Download - Rhodococcus equi
Rhodococcus Equi Rhodococcus Equi
Trey RumphMercer University
Internal Medicine Rotation
…is it in you?
Patient CasePatient Case
PH is a 65 y/o WM admitted 2/5/2010
CC: N&V for 2 days, cough for weeks and left foot pain
PMH: ESRD, s/p related donor living renal transplant, T2DM, HTN, Polycystic Kidney disease, hx of Gout, hx of left upper lung pneumonia
SH: married, lives on farm in South Pittsburg, (-) tobacco, (-) EtOH, Owns and manages a demolition company, but has been a coal miner for approximately 12 years
Allergies: Demerol and Phenergan
Patient Case (HPI)Patient Case (HPI)
History of ESRD 2o polycystic kidney disease, s/p living related donor renal transplant from his daughter in 2005 (Baseline Cr ~1.4-1.6).
Presents to ER with CC of N&V with onset of 2 days ago
Cough worsened over the last several weeks ever since d/c from hospital with left upper lung pneumonia on 1/15/10
Left foot pain that has progressively worsened over the last several days (Gout)
BUN/Cr note to be 68/2.1 on presentation and volume
Home MedicationsHome Medications
Prograf 1mg PO BID Lasix 40mg BID Zyloprim 300mg Qdaily
CellCept 1gm PO BID Verapamil 120mg PO BID
Starlix 120mg QD
Prednisone 5mg PO BID Metoprolol 12.5mg PO BID
Lantus 20 units QHS
ASA 81mg BID Tessalon Perles prn
Immunosuppressants Heart Medications GoutDiabetes
Hospital medsHospital medsCellcept 500mg IV Q12
Morphine 4-8mg Q1/prn
Ambien 5mg QHS
Cytovene 500mg IV BID
Lopressor 12.5 BID Mycostatin 5mL QID
Solumedrol 10mg IV Q12
Calan 120mg BID Carafate 1gm Q6
Zithromax 500mg QDaily
Bumex 1mg IV Q12 Lantus 30units QHS
Vancocin 0.75g IV QDaily
Nitrol Ointment 1 inch Q6h
NovoLog SSI level 4
Roxicet UDL Q4/PRN
Phenergan 6.25-12.5mg Q6/prn
Procrit 10,000units on MWF @1600
Lortab 7.5mg Q4/prn
Zofran 4mg Q4/PRN
Apresoline 10-20mg Q6
ImmunosuppressantsAntibioticsPain Management
Pain ManagementHeart MedicationNausea Medication
Sleep AidAnti-FungalDiabetes
Patient Case (Hospital Course)Patient Case (Hospital Course)
Upon AdmissionAdmitted via ER with CC of nausea and
vomiting for 2 days and a cough for weeksCT scan shows left upper lobe mass of
6.5cm with lymph node involvement
Fig 1: There is an irregular large soft tissue mass in the left upper lung field which opposes the descending proximal thoracic aorta measuring some 5.5 x 6.5cm.
Course of ActionIV Solu-MedrolHold Prograf
◦Use of Rapamune?Zosyn 2.25mg Q8- obstructive pneumoniaBronchoscopy – left upper lobe mass
Prograf vs RapamunePrograf vs Rapamune
Tacrolimus Sirolimus
Post-transplant Diabetes (~20% first year)
At high doses:◦ Nephrotoxic◦ Neurotoxicity
Renal adjustmentsQT prolongation
Impaired wound healing
↑ K↓ MgHyperlipidemiaHypertriglyceridemiaLeukopenia
Results of BronchoscopyGeneralized erythema, mucosal bleeding
with no obstructing mass noted in the left upper lobe
Patient Case (Hospital Course)Patient Case (Hospital Course)
Patient is coughing up blood, productive with a green coloration
Course of ActionAdd Vancomycin IV 1g Q24o to treatment
(10.6mg/kg) and Zosyn 2.25mg Q8 (CrCl ~29.2)
Vancomycin Dosing and Trough Levels
Date Dose Date Trough level
2/9/10 1g
2/10/10 1g 2/12/10 17.6
2/20/10 30
2/21/10 27.6
2/24/10 27.3
2/25/10 0.75g 3/1/10 13.9
3/9/10 1g 3/9/10 23.6
Patient Case (Hospital Course)Patient Case (Hospital Course)
Blood in cough resolves, but kidney function begins to decline. Patients develops a hemothorax.
Planned Video-Assisted Thoracoscopic Surgery (VATS)◦Retained hemothorax via trapped lung
procedureID Consulted
◦Differential: CMV or atypical mycobacterium◦Ordered urine antigens and serology for Q-fever◦d/c Zosyn
Atypical PneumoniasAtypical PneumoniasLegionnaires disease (Legionella pneumophila)
Q fever (Coxiella burnetii )
Psittacosis (Chlamydia psittaci )
• Lung infection (pneumonia) CAP or HAP lasts 2-14 days
• Pontiac Fever symptoms usually last for 2 to 5 days and may also include fever, headaches, and muscle aches; however, there is no pneumonia.
• During birthing the organisms are shed in high numbers within the amniotic fluids and the placenta and aerolized
• Usually inhaled, extremely virulent
• Resistant to heat, drying, and many common disinfectants
AKA: Parrot Disease or Parrot Fever
•Found in bird droppings
Course of ActionLab Evaluation
◦Rare Gram(+) cocci to be identified…
◦?Malacoplakia or Rhodococcus Equi◦Vancomycin 1g Qdaily and Ancef 1g Q8o
◦Immunosuppressants started back Prednisone 20mg QD Cellcept 250mg Q12 Prograf 1g Daily
MalakoplakiaMalakoplakia
Inflammatory condition that leads to formation of papules, plaques and ulcerations (usually affecting the genitourinary tract)
Thought to result from the insufficient killing of bacteria by macrophages, that accumulate inside depositing iron and calcium forming the papules, etc.
Associated with patients who are immunosuppressed
Rhodococcus EquiRhodococcus Equi
Background Background R. EquiR. Equi
Characterized by rod-to-coccus morphologic variation during its growth cycle
Rhodococcus genus due to its ability to form a red (salmon-colored) pigment - “red-pigmented coccus”
Primarily causing zoonotic infections in grazing animals (ex: horses and foals)
A soil organism that require simple requirements to survive, which seem to be met perfectly by herbivore manure and summer temperature in temperate climates
BackgroundBackground
R Equi is an obligate aerobic, intracellular, nonmotile, non-spore-forming, gram-positive coccobacillus
Commonly transmitted via inhalation on farms
This latter histologic picture, termed malakoplakia, is extremely rare within the lung and, when present, is highly suggestive of a R. equi infection
PathogenesisPathogenesis
R. Equi is facultative intracellular pathogen, surviving inside macrophages to cause granulomatous inflammation and eventually destruction of macrophage.
In humans, has only be found in patients with compromised immune systems in the lungs
Patient PresentationPatient Presentation
#1 Pneumonia (~66%)
Other possible presentations◦Penetrating eye wound◦Inflammatory mass in the pelvis◦Bloody diarrhea and cachexia◦Pleural effusion◦Osteomyelitis◦Paraspinal abscess◦Inflammatory pseudotumor
Primarily CAP CulpritsPrimarily CAP Culprits
Typical Pathogens for CAP◦Streptococcus pneumoniae◦Moraxella catarrhalis◦Haemophilus influenzae
Pneumonia PresentationPneumonia Presentation
Physical Findings◦Rales heard upon Auscultation over the chest◦Pleural Effusion◦Purulent sputum ◦Blood-tinged sputum ◦Signs of consolidation
Typically seen with Legionella, Q fever, or psittacosis
Summary of Clinical Summary of Clinical PresentationPresentation
Surgical PathologySurgical Pathology
Left Upper Lobe Lung Mass – CT directed Core Biopsy◦Malakoplakia of the lung◦Gram (+) organisms present◦Cytomegalovirus Inclusions Present (in adjacent lung
tissue)
Comment:Pulmonary malakoplakia has been described in immunocompromised patients, including organ transplant patients. The most commonly isolated organism in this setting is Rhodococcus equi – initial cultures do show growth of a difficult to identify organism; the culture has been referred to a reference laboratory for typing.
PathologyPathology
Hematoxylin-and-Eosin Stain(Calcospherites)
Calcium Stain
PAS + material Gram Stain
Pathology
CMV inclusion
Pathology
PathologyPathology
From the pathology as well as the culture coming back with rare gram (+) cocci (Rhodococcus species), Infectious Disease concluded the presence of R Equi
Patient Case (Hospital Course)Patient Case (Hospital Course)
Changed Therapy to…◦∆ Vancomycin 1 g QDaily and Clindamycin◦Renal decides to hold Prograf due to declining
renal function◦∆ Clindamycin Zithromax◦Added Levaquin for cover for new cultures of
Klebsiella and Serratia found in the sputum
Vancocin 1g QDaily/ Levaquin 750mg QDaily/ Zithromax 250mg QDaily
Strategy to treatStrategy to treatR EquiR Equi
Must be covered by at least two or more agents
Combination antibiotics should include one agent with intracellular penetration (ex: Erythromycin or Rifampin)
Besides the use of anti-microbial drugs, the approach used in treatment of human infection involves drainage of the suppurative lesions, surgical resection of granulomatous tissue, and control of concurrent immunosuppressive drugs or control of underlying malignancies.
Duration of treatment 4-9 weeks
Antibiotics used to treatAntibiotics used to treatR. EquiR. Equi
ErythromycinAzithromycinClarithromycinClindamycinCiprofloxacinAminoglycosidesRifampinImipenemMeropenemVancomycinLinezolid
Macrolides
Lincosamides
Fluoroquinolones
Anti-tuberculosis Agent
Carbapenems
Oxazolidinones
Patient Case (Hospital Course)Patient Case (Hospital Course)
Patient still in Respiratory failurePatient suspected of CMV per Lung biopsyAdded Cytovene® (Ganciclovir) 200mg BIDPatient was scheduled for Tracheotomy
Surgery
Vancocin 1g QDaily/ Levaquin 750mg QDaily/ Zithromax 250mg QDaily/ Cytovene 200mg BID
Patient Case (Hospital Course)Patient Case (Hospital Course)After 14 days of treatment the Levaquin was
d/c’dPlaced DHT bedside via CORTRAK
Patient Case (Hospital Course)Patient Case (Hospital Course)
Still in Respiratory failureUnderwent the T-piece Trials on the ventPlaced catheter
Vancocin 1g QDaily/ Zithromax 250mg QDaily/ Cytovene 200mg BID
Patient Case (Hospital Course)Patient Case (Hospital Course)
Patient feels betterCase Management refer him to Siskin and
Kindred Kindred acceptsCytovene d/c, ID was never really clear if
CMV was a pathogen
Vancocin 1g Q48h/ Zithromax 250mg QDaily
Patient Case (Hospital Course)Patient Case (Hospital Course)Patient is transferred to Kindred Hospital
on…Cellcept 500mg BID Augmentin 875mg
QdailyZyloprim 300mg Qdaily
Prograf 2mg Qdaily ASA 325mg Qdaily Flomax 0.4mg after supper
Deltasone 5 mg BID Lopressor 25mg BID Mag-Ox 400mg BID
Lantus 20 units QHS Calan SR 240mg Qdaily
Colace 100mg BID
Lasix 60mg Qdaily
Immunosuppressants
Diabetes
Antibiotics
Heart Medications
Gout
Prostate Medication
ReferencesReferences
Munoz P, Palomo J, Guinea J, et al. Relapsing Rhodococcus equi infection in a heart transplant recipient successfully treated with long-term linezolid. Diagn Microbiol Infect Dis. Feb 2008;60(2):197-9
Prescott, John. Rhodococcus Equi: an Animal and Human Pathogen. Clinical Microbiology Review. Jan 1991; 20-30
Verville TD, Huycke MM, Greenfield RA, et al. Rhodococcus equi infections of humans. 12 cases and a review of the literature. Medicine (Baltimore). May 1994;73(3):119-32