Clinical Case Conference

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Clinical Case Conference

• Clinical Case Conference
• May 8, 2006
• Robin Trotman, D.O.

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Case 1

• 69 yo wf seen as an emergency consult for
  dermatology for parasitosis.
• CC Skin lesions and larvae crawling on her skin.

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Case 1

• HPI
• 5 mos ago her son dev. scabies.
• He was unsuccessfully treated in Aug.
• She presented to Derm clinic in Aug with possible
  Scabies.
• Treated with second course of Elimite and
  cephalexin.

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Case 1

• HPI
• Return apt. to dermatology, entertained the dx of
  delusional parasitosis.
• Trial of pimozide, followed by haloperidol
• She did not tolerate these meds.
• She is referred to ID clinic for urgent apt per
  dermatology attending.

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Case 1

• Hx obtained from pt., despite her son gray and
  white specks that crawl out of my mouth at
  night.
• White larvae crawl out of her eyes and out of her
  nose
• Her brother is afflicted with similar ailment.
• She points at him and says look at him, he has
  it too.

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Case 1

• Son is a minister and was an exterminator, he
  conducted the remainder of the interview.
• He has been treated with multiple courses of
  scabies regimens.
• He brings in a jar of small dead insects that
  were disregarded when taken to the HD.

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Case 1

• Jar contained exoskeletons of multiple bugs.
  Silverfish, dustballs, etc.
• These were obtained from under her bed.
• She states that these emanate from her skin and
  cause insatiable itching.

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Case 1

• ROS pruritis and her brother with Downs synd.
  has the same complaints.
• PMH Inflammatory muscle disorder, HTN, G5P4
• MEDS clonidine, methylpred,
• ALL nkma

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Case 1

• SOC HX caretaker for her brother who requires
  much care, no tob, etoh, or drugs, lives in VA
  currently and KS, IL, AZ in the past, no pets,
  well water, no travel, no other family with
  similar sx.

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Case 1

• PE170, 160/73076096.8
• Pleasant with constant interjections and
  disruptions from her son.
• Well healed, crusted, excoriations on ant tibia,
  no other skin lesions seen
• Nml remainder of exam.
• Exam of dead insects in the jar was unrevealing

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Case 1

• LABS punch biopsy at WFUBMC showed ulceration
  secondary to excoriation.

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Case 1

• THE CATCH!
• Son states that this is obviously Colembola
  infestation.

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Colmebo what?
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Case 1

• Quick MEDLINE search revealed no referenced,
  human, peer reviewed literature on this.
• Environmental literature revealed that they live
  in soil in which ivermectin is used.
• I explained to them that her symptoms were not
  consistent with any known human pathogen.

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Case 1

• Good cop vs bad cop.
• Successful and consensual diagnostic and
  treatment plan.
• CBC with diff, CMP, ivermectin 12mg X1
• F/U with PCP for referrals (did not want us to
  refer for psychiatric eval.)

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Case 1

• Show of hands as to how many people have seen a
  consult for infestation/delusional disorders.

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Delusional ParasitosisObjectives

• Differential diagnosis for infestation disease in
  non-traveler.
• Psychiatric disorders referred to ID specialists.
• -Conversion
• -Borderline
• -Factitious
• -Delusional (delusions of parasitosis)

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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Lice (Pediculosis)
• Pediculosis capitis- head lice - Pediculus
  humanus var capitis
• Pediculosis corporis- body lice - Pediculus
  humanus var corporis
• Pediculosis pubis- pubic lice - Phthirus pubis

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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Body louse and head louse are similar, 2-4mm,
  elongated, with pointed heads
• Eggs laid by fertilized female are glued to hairs
  or clothing fibers.
• Nymphs emerge 7 days later, molt 3 times, and
  mate after 3 weeks.
• Females lay up to 300 eggs and die

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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Nymphs and adults obtain blood meal by piercing
  the skin, inject saliva, defecate.
• Pruritic papules develop from hypersensitivity
  reaction to saliva.
• Lice can transmit
• R prowazekki (epidemic typhus)
• B quitana (trench fever)
• Borellia recurrentis (relapsing fever).

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Delusional ParasitosisInfestation/Ectoparasitic
Infections
Pubic louse
Head louse
-Look for other STIs -Check other hair
beds -Viable for 1 month on clothes -lt1cm
blue/gray macules on trunk maculae cerulae blue
spots
-Temporal/occipital scalp -Nits oval on base of
hair shafts -Body louse is seen in clothing, not
skin
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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Scabies itch mite, Sarcoptes scabei
• Obligate parasite, adult is .35mm in length
• Lay eggs in skin, molt in stratum corneum
• Intense pruritis, worse at night.
• Erythematous papules on intertriginous and
  interdigital areas, wrists, ant. ax. folds,
  groin.

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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Scabies diagnosis is made by skin scraping
• Scrape over papule with blade or cover slip
• Wet mount

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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Norwegian Scabies debilitated, immunosup,
  institutionalized patients
• Higher mite burden, secondary infection

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Delusional ParasitosisInfestation/Ectoparasitic
Infections

• Myiasis-Tumbu, botfly, horse or cattle botflies
• Sea lice (Fla, Caribbean)
• Bites-fleas, bedbugs, reduvid bus
• Chigger (harvest mites or redbugs)-scrub typhus
  vector
• Screwworms, Housefly, Lucilia spp. (greenbottle
  flies) Wound myiasis

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Estimates of up to 1/3 of visits to dermatologist
  involve psychological problems
• Factitious fever in up to 10 of prolonged
  outpatient FUOs.
• Purely Pshychiatric or related conditions were
  diagnosed in 4 of consults in ID referral
  clinic. (next slide for list of dx.)
• Multiple reports of iatrogenic harm from
  investigations or treatments of these diseases.
• Rebecca Wurtz. CID 199826924-32

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Factitious Disorder
• FD Munchausen Syndrome
• Malingering
• Phobia
• Veneroneurosis
• OCD
• Somatization disorder
• Hypochondriasis
• Conversion disorder
• Delusional disorder
• Physician facilitation Rebecca Wurtz. CID
  199826924-32

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Factitious infection simulated illness, ie.
  fever and infection. Can be up to 10 of FUOs.
• Young adults with medical background
• Polymicrobial infections, undocumented fevers
• Factitious illness is its own DSM4 diagnosis
• TX is acknowledge the real stresses of the
  situation, typically resist psychiatric eval

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Factitious Disorder Munchausen Syndrome
• The most refractory subset of FDs
• Wander from doc to doc saying they have HIV
• Distinuish from phobia of illness
• Refractory to behavior modifications

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Phobias Persistent fear of specific objects or
  situations ie. HIV, TB, blood-injection-injury
  subtype.
• Not associated with rituals of OCD
• Often recognize the problem and will not resist
  psychiatric referral

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Veneroneurosis Genitally focussed
  hypochondriasis, syphililophobia
• Will respond to structured programs to formalize
  communication with their PCP and reevaluate their
  symptoms and sensations.

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• OCD Germophobia resultant in obsessions and
  compulsions that cause distress, are time and
  resource consuming, and interfere with
  functioning.
• Half of patients with OCD have contamination
  obsessions and washing compulsions.
• Can be referred from psychiatrist as part of
  cognitive therapy
• SSRIs may help
• Behavioral therapy

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Somatization Disorder Multiple unexplained
  complaints, dx req. rigorous criteria
• 4 pain symptoms-2 GI, 1 reproductive, 1
  neurological and age lt30 yo. Sx for years
• Much overlap with other psychiatric diagnoses
• Chronic fatigue Syndrome?
• Diagnosed as chronic brucellosis, chronic EBV,
  systemic candidiasis, HHV6
• Avoid inpatient w/u and schedule routine visits
  for reassurance

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Hypochondriasis preoccupation with fears of a
  serious disease based on miinterretation of ones
  own SS.
• In same class of DSM4 disorders as somatoform.
• Can also blend with OCD
• Reassurance and scheduled educational visits

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Conversion Disorder Unconscious production of
  symptoms to portray a serious illness
• Generally neurological sx.
• NOT intentionally produced
• Focus is on the symptom in Conversion D/O rather
  than the disease the disease as in hypochondriacs
• Resist psychiatric referral
• The authoritative specialist may help
• Hypnosis may help

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Delusional ParasitosisPsychiatric disorders
presenting as infectious diseases

• Physician Facilitation Physician may not
  recognize one the above disorders (chronic Lyme
  Disease and in a patient from an area with no
  endemic Lyme disease)
• No thorough exam and evaluation
• Subject the patient to tests and therapies
• Reinforce the misconceptions or beliefs/delusions

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Delusional Disorder
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Delusional ParasitosisPsyhiatric disorders

• DSM4 definition of Delusional Parasitosis
• Non-bizarre delusion of the somatic type for over
  one month.
• Rule out effects of substance of another medical
  condition.-formication, EtOH withdrawl.
• Not due to schizophrenia
• Mean age 57, FgtM
• Matchbook sign-bag-o-scabs
• Wilson. Mayo Clinic Proc 2004791470

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Delusional ParasitosisPsyhiatric disorders

• Even more consistent with the DX is when the
  delusion develops in another individual folie a
  deux
• family members are enlisted to believe the
  psychotic belief.
• Rarely seek psychiatric help, but rather a
  dermatologist or ID doc.
• DP involves the skin and soft tissues
• Wilson. Mayo Clinic Proc 2004791470

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Delusional Parasitosis

• DPEkboms Syndrome described in 1938
• DP is not a phobia of being infested with
  parasites, rather a delusional condition
• Aka monosymptomatic hypochondriacal psychosis,
  psychogenic parasitosis
• Typical presentation is with excoriations.
• Self-mutilation is not uncommon

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Delusional Parasitosis

• True infestation must be ruled out with skin
  scrapings and biopsy
• Empathetic listening
• Rule out medical cause. Ie. Lymphoma or a
  systemic disorder causing pruritis.
• Rule out substance abuse coccaine or amphetamine
• Some patients are receptive to definitive tests
  that rule out infestation

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Delusional Parasitosis

• Shakable vs non-shakable beliefs
• If non-shakable, medical and neuropsychiatric
  therapy required.
• Pimozide was the standard of therapy after a
  meta-analysis of 1223 pts showed 50 response
  rate. Trabert. Psychopathology 199523238-46
• No controlled studies on pharmacotherapy.
• Pimozide causes prolongation of QT interval and
  typical antipsychotics are avoided.

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Delusional Parasitosis

• Nicolato General Hospital Psychiatry
  20062885-87
• 10 patient series 7 female, 3 male
• SX for mean 18 mos.
• Matchbox sign in only one
• Derm signs varied
• Only 5 were diagnosed with delusional only
• Schizophrenia (1), major depression(2), dementia
  (2)
• 3 had neuroimaging abnormalities

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Delusional Parasitosis

• Nicolato General Hospital Psychiatry
  20062885-87
• Review of literature shows that social isolation
  and female preponderance are the typical
  features.
• Favorable outcome of treatment in 60

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Delusional Parasitosis

• Meehan. Archives of Dermatology142352-355
• Series of three patients successfully treated
  with olanzapine.
• Pimozide causes prolongation of QT interval and
  typical antipsychotics are avoided.
• Tell the patient that there is no evidence of
  infestation today.

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Delusional Parasitosis

• Summary
• Infectious Diseases consultant and primary care
  givers must have these diseases in their
  armamentarium
• Index of suspicion based on characteristic
  presentations and profiles
• Referral when necessary and feasible
• Atypical antipsychotics may be used by
  non-psychiatrists to treat delusions of
  parasitosis once organic causes are ruled out.

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No. 7 Baseball sweeps series with 11-1 victory in
eight innings over Kansas and can clinch B12
title with one more conference win.
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Case 2

• 50 yo wf with poorly controlled DM admitted for
  ab pain
• Gastroenteritis one month prior, and for past 3
  weeks has had LUQ pain and N/V/D
• PCP 3 weeks ago diagnosed viral GE, same as her
  grandchildren

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Case 2

• Seen in ED 4/30, labs, CT A/P.
• Large 10X5cm splenic cyst.
• Otherwise, her ED course was unremarkable and she
  was d/cd home on ciprofloxacin
• Pain increased and developed fever, chills,
  rigors, confusion.

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Case 2

• Returns to ED on 5/5/06, with temp 102.
• Blood cultures from 4/30/06 now positive, a GPC.
• Admitted to ICU.
• ID consult called.

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Case 2
BXC grew?
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Case 2

• In anaerobic culture BCX
• Streptococcus constellatus
• 2/2 anaerobic and no aerobic, GMS pos, vanco
  susc., catalase negative, Rapid ANA Kit for
  rapid ID of anaerobes

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Case 2

• On admit, she was afebrile and nauseated and
  complained of severe LUQ pain.
• N/V/D resolved.
• ROS otherwise, negative
• No recent procedures or dental work

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Case 2

• PMH DM, HTN, Hyperlipid
• SOX HX lives near hanging rock, no travel,
  homemaker, married, no tob, rtoh, drugs, inside
  and outside dogs and cats, lived in NC, NJ, FL,
  no sick contacts, no fam hx of IBD or ca.

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Case 2

• MEDS atenolol, Unasyn D0, ciprofloxacin D4
• NKMA

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Case 2

• PE Tm97.7, 140/80, 84,19
• Alert and in NAD, eating supper
• HEENT nml, missing several teeth but dentition
  was in good repair, no LAN
• CV/PULM reg, no murmur on HD1, but on HD2 there
  was a SEM, early, loudest at RSB and into rt
  neck, lungs were clear
• ABobese, soft, tender to palp at LUQ with palp
  spleen tip at left costal margin
• Otherwise, PE was unremarkable, no stigmata of IE.

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Case 2

• LABS
• WBC 6.7, H/H9/27, PLTS167
• CMP nml except BUN/Cr 17/1.6
• BCX 2/2 with anaerobic bottles grew at 1.5 days
• Streptococcus constellatus, repeat BCX neg at 24h

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Case 2

• Called on HD1 to see the patient.
• Tell me what you would recommend, Ill tell you
  what I did.

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Case 2

• ID Doc recs
• 1. Triple vaccinate
• 2. Unasyn
• 3. Repeat BCX
• 4. Surgery consult
• 5. TTE, TEE, identify the source
• 6. Repeat CT at 7d after initial scan
• 7. Read about S. constellatus

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Case 2

• OBJECTIVES
• 1. Review S. milleri group-Very
  confusing/inconsistent
• -virulence factors
• 2. Etiology of BSI with S. constellatus
• -do you have to hunt for an abscess/tumor/source?
• 3. Mgt of splenic abscess
• -medical
• -perc drainage
• -surgical

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Streptococcus constellatusMicrobiology

• GroupStreptococcus angiosus Group. Aka
  Streptococcus milleri group or S. intermedius
  group. 3 species comprise this group
• S. intermedius
• S. constellatus
• -subsp. constellatus
• -subsp. pharyngis
• S. angiosus

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Streptococcus constellatusMicrobiology Powderly
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Streptococcus constellatusMicrobiology

• Streptococcus angiosus Group all have a tendency
  to cause invasive pyogenic infections.
• Require CO2, not true anaerobes?
• Tiny strep colonies that smell like caramel on
  BAP diagnostic?
• Variable hemolysis-S. constellatus is beta
  hemolytic
• Lancefied gp F or C
• Biochemical tests distinguish this group from
  other strep

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Streptococcus constellatusMicrobiology

• J Clin Microbiol. 2006441836-38
• Most labs report to the group level
• Able to identify more precisely with species
  within the group using PCR
• Biochemical and morphologic tests are not 100
  reliable for species identification.

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Streptococcus constellatusMicrobiology

• ID is by viridans strep commercial kits.
• Considerable disagreement with S constellatus
• At most micro labs
• Bcx from BacT-alert, anaerobically incubated, pos
  _at_ 2 days
• GMS with GPC
• BAP innocuolated and show pin-point colonies at
  high CO2/anaerbic environ
• Catalase neg, vanc susc.
• Rapid-ANA kit to identify at the species level

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Streptococcus constellatusMicrobiology

• S. angiosus group-commensal in oral cavity
• Much literature from the periodontal literature
• S intermedius - detal plaques
• S angiosus in vaginal tract
• All species can inhabit the GI tract

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Streptococcus constellatusMicrobiology
Virulence factors

• This group grows well at low pH
• Abscess formation along with anaerobes that can
  enhance growth of this group.(Eikenella)
• Important in pulmonary infections
• Virulence factors like a adhensins allow binding
  of things like fibrin and platelets-IE!
• Capsule may protect from phagocytosis
• Hydrolytic enzymes like hyaluronidase allow pus
  formation and tissue plane penetration

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Streptococcus constellatusMicrobiology
Virulence factors

• Superantigens-can super activate lymphocytes
  without specificity and specific T cell
  specificity
• -Potent Th1 cytokine inducers
• Able to avoid or tolerate PMN ingestion
• Commensal organisms of the GI tract and are often
  the sole agent causing intra-abdominal abscess
  fromation.
• Not able to find splenic abscess but other
  visceral and solid organ infections are described

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Streptococcus constellatusMicrobiology
Virulence factors

• The use of metronidazole and gentamicin alone may
  select for this group
• S. constellatus and S. angiosus are the isolates
  from this group recovered from ab infections.
• S. intermedius is the most pathogenic (often sole
  pathogen)
• Silent colon cancer must be considered
• Viridans strep in neutropenic patients receiving
  chemo, with more severe disease that in
  non-neutropenic patients.
• Chemo agents that ulcerate the GI tract
  predispose patients to these infections

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Streptococcus constellatusClinical
characteristics

• Brain abscess and lung abscess. Case report and
  discussion. CID 200030397-8
• Indian J Med Res 2004119(sup)167-7
• Case series of 28 patient with BSI
• 10 of sterp BSIs (c/w prev reports)
• 55 had intra-abdominal sepsis (no splenic
  abscess)
• S. constellatus was associated with abscess

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Streptococcus constellatusClinical
characteristics

• CID 2001321511-5
• Using 16s rRNA idenitified 118 SMG isolates
  causing disease in Houston
• Illness was described without knowledge of the
  isolate/microbiology

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CID 2001321511-5
7/7 S. constellatus BSIs were assoc with
intra-abdminal process In 73 of isolates
obtained, S. constellatus was implicated as the
cause of an abscess 51 of SMG isolates were
from patients who has abscess as the presumed
source S. constellatus was often
polymicrobial S. intermedius was assoc with Head
and neck infections.
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Streptococcus constellatusTreatment

• PCN resistance has emerged and can be
  transmitted, probably dynamic process
• Aminoglycoside and beta-lactams demonstrate
  synergy and can be used if there is intermediate
  beta-lactam susceptibility
• Vanco and clinda (studies below did not show
  emergence of Clinda res. in SMG isolates)
• Specied id may not govern susceptibility
• Tracy et al. AAC 2001451511-14 (same group
  from Houston)
• Whiley et al. AAC 199230243-4

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Streptococcus constellatusSummary

• S. constellatus is associated with abscess
  formation and a source should be diligently
  sought.
• Identification of SMG, S. angiosus group, S.
  milleri to the species level can be clinically
  significant
• Treatment and diagnostic workup should be guided
  by the species within this group
• However, antimicrobial susceptibility may not be
  influenced by species id.

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Streptococcus constellatusSplenic Abscess?

• IE is the leading cause of splenic abscess, esp
  in immunocompromised
• Staph, Strep, Salmonella, E coli, fungal,
  Mycobacteria
• No cases of SMG
• Abx rarey curative
• Larger, loculated abscesses have high rates of
  failure with perc drainage.
• Mandell 6th ed.

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Streptococcus constellatusSplenic Abscess?

• What do we do with this pt if the surgeon does
  not want to perform splenectomy?