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Case

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Case #1. 34 year old male with AML status-post allo-BMT complicated by severe GVHD ... Smoker with COPD, clinically like TB. Patient with known bronchiectasis ... – PowerPoint PPT presentation

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Title: Case


1
Case 1
  • 34 year old male with AML status-post allo-BMT
    complicated by severe GVHD
  • Admitted with lower fevers, GI bleed and
    diarrhea.
  • Nodule noted in right lower lobe of lung and a
    bronchoscopy was performed.
  • Modified acid fast stain requested.

2
BAL-Modified Acid Fast Stain
3
Case 1
4
Identification of Fungi
lt1um Branching Filaments (actinomycetes)
Filamentous fungi
Yeast
5
Actinomycetes
  • Resemble fungi in that they form filaments but
    their lack of mitochondria/membrane bound nucleus
    and susceptibility to anti-bacterial agents
    define them as bacteria.
  • Includes Nocardia, Nocardiopsis, Actinomadura,
    Streptomyces.
  • Initial distinction made on basis of partial
    acid-fast stain followed by chemical tests.
  • Nocardia are acid-fast positive.

6
Modified Acid Fast
Gram Stain
7
Nocardia
  • Can cause pulmonary, systemic or cutaneous
    disease.
  • Special request for modified acid-fast stain.
  • Special request for Nocardia culture.
  • Grow on Sab agar and LJ agar
  • White, orange chalky colonies
  • Will grow on blood, chocolate but can take over a
    week and normal sputum culture plates only held
    48 hours.
  • After suspect an actinomycetes will do further
    tests to determine genus/species (e.g., lysozyme
    sensitivity, casein decomposition)

8
Nocardia
9
Case 2
  • 23 year old woman presents with worsening left
    groin pain.
  • At age 15 developed cough and fever while living
    in Arizona which cleared on its own.
  • CT scan shows retroperitoneal abscess from which
    fluid was aspirated and sent for cytology and
    fungal culture.

10
Case 2
11
Case 2
12
Case 2 Abscess Fluid
13
Csae 2 Abscess Fluid
14
Identification of Fungi
lt1mm Branching Filaments (actinomycetes)
Filamentous fungi
Yeast
15
Filamentous Fungi
Hyaline monomorphic
Septate hyphae
Aseptate hyphae
Saprophytes -Aspergillus -Penicillium -Fusarium -S
copulariopsis -Others
Dermatophytes -Microsporum -Trichophyton -Epidermo
phyton
Hyaline Dimorphic -Histoplasma -Coccidioides -Othe
rs
Zygomycetes -Rhizopus -Mucor -Absidia -Cunninghame
lla -Others
Dematiaceous (dark mold) -Exophiala -Clodosporiu
m -Others
16
Dimorphic Fungi
  • Grow as filamentous molds in the environment or
    when cultured on routine mycology agar at 25-30
    degrees C
  • Yeast-like in vivo or when grown on enriched
    media at 35-37 degrees C
  • Includes Histoplasma, Coccidioides,
    Paracoccidioides, Blastomycoces, and Sporothrix

17
Coccidioides immitis
  • Endemic in Southwestern US, Central and South
    America
  • Typically asymptomatic or self-limiting
    respiratory infection although can infect almost
    any tissue.
  • Growth typically in 3-5 days although
    characteristic arthroconidia (barrel-shaped
    alternated with empty cells) may take 1-2 weeks
    to grow. White cottony colony.
  • Appears as spherule filled with endospores in
    tissue. Can produce spherules in vitro but need
    special conditions and not typically done.
  • Infection can be confirmed by exoantigen testing
    or nucleic acid probes.

18
Coccidioides-fungal form
19
Spherules and Endospores
20
Histoplasma capsulatum
Blastomycosis dermatididis
Coccidioides immitis
21
(No Transcript)
22
Case 3
  • 78 yo female presented to her PCP in 1999 with
    cough. Labs showed eosinophilia. CXR showed
    infiltrates. AFBx3 negative.
  • Eosinophilia decreased but developed
    bronchiectasis and pulmonary nodules.
  • Culture obtained from open lung biopsy.

23
MGIT System
  • Middlebrook media
  • Fluorescent compound on bottom that is quenched
    by oxygen in the tube.
  • As mycobacteria consume oxygen, fluorescence can
    be detected.
  • Most of MAC detected in nine days while MTB by 14
    days.
  • Follow up with acid fast stain.
  • Can test if fast grower by growth on MacConkey
    minus crystal violet
  • If growth, do further chemical tests (e.g,
    nitrate)
  • Otherwise, Gen-Probe

http//labmed.ucsf.edu/CP/SFGH/Microbiology/images
/MAI.jpeg
24
Gen-Probe
  • Start with Gen-probe to MTB, MA, MI
  • If negative, M. kansasii, gordonae
  • If unidentified, send to State Lab
  • All antibiotic testing done as send-out.

25
MAI
  • Major clinical scenarios in HIV negative
    patients.
  • Smoker with COPD, clinically like TB
  • Patient with known bronchiectasis
  • Elderly woman with infiltrates (Lady Windermere
    Syndrome)
  • CT often reveals small nodules

26
Case 3 continued
  • Patient presents in 2/2003 with worsened cough
    and sputum production.
  • Sputum sent for culture.

27
Identification of Fungi
lt1mm Branching Filaments (actinomycetes)
Filamentous fungi
Yeast
28
Filamentous Fungi
Hyaline monomorphic
Septate hyphae
Aseptate hyphae
Saprophytes -Aspergillus -Penicillium -Fusarium -S
copulariopsis -Others
Dermatophytes -Microsporum -Trichophyton -Epidermo
phyton
Hyaline Dimorphic -Histoplasma -Coccidioides -Othe
rs
Zygomycetes -Rhizopus -Mucor -Absidia -Cunninghame
lla -Others
Dematiaceous (dark mold) -Exophiala -Clodosporiu
m -Others
29
Pseudallescheria boydii
30
Pseudallescheri boydiiScedosporium
apiospermumGraphium
  • All the same organism
  • S. apiosperum and Graphium are asexual stages.
  • P. boydii is the sexual stage and you see
    cleistothecia

P. boydii
Graphium
S. agiospermum
31
Pseudallescheria boydii
  • Most commonly a cause of mycetoma
  • Can also infect other tissues (e.g., bone, lung)
    or be disseminated particularly in
    immunocompromised patients.
  • Resistant to amphotericin B

Khurshid, A, et al., Chest (1999), 116, 572.
32
Case 4
  • 55 yo male with newly diagnosed pulmonary
    fibrosis.
  • Right middle lung biopsy showed usual
    interstitial pneumonitis with active inflammatory
    component c/w possible recent infections or toxic
    insult.
  • Biopsy also sent for culture.

33
Filamentous Fungi
Hyaline monomorphic
Septate hyphae
Aseptate hyphae
Saprophytes -Aspergillus -Penicillium -Fusarium -S
copulariopsis -Others
Dermatophytes -Microsporum -Trichophyton -Epidermo
phyton
Hyaline Dimorphic -Histoplasma -Coccidioides -Othe
rs
Zygomycetes -Rhizopus -Mucor -Absidia -Cunninghame
lla -Others
Dematiaceous (dark mold) -Exophiala -Clodosporiu
m -Others
34
Aspergillus
35
Aspergillus terreus
  • Cinnamon-brown colony
  • Biseriate phialides, compactly columnar
  • Aleuriospores found submerged in agar

36
Aspergillus niger
  • Black colony
  • Biseriate phialides which cover entire vesicle
    and radiate

http//www.iums.org/ICPAAspnig.htm
37
Aspergillus flavus
  • Light green to brown colonies. Produce
    aflatoxin.
  • Uniseriate and biseriate phialides that cover
    entire vesicle and point out in all directions.
  • Orange growth on Aspergillus differentiation
    media.

http//www.apsnet.org/online/archive/1998/pean074.
htm
38
Aspergillus fumigatus
  • Velvety, dark green colonies.
  • Uniseriate phialides, usually on upper 2/3 of
    vesicle.
  • Also can grow at 50 degrees.

39
Case 5
  • Recently homeless male
  • Presented to primary doctor with dystrophic
    toenails and tinea pedis not responsive to OTC
    anti-fungals.
  • Toenail sent for culture.

40
Filamentous Fungi
Hyaline monomorphic
Septate hyphae
Aseptate hyphae
Saprophytes -Aspergillus -Penicillium -Fusarium -S
copulariopsis -Others
Dermatophytes -Microsporum -Trichophyton -Epidermo
phyton
Hyaline Dimorphic -Histoplasma -Coccidioides -Othe
rs
Zygomycetes -Rhizopus -Mucor -Absidia -Cunninghame
lla -Others
Dematiaceous (dark mold) -Exophiala -Clodosporiu
m -Others
41
Scytalidium dimidiatum
  • 20 year old Pakistani female rice-field worker.
  • Disease began 6 years ago.
  • Does not grow on mycobiotic agar (due to
    cycloheximide.
  • 50 improvement after 6 weeks of treatment with
    ketoconazole.



42
Scopulariopsis
Annellide
Conidia
  • Hyaline, monomorphic, saprophyte.
  • Often a contaminant but can cause nail infection.
    Rarely soft tissue, bone or lungs in
    immunocompromised.

43
Case 6
  • 51 yo female s/p double lung transplant presents
    with productive cough
  • CXR showed clear lungs
  • Sent for flexible bronchoscopy with culture.

44
Bordetella bronchiseptica
  • Gram negative pleomorphic rods.
  • Unlike B. pertussis, will grow on blood and often
    MacConkey.
  • Cause of kennel cough (dogs), snuffles (rabbits),
    atrophic rhinitis in pigs.
  • Also know to cause pertussis like syndrome in
    humans especially those exposed to animals and
    immunocompromised hosts.

45
Bordetella
  • Antibiotic susceptibility
  • B. pertussis and parapertussis usually sensitive
    to erythromycin.
  • B. bronchiseptica is resistant to erythromycin.


46
Case 7
  • 34 yo male with AIDS presents with dizziness,
    nausea and vomiting.
  • Develops diarrhea while in hospital.

47
Microsporidium
Trichrome stain
48
Microsporidium
Legend Pt Portion of coiled polar tubuleEx
Electron dense exosporeEn Electron lucent
endosporePv Posterior vacuole
Species by EM Treatment albendazole
http//www.zoo.utoronto.ca/dgodt/Microspridia20EM
.html

http//www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/Micr
osporidiosis_il.asp?bodyM-R/Microsporidiosis/body
_Microsporidiosis_il_th.htm
49
(No Transcript)
50
E. Intestinalis vacuole
Eukaryotic cell bursting and Releasing E. hellem
spores
51
(No Transcript)
52
Case 8
  • 69 yo patient found unresponsive outside after
    housefire. Intubated in field, soot in airway.
  • Brought to BWH for burn management.
  • Developed fever while in SICU. CT scan showed
    free gas in peritoneum.

53
Anaerobic Isolation
Growth in anerobic blood culture bottle
Plate on CNA, KV and Brucella plates
for anaerobic growth
No growth
Gram stain. Plate on blood, chocolate and
McConkey and grow aerobically.
Gram stain, plate with kanamycin, colistin and
vancomycin discs
Gram postive, Boxcar shaped rods
Growth
Look for other features suggestive Of C.
perfringens RapidANA.
Work-up for aerobic culture.
Double zone of Beta-hemolysis
Lecthinase production
54
Clostridium perfringens
  • Box-car shape
  • Lecithinase positive on egg-media.
  • Double zone beta-hemolysis
  • Sepsis characterized by spherocytes with severe
    intravascular hemolysis.

55
Case 9
  • 18 yo Harvard student developed sore throat.
  • Heterophile positive. Very severe sore throat
    treated with steroids.
  • Presented one month later with SOB and pain in
    right shoulder. CXR showed RLL pneumonia with
    effusion (empyema).
  • Culture of effusion grew Streptococcus.
    intermedius.

56
Case 9
  • 18 yo Harvard student developed sore throat.
  • Heterophile positive. Very severe sore throat
    treated with steroids.
  • Presented one month later with SOB and pain in
    right shoulder. CXR showed RLL pneumonia with
    effusion (empyema).
  • Culture of effusion grew Streptococcus.
    intermedius.

57
Strep and Staph
Streptococci in sputum sample
Staphylococci in wound sample
58
Isolation of Strep and Staph
Gram cocci
Clusters, catalase
Chains, catalase -
Staphylococcus
Streptococcus, Enterococcus
Coagulase
Coagulase -
S. aureus
R
S
Novobiocin
S. saprophyticus
S. epidermidis
59
Coagulase Test
  • Initial test is Staphaurex
  • Fibrinogen coated particles to detect bound
    coagulase.
  • IgG coated particles to detect protein A
  • Sensitivity 99.8
  • Should do tube coagulase to detect free coagulase
    if high clinical suspicion of S. aureus
  • Specificity 99.5
  • False positives with S. saprophyticus
  • Tube coagulase test (some strains only produce
    free coagulase)
  • In plasma
  • Look for clumping after 4 hours.
  • To detect weak coagulase producing strains, read
    again at 18 hours. Strong producers can look
    negative at this point.

60
Isolation of Strep and Staph
Streptococcus, Enterococcus
Hemolysis on sheep blood agar
Alpha
Gamma
Beta
Optochin, Bile solubility
Strepstrip
Bile esculin High salt growth PYR test
Type Also, Grp A bacitracin sensitive.
Sensitive, soluble
Viridans Strep
Enterococcus
S. pneumoniae
61
Alpha-hemolytic Streptococci
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