ID Case Conference 10-10-07ID Case Conference 10-10-07

Gretchen Shaughnessy, MDClinical FellowDept of Infectious Diseases

CC: Foot UlcerCC: Foot Ulcer

52 yo woman w/ DM and Charcot foot who presents with worsening swelling and redness around diabetic foot ulcer.Patient reports that her foot ulcer had been present for several years, but that it changed about 1 week ago. She denies any known history of trauma.Her daughter was the one to notice that the ulcer on the bottom of her left foot was red and swollen, smelled horribly, and had a black area with white splotches. The patient claims she feels no pain in the area but has had decreased sensation in that foot from neuropathy.

ABX CourseABX Course

Patient was initially started on Zosyn, received 4 days of therapy then lost IV access and got levaquin/clinda x 1 dose until IV access could be secured. ID was consulted for assistance with ABX

PMHPMH

CVA '03 - short term memory deficits per daughter HTN DM TYPE 2 HYPERLIPIDEMIA OBESITY CHF

PMH (Cont)PMH (Cont)

Soc Hx - Lives in Burlington, and she hasn't worked since her stroke in '03. Denies any etoh, tobacco, or illict drug use. No recent travel. No contact with dogs or birds. Has a cat – h/o bites to the hand but no bites or licks on the foot. Fam Hx - Aunt with Breast CA, Cousin with Breast CA, FH of DM, HTN, Hyperlipidemia.

MedicationsMedications

NKDA

ASA 81MG ONCE DAILY EFFEXOR XR 225 MG ONCE DAILY ENALAPRIL MALEATE 20MG TWO TIMES A DAY FUROSEMIDE 60MG ONCE DAILY HYDROCHLOROTHIAZIDE 25MG ONCE DAILY METFORMIN HCL 1000MG TWO TIMES A DAY NORVASC 10 MG ONCE DAILY PLAVIX 75MG ONCE DAILY SIMVASTATIN 80 MG ONCE DAILY TOPROL XL 150MG ONCE DAILY

ROSROS

She admits to polyuria/polyphasia. She denies any fevers or chills, but reports nausea and vomitting this am, where she vomitted water x3 this morning and couldn't keep her medications down. Patient denies any increased swelling in her legs.

Physical ExamPhysical Exam

BP 147/86 HR 90 RR 20 T 37.0 97% RANAD, alert/oriented x3, appropriateEOMI, PERRLAMMM, OP clearno palpable cervical nodes

no carotid bruitsRRR, no m/r/gCTAB, nonlaboredsoft, nontender, + bowel sounds, obeseFROMCN 2-12 Grossly Intact moves all 4 extre's wellLE exam – next slide

Foot ExamFoot Exam

2x2 cm wound over plantar surface of Left foot; moderate purulent drainage; moderate erythema & swelling. Area of fluctuance present over ulcer2-3+ pitting edema of lower extremities and feet. Well circumscribed area of erythema and heat on left lower leg and left foot. no clubbing, cyanosis.

LabsLabs

29.113.5

10.3304

1304.4

9527

42

1.9255 CRP >45

ESR 140Ferritin 462Hgb A1C 7.0

N-12.4L-0.2M-0.5E-0.1B-0.0

Diagnostic StudiesDiagnostic Studies

X-ray of foot on admission demonstrated presence of cortical bone effacement, concerning for osteomyelitis.

xrayxray

MRIMRI

Subtle enhancement seen within the distal cuboid overlying the large skin ulcer as above may represent osteitis. Early osteomyelitis cannot be fully excluded and follow-up plain radiographs in 7 to 10 days is advised to assess for interval progression. Diffuse cellulitis and/or edema of left foot and ankle. Small joint effusion. A septic joint cannot be fully excluded; however, no signal abnormalities in the adjacent bones are seen to suggest this diagnosis. Abnormal enhancement at the base of the metatarsals are most likely secondary to advanced neuropathic arthropathy.

Discussion

Blood Culture ResultsBlood Culture Results

3/3 blood cultures positive for

Pasteurella multocida 3+ Oxacillin Susceptible Staphylococcus aureus 3+

2007-07-24PENICILLINR 2007-07-24OXACILLINS 2007-07-24GENTAMICINS 2007-07-24VANCOMYCIN MIC2S 2007-07-24ERYTHROMYCINR 2007-07-24CLINDAMYCINS 2007-07-24TRIMETH/SULFAMETS 2007-07-24DOXYCYCLINES

Streptococcus species 3+

Polymicrobial Bacteremia including pasteurella multocida

Polymicrobial Bacteremia including pasteurella multocida

MicrobiologyMicrobiology

Zoonotic (related to animal sources)Short, encapsulated gram negative coccobacilliAerobic, facultatively anaerobicSmall, gray, shining colonies on blood agar

Grow well on sheep blood, chocolate, MHAGrowth uncommon on MacConkey

Resistance associated with degree of encapsulation

EpidemiolgyEpidemiolgy

Found worldwideCommensals in the upper respiratory tract of fowl and mammalsCarrier rate 55% in dogs and 60-90% of catsCauses a variety of disease in animals

Fowl choleramastitis

Epidemiology (cont.)Epidemiology (cont.)

0.6-1.8 cases of P. multocida infection per 100,000 per yearMost commonly transmitted to humans through bites (cat, dog, other felines, horses, pigs, rats, rabbits, wolves)Isolated from 50% of dog and 75% of cat bites Infections not related to bites probably stem from contact with animal secretions

Clinical ManifestationsClinical Manifestations

Soft tissue, bone, and joint infection (usuallly following animal bites/scratches)Oral and respiratory infectionsSerious invasive infection

Soft tissue infectionSoft tissue infection

Rapid development of intense inflammatory response, often within hours of bitePurulent drainage in 40%, lymphangitis in 20%, regional adenopathy in 10%Necrotizing fascitis can occur

ImageImage

See UpToDateAvailable online at UNC Health Sciences Library [on campus only]

Septic arthritisSeptic arthritis

Septic arthritis most commonly involves a single joint, usually the knee. Predilection for joints already damaged (RA, DJD, prostheses). Bite usually distal to involved joint without direct penetration.NOT preceded by a bite or scratch in 1/3 of cases (hematogenous spread)More than 50% of patients with septic arthritis are immunosuppressed.

OsteomyelitisOsteomyelitis

Local extension of soft-tissue infection or direct innoculationCat bites > dog bites because of the sharp little teeth that go down to boneTreatment requires at least 4 weeks of IV antibiotics followed by oral antibiotics50% of patients experience slow healing, nonunion, joint fusion, limitations of motion, or residual deformityPoor functional outcome in hand infections

Respiratory infectionsRespiratory infections

Usually have underlying COPD (37%), bronchiectasis (21%), malignancy (15%), cirrhosis (8%)Pneumonia, pharyngitis, sinusitis, lung abscesses

Other infectionsOther infections

Endocarditis: 15 case reportsMeningitis: 50% of cases infants < 1 year, 30% adults > 60 yearsPeritonitis: usually associated with peritoneal dialysis (cat had punctured dialysis tubing in 65%)Endophthalmitis

BacteremiaBacteremia

BacteremiaMost are immunocompromised (cirrhosis, malignancy/chemotherapy)Mortality approximately 30%

Commonly accompanies a localized infectionOften seen with liver dysfunction

Bacteremia (cont)Bacteremia (cont)

Very rareIn the past 5 years, we’ve had 4 positive pasteurella multocida isolates from blood at UNC

Fun fact –pasteurella bacteremia at UNC is associated with Shaughnessy exposure (no causation. all patients had positive blood cultures prior to exposure. I promise I wash my hands!)

Association with liver diseaseAssociation with liver disease

Cirrhosis of any etiology, hepatitis, infiltrating tumorsImpairment of reticuloendothelial system makes patient prone to infection with encapsulated organisms

TreatmentTreatment

Penicillin is drug of choiceIf PCN allergic, quinolone, doxycycline, 1st generation cephalosporin, septraIn cases of septic arthritis, IV abx and serial joint aspirations

Our PatientOur Patient

Pip/tazo chosen for good coverage of pasteurella, OSSA, and anaerobes/pseudomonas (given diabetic foot ulcer)Intensive debriedments and IV abx x 2 months showed only mild clinical improvement, no change in ESRRepeat wound culture confirmed OSSA, no further positive cultures for pasteurella. All repeat blood cultures negative to date.Currently getting hyperbaric oxygen therapy via our vascular surgery colleagues Continuing IV Abx – trying to save the foot

SourcesSources

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine, 15th edition.

Book available online via the UNC-CH Libraries

Tseng, Su, Liu, & Lee. Pasteurella multocida bacteremia due to non-bite animal exposure in cirrhotic patients: report of two cases. Journal of Microbiology, Immunology, and Infection. 2001; 34: 293-296.Morris MJ, Mcallister CK. Bacteremia Due to Pasteurella multocida. Talan, Citron, Abrahamian, Moran, Goldstein. Bacteriologic Analysis of Infected Dog and Cat Bites. The New England Journal of Medicine. Vol 340, number 2. 1999.

Sources (continued)Sources (continued)

Levinson, Jawetz. Medical Microbiology and Board Review. McGraw-Hill, 1998. Pgs 133-134.UpToDate [available online at UNC HSL – on campus only]Mandell’s Principles and Practices of Infectious Disease, 6th Ed.

Book available online via the UNC-CH Libraries

Weber, DJ, Wolfson, JS, Swartz, MN, Hooper, DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984; 63:133. Weber, DJ, Hansen, AR. Infections resulting from animal bites. Infect Dis Clin North Am 1991; 5:663.

Search by journal title in E-Journals to find copy of full-text article

Search PubMedSearch PubMed

Pasteurella MultocidaCase ReportsReviewsDifferential DiagnosisDrug Therapy