopenic)
• ALT 180, AST 205
Case 7: Thai thigh
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• The patient had negative malaria smears x3
• The patient had negative Rickettsial serologies
performed at a local reference lab (both
spotted fever and typhus group)
• The diagnosis of this rickettsial disease was
made by serology testing performed at the
CDC
Name the etiologic agent of
this patient’s infection and its vector
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Answer
• Infection: Orientia tsutsugamushi
• Vector: Chiggers (Leptotrombidium spp)
Looking at 5 distinct
regions, prevalence
varied from 4.1-23.4%
Suttinont et al. Ann Trop Med Parasitol. 2006 Jun;100(4):363-70
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Scrub typhus: “The tsutsugamushi
triangle”
Image: WHO
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• 55 yo female visiting from Cameroon, Africa
• Two days after arrival in U.S. began to experience nausea and NBNB emesis 8-10 times a day and diarrhea more than 8 times a day
• A further two days later, was found slumped over by her sister and an ambulance took her to an OSH – mildly tachycardic and hypertensive
– AST >4440, ALT>5000, INR of 8.42, lactate 8.4, troponin 16.1
• Transferred to LAC+USC for transplant evaluation – suspected acute liver injury due to medication taken immediately prior to leaving for the U.S.
• 9 days after coming to the U.S. pt became progressively more altered and intubated for airway protection
Case 8: A long way from home
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• Blood sample drawn at 00:46am 6 days after
arrival in the U.S. was positive for the
following
Sheath?
220-232µM
Name that bug!
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Answer
• Loa loa
At what time are Loa
loa microfilaria most
likely to be detected in
the blood?
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Answer
• 10am-2pm i.e. diurnal periodicity
• Need to account for time at the patient’s original destination – microfilaria can be jet-
lagged too
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Diethylcarbamazine (DEC) is
the drug of choice when the
concentration of microfilaria
is <8000 MF/mL. However,
co-infection with which other
microfilaria species must be
ruled-out prior to initiation of
DEC therapy?
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Answer
• Onchocerca spp
• Risk of fatal encephalopathy if co-infected
• No role for doxycycline as Loa loa do not
contain Wolbachia
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• 17 y/o Filipino boy with a history of fevers & chronic cough with sputum for 6 months PTA – no weight loss or night sweats
• Diagnosed with acute bronchitis at 4 separate ED visits at OSH’s – tx with azithromycin, promethazine,
dextromethorphan
• 2 months PTA his right cheek became swollen and he developed scaly skin lesions on back, chest, extremities as well as cutaneous horns on face – cheek swelling grew and extended to lid and forehead
• PCP referred pt to Optho who instructed him to come to the ED
Dr. David Yau
Case 9: What’s horny is thorny
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Case continued… • Patient was born in USA, lives in Glendale
– no out of state travel
– visited Palm Springs 9 months PTA, and 3 months PTA stayed in cabin “in the snow”
• On Exam: – Shotty cervical lymphadenopathy; prominent
supraclavicular lymph node, right axillary node palpable, no palpable inguinal nodes
– HEENT: Right eye swollen, periorbital edema/STS, + eye discharge, +fluctuant swelling
– exophytic hyperkeratotic yellowish horn-like nodules on left lateral eyebrow and left cheek:
– L lateral upper arm, mid back, central upper back, R chest with vegetative crusted plaques with erythematous base
– WBC 11.1
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• “Complex multilocular cystic mass with enhancement in the right frontal scalp extending inferiorly to just beneath the right zygomatic arch with cortical irregularity and a permeative appearance of the underlying bones, as above, concerning for neoplastic process.
• Multiple enlarged cervical lymph nodes, some with central necrosis, concerning for a neoplastic process”
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Wet mount of drainage (40X)
Name that bug!
Structures >5µM
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Answer
• Coccidioides spp.
H&E Back lesion punch
Qs. What other ethnic
group has a greater
risk for developing
disseminated
Coccidioides infection?
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Answer
• African ancestry
– 10 times greater risk
• Filipino ancestry
– 175 times greater risk
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• 51 yo man taken to LAC+USC after being found down – currently incarcerated
• Patient has a history of schizophrenia and seizure disorder
• Had a similar presentation one month prior; at the time was attributed to sepsis from aspiration pneumonia – improved on fluids and antibiotics
• On exam, he was bradycardic to the 30’s, hypothermic and altered
• CT head was normal – no intracranial abnormalities, hemorrhage, large territory infarct, or mass effect
Case 10: Panel it out
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Case continued…
• VZV detected by Biofire ME panel
CSF
WBC 47
% Lymphocytes 92%
Glucose 22
Protein 173
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True or False: There are
patients with VZV
meningitis/encephalitis
that do not have skin
lesions
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Answer • True
• VZV reactivation can produce chronic radicular
pain without rash (known as zoster sine
herpete)
• Neurological disorders associated with VZV
can also occur without a rash
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• 49 y/o F presents to ED for with severe throat pain,
dysphagia, hoarseness, myalgia, fevers, and chills for 3 days
– no recent sick contacts; has 3 school aged children
– Unknown vaccination status
• PMH of connective tissue disease, diabetes mellitus
• On physical exam, membranous plaques on posterior
oropharynx, tonsillar erythema and enlargement as well as
tender cervical lymphadenopathy were noted
– patient spoke with a muffled voice
• T 38°C, tachycardic (127), BP 127/82, O2 Sat 99% on room
air
– Cardiac: Normal S1/S2, RRR
• WBC 12.9 K
Case 11: The horse is out of the barn
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Name that bug!
Image: Dr. Noah Wald-Dickler
Image: Dr. Noah Wald-Dickler
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Answer
• Corynebacterium diphtheriae
Prior to initiating anti-toxin
therapy, patients must be
tested for hyper-sensitivity to
what substance?
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Answer
• Horse serum
• 10% risk of hypersensitivity and/or
serum sickness
• Dose of antitoxin depends upon the site
and severity of infection
What test is used to
demonstrate toxin production
in vitro?
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Answer
• Elek test An immuno-precipitation test
• filter paper saturated with
diphtheria anti-toxin is
submerged in agar
• test isolate is streaked
perpendicular to filter paper
• precipitin at 45° angles if isolate
produces toxin
• Strains of C. ulcerans & C.
pseudotuberculosis can also
potentially produce diphtheria
toxin
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• 3 yo previously healthy female presenting with fever (40.2°C)
– fevers started 3 months ago, lasted for several weeks, then returned 10 days ago
– now occurring daily, fevers last several hours then resolve with acetaminophen
• Had cervical lymphadenopathy, hepatosplenomegaly on exam
– hepatosplenomegaly confirmed by ultrasound
• Normal WBCs, but labs showed microcytic anemia and increased ALT (134), AST (134), Alk Phos (381) and CRP (22)
• Mom reports that the entire family had eaten goats cheese from Mexico 6 months ago
• 2/2 blood culture sets drawn are positive for growth at 3 days (aerobic bottles)
Case 12: You are what you eat…
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Name that bug!
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Answer
• Brucella species
B. abortus strain RB51
was developed to
immunize which
domestic animal
against brucellosis?
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Answer
B. abortus strain RB51 is
resistant to which
antibiotic? Table: CDC
• Cattle
• Accidental exposure has
led to infection in
humans
• Raw milk consumption
• Human infections with RB51 are not detectable with
standard serologic assays!
• B. abortus S19 for cattle and B. melitensis Rev-1 for
sheep and goats – accidental exposure leading to
infections also reported
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Answer
• Rifampin-R
• Post-exposure prophylaxis for suspected B.
abortus RB51= 21-day course of doxycycline
and trimethoprim/sulfamethoxazole
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• 40 yo M from Mexico
• Reports experiencing steadily worsening exercise
tolerance/increasing SOB, increased fatigue,
intermittent chills and myalgias
• Hx of EtOH cirrhosis and recurrent
hospitalizations for anemia (Hgb 2.4-5.5)
• Feels his abdomen has been growing in
circumference and reports recent decreased PO
intake
Case 13: Unlucky for some…
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• Worked on a farm in Mexico
– drank occasionally from
rivers while living in
Mexico
• Moved to L.A. one year PTA
– works as a street vendor
• Alk Phos 164 U/L
• AST 20 U/L
• ALT 16 U/L
• WBC 5.2, 23% eos
• Hgb 3.6 , MCV 61.3
MRI: Marked intra- and extra-
hepatic biliary dilatation with
abnormal signal in the right
and common bile ducts
concerning for
cholangiocarcinoma
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• Pt underwent ERCP
• No evidence of cholangiocarcinoma
• ERCP showed debris in the gallbladder
and extra-hepatic bile duct, which was
"swept" with a balloon…
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Video: Dr. Erin Dizon
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Name that bug!
Image: Dr. Ryan McConnell
Size: 130µM x 75µM
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Answer
• Fasciola hepatica
What agent should not
be used to treat this
infection?
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Answer
• Praziquantel
– active against most trematodes, but not Fasciola
• Triclabendazole is the drug of choice
– in the United States, this can only be obtained
through the CDC Drug Service
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A Special thanks to the amazing Clinical Laboratory Scientists, residents and fellows who took care of all
the patients in the cases presented today!
www.cheezburger.com
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• 3yo M with hemophilia A presents to establish
care
– family recently emigrated from Afghanistan
– treated in Afghanistan with monthly “plasma injections”, which were donated from Italy
• Mother denies history of blood transfusions
• The child bruises easily & experiences
prolonged bleeding with trauma
• Review of systems was otherwise negative
• HepBsAg: nonreactive
• HCV Ab: nonreactive
• RPR: nonreactive
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HIV Antibody/Antigen Results:
Repeatedly Reactive
HIV1 Ab: negative
HIV2 Ab: indeterminate
HIV1 RNA: not detected
What testing should be
performed next?
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Answer
• HIV-2 RNA (quantitative)
• HIV-2 viral loads are frequently
undetectable
• Titer is 2–3 log 10 lower than in HIV-1-
matched controls
• 80% of people living with HIV-2 behave
like HIV-1 long-term non-progressors HIV-2 is intrinsically
resistant to which
class of ARs?
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Answer
• Non-nucleoside reverse transcriptase
inhibitors
Image: aidsinfo.nih.gov
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• 67 yo F presents to ED with breakthrough seizures
– PMH of epilepsy, chronic R sided headache, vertigo,
DM, hypertension, cirrhosis
• While in the ED, she had a witnessed tonic-clonic
seizure with drop in Sp02; was intubated for airway
protection
• Chest X-ray showed bilateral opacities & interstitial
opacities
• Over the course of her hospitalization, she developed
worsening shortness of breath
• Pt was started on ceftriaxone/flagyl for presumed
aspiration pneumonia & was subsequently switched to
vanco/cefepime for VAP
• No improvement in her respiratory status & pt
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Name that bug!
H&E GMS
Mucicarmine
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Answer
• Cryptococcus spp
Vs. “C. neoformans
complex” & “ C.
gattii complex”
Kwon-Chung KJ et al. mSphere. 2017. 2(1). pii:
e00357-16. Images: relatably.com & Pin
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Patient’s CSF Cryptococcal antigen: Initially Reported as negative
What is this
phenomenon called?
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Answer
• High dose Hook effect (prozone)
True or False: Positive
CSF CrAg results
correlate strongly with
positivity for the
Cryptococcus target on
the Biofire ME panel
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Answer
• False
Liesman RM et al. 2017. J Clin. Microbiol. 56(4): pi
17
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• 56 yo male with mantle cell lymphoma, underwent 6 cycles of chemotherapy and an autologous BM transplant
• Post-transplant course complicated by neutropenic fever and mucositis
• Received 2 bags of RBC’s, followed 3 days later by 2 bags of pooled platelets after which hematocrit was 27 and his platelet count was 10,000
• Two months later, presented with fever and hemolysis; also reported a 14 lb weight-loss and severe fatigue
• He was pancytopenic upon admission
• Patient lives in a wooded area in Western WA, but denied working outside since his lymphoma diagnosis
• No recent travel history and denied tick bites
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Name that bug!
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Answer
• Babesia spp.
What Babesia species is
native to the US West
Coast?
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Babesiosis in the US
• Identified by CDC as Babesia microti
Infections in CT, MA, MN, NJ, NY,
RI and WI account for 95% of
Babesiosis cases – B. microti
Three reported cases of B.
divergens-like spp. in the US
Vannier EG et al Inf Dis Clin N Am. 2015. 29(2):357-70
Image: CDC, 2013 babesiosis data
• Answer = B. duncani and B. duncani-type
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vs.
• Majority of infections associated with tick bites, but infections can be acquired via blood transfusions or transplacentally
• Transfusion-associated infections can occur year round – mortality rates up to 18%
• Asymptomatic infection is common – 53% of Ab-positive donors are also PCR-positive
• Donated blood or blood donors are not currently routinely tested for Babesia – BPAC & FDA met in 2015 to discuss this – http://www.aabb.org/advocacy/government/bpac/Pa
ges/bpacmeeting150513.aspx
Leiby DA et al, Transfusion. 2005. 45: 1804-1810
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• 50 yo M with history of HIV – CD4 363, undetectable HIV-1 RNA two months ago
– on ART
• Presents to the LAC+USC ED with 3 days of acute onset of fevers, chills, cough, abdominal pain, nausea, vomiting – no diarrhea or hemoptysis
– on exam, his abdomen was soft, non-tender & non-distended
• T38.1°C
• CXR showed right lower lobe consolidation
• WBC 17.8, 92% N, 4.7% L, 0% E
• Renal impairment (Cr 5.2) & hyponatremia (Na 129, normal 134)
• US born, no travel outside of California
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Diagnosis of the cause
of this patient’s infection was made with
which urine antigen
test?
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Answer
• Legionella pneumophila
• Some studies suggest that hyponatremia occurs
more commonly in patients with Legionaire’s
disease than with other causes of pneumonia
• Hyponatremia is also noted to occur in patients
with HIV, bacterial meningitis, malaria,
leptospirosis, leishmaniasis and others…
Liamis et al. J Inf. 2011. 63(5): 327-335
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Which Legionella
pneumophila serogroup
is detected by the
Legionella urine antigen
test?
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Answer
• Legionella pneumoniae serogroup 1
Sivagnanam S et al. Transpl Infect Dis. 2017. (in press)
Anvi T et al. JCM. 2016. 54(2): 401-411
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Which Legionella species is
modified-acid fast in primary
specimens?
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Answer
• Legionella micdadei
Image: Louis P et al. JCM. 2007. 45(9):3135-3137
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• 12 yo girl presents to LAC+USC ED with hip pain that began 3 weeks ago
– describes pain as 8/10
– waking her up at night
• Sharp pain, no numbness or tingling – radiates from hip to knee
• Pain worse when she stands – causes her left leg to shake and affecting her gait
• Pain with palpation, flexion, extension, external and internal rotation
• Reported subjective fevers though was afebrile on examination
• All vitals, WBC & CRP were normal
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• The pt is up-to-date with her vaccines
• No travel outside of California
• No pets, no contact with farm animals
• Ate unpasteurized cheese from Mexico 4 months prior to admission
• MRI showed 1.6cm Brodie abscess at the base of the greater trochanter of the left femur with extensive adjoining bone edema and inflammatory changes
– Brodie abscess = intraosseous abscess associated with sub-acute pyogenic osteomyelitis
• Pt underwent CT-guided biopsy
– Gram showed 4+PMNs, but no organisms seen
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• 32 yo female presents with complaint of lower back pain for the last 6 months
• Now reports the pain to be constant, 10/10, and no radiating
• Also reports fever/chills, dry-to-productive cough and weight loss over the last 3 months
• Pt was born in Mexico and moved to the US 10 years ago
• Has also lived in Arizona & Kansas; had been previously incarcerated in Mexico
• No drug use, in monogamous relationship with her boyfriend for the last 2 years
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• The patient had 3 smears that were AFB
smear negative
• Xpert MTB-Rif assay: positive for M.
tuberculosis
• Rifampin resistance detected
• Culture was subsequently positive but
susceptible to Rifampin in vitro
What is the explanation for
the observed discrepant
results?
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Answer
• Silent mutation observed in the rpoB gene
(S14 TTT)
• Haiti: 93% of RIF-R by Xpert were rifampin-R
by susceptibility testing, but FP rate of 54%
among samples with “very low” Mtb (Ct>28)1
1Ocheretina O et al. DMID. 2016. 85(1):53-5
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Oxidase-neg
TSI: K/A, H2S+, Gas
ODC+
LDC+
• MALDI only ID’d to genus level
Name that bug!
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Answer
• Salmonella spp.
• Identified by PHL as Salmonella group D
serotype Panama
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• 45 yo male fainted and struck his head on the ground at work
• Reported a one-month long hx of body aches and mild cough
• HIV positive, but had stopped taking triple therapy 18 months prior to presentation – viral load = 136,000 copies/mL, CD4=9 cells/mm3
• Traveled to Thailand one year ago, but no travel since then
• CXR showed LLL consolidation consistent with pneumonia
• No clinical improvement on broad-spectrum abx, CT without contrast showed a 2.5 cm mass – underwent bronchoscopy and BAL grew the following…
Case 7: Tales from Thailand, part I
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30°C
37°C
What is the diagnosis?
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Answer
• Penicilliosis
What is the new name for the
etiologic agent of penicilliosis?
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How fungal taxonomic changes
make me feel…
• Talaromyces
marneffeii
• Latent infection?
• Immunocompromised develop penicilliosis – variety of clinical manifestations
• **skin papules seen in up to 70% of pts
Wong SYN. Path. Res. Intl. 2011.
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• 52 yo M brought in by ambulance after he
was found unconscious by a
family member
• Covered in his own feces
• Pt is a heavy drinker – drinks 1 pint of
vodka a day
• Lactate 4.3, WBC 4.9K
• UA was normal, salicylate/tylenol negative
• Given Ativan for alcohol withdrawal
• One out of two blood culture sets were
positive (anaerobic bottle) Image: www.zazzle.co
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Identified as C. perfringens
• Growth on BAP = pos
• Terminal spores when
grown on Brucella
agar
Name that bug?
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Answer
• Clostridum tertium
Name one other
aerotolerant
Clostridium species?
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Answer
• C. histolyticum
• C. carnis
• (Occasional strains of C. perfringens)