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ID Case Conference

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Original injury in 04/07, when pt's toe got stuck on a fringe in carpet, causing ... Osteomyelitis of first great toe, and grossly displaced calcaneal cuboid ... – PowerPoint PPT presentation

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Title: ID Case Conference


1
ID Case Conference
  • September 4, 2007
  • Yvonne L. Ballard

2
Case
  • CC right foot pain
  • HPI
  • 44yo WF with DM presented to vascular surgery
    clinic with right foot pain, at first metatarsal
  • Original injury in 04/07, when pts toe got stuck
    on a fringe in carpet, causing a fallpt
    developed ulcer of right first toe, which
    progressively got worse

3
  • PMH
  • Diabetes Mellitus
  • Hypertension
  • CHF
  • Morbid Obesity
  • Medications
  • Glucophage
  • Insulin 70/30
  • Lasix
  • Lisinopril
  • Neurontin
  • Spironolactone
  • Zocor
  • Celexa
  • Aspirin
  • SocHx
  • Smokes 1ppd
  • No Etoh, illicits
  • No pets
  • No recent travel
  • NKDA
  • FamHx
  • CAD

4
Sequence of Events
  • 6/28/07 Pt reports increasing pain to right
    first MTP, with associated color changes of the
    toe
  • 7/5/07 Seen in Vasc Surg clinic, and admitted to
    hospital
  • Xray Osteomyelitis of first great toe, and
    grossly displaced calcaneal cuboid joint
  • Arterial duplex ABIs of 0.49 and 0.59 in the
    anterior and posterior tibial arteries
  • 7/9 Angiography and stenting of R SFA
  • 7/10 Repeat Xray showed multiple displaced
    fractures at the mid foot level, and 3rd and 4th
    metatarsals

5
(No Transcript)
6
  • 7/6 bedside debridement (resection of
    superficial necrotic skin only in the region of
    the first toe)
  • 7/11 Discharged home on IV antibiotics
    Vancomycin, Zosyn
  • (stop date of 8/15/07)
  • 7/24 Amputation of first right toe
  • 8/16 re-admitted for new black eschar in middle
    of her wound, with increased drainage
  • 8/16 wound debridement (down to bone) and biopsy
    sent to Micro

7
Physical Exam, 8/21
  • Vitals Tm 36.1, BP 107/62, P 56
  • Physical Exam
  • Gen NAD
  • CV RRR
  • Resp CTA B/L
  • Ext large surgical wound on right foot, wound
    from amputation shows small black area at base
    without purulence

8
Labs, 8/21
  • WBC 10.3
  • Hct 36.5
  • Plt 137
  • LFTs WNL
  • Coags WNL
  • BUN/Cr 20/1.5
  • ESR 45

9
  • 8/21 Discharged home with IV Abx
  • Vancomycin
  • Ertapenem
  • Posaconazole

10
Discussion
11
  • 8/16 Biopsy Results
  • 4 Candida parapsilosis
  • HOWEVERThere was a significant amount of mould
    growing UNDER the Candida on the plate

12
Alternaria alternata
  • One of the causative agents of phaeohyphomycosis
  • Emerging opportunistic pathogen in
    immunosuppressed patients
  • Is ubiquitous common laboratory contaminant

13
Phaeohyphomycosis
  • Immunocompetent
  • Cutaneous
  • Subcutaneous
  • Brain abcesses
  • Sinusitis
  • Immunocompromised
  • Fungemia
  • Disseminated disease
  • Other Described Cases
  • Meningitis
  • Pneumonia
  • Prosthetic valve endocarditis
  • Peritoneal dialysis catheter infection
  • Osteomyelitis
  • Septic Arthritis

14
Alternaria alternata
  • A fungus commonly isolated from plants, soil,
    food, and indoor air environment
  • Produces a melanin-like pigment
  • A. alternata is the most common species of 50
    species in the Alternaria genus
  • Colonizes the paranasal sinuses, leading to
    chronic hypertrophic sinusitis

15
Alternaria alternata
  • Onychomycosis
  • Sinusitis
  • Ulcerated cutaneous infections
  • Keratitis
  • Visceral infections
  • Osteomyelitis

16
Patient Characteristics
  • See table in
  • Lyke KE, Miller NS, Towne L, Merz WG.
  • A case of cutaneous ulcerative alternariosis
    rare association with diabetes mellitus and
    unusual failure of itraconazole treatment.
  • Clin Infect Dis. 2001 Apr 1532(8) 1178-87. Review

17
Other species
  • A. chartarum
  • A. dianthicola
  • A. geophilia
  • A. infectoria
  • A. stemphyloides
  • A. teunissima

18
Images
  • To view images of the fungus,
  • go to Doctor Fungus at
  • http//www.doctorfungus.org/index.htm

19
Macroscopic Features
  • Grows rapidly on potato glucose agar (at 25 C)
  • Colony flat, downy/woolly
  • Covered by grayish, short aerial hyphae
  • Initially greyish white, later turns greenish
    black or olive brown with light border

20
Microscopic Features
  • Septate brown hyphae
  • Simple or branched large conidia, with transverse
    and longitudinal septations
  • May produce germ tubes
  • Ovoid, darkly pigmented, smooth or roughened
  • End is round, tapers at apex (beak-like
    appearance)

21
Histopathologic Features
  • HE stain
  • Dark colored filamentous hyphae
  • Fontana-Masson silver stain
  • Specific to melanin

22
Susceptibilities
  • No standardized in vitro susceptibility testing
  • Caspofungin shown to be active in vitro
  • Voriconazole
  • Generated lower MICs than Itraconazole

23
Treatment Case Reports
  • Systemic -azoles
  • Intralesional Ampho B and surgical excision
  • Immunotherapy

24
Search PubMed
  • Alternaria alternata infections
  • Case reports
  • Reviews
  • Differential Diagnosis
  • Drug Therapy
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