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Clinical Case Conference

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Title: Clinical Case Conference


1
Clinical Case Conference
  • Clinical Case Conference
  • May 8, 2006
  • Robin Trotman, D.O.

2
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3
Case 1
  • 69 yo wf seen as an emergency consult for
    dermatology for parasitosis.
  • CC Skin lesions and larvae crawling on her skin.

4
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.

5
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.

6
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.

7
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.

8
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.

9
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

10
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.

11
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

12
Case 1
  • LABS punch biopsy at WFUBMC showed ulceration
    secondary to excoriation.

13
Case 1
  • THE CATCH!
  • Son states that this is obviously Colembola
    infestation.

14
Colmebo what?
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17
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.

18
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.)

19
Case 1
  • Show of hands as to how many people have seen a
    consult for infestation/delusional disorders.

20
Delusional ParasitosisObjectives
  • Differential diagnosis for infestation disease in
    non-traveler.
  • Psychiatric disorders referred to ID specialists.
  • -Conversion
  • -Borderline
  • -Factitious
  • -Delusional (delusions of parasitosis)

21
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

22
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

23
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).

24
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
25
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.

26
Delusional ParasitosisInfestation/Ectoparasitic
Infections
  • Scabies diagnosis is made by skin scraping
  • Scrape over papule with blade or cover slip
  • Wet mount

27
Delusional ParasitosisInfestation/Ectoparasitic
Infections
  • Norwegian Scabies debilitated, immunosup,
    institutionalized patients
  • Higher mite burden, secondary infection

28
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

29
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

30
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

31
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

32
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

33
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

34
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.

35
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

36
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

37
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

38
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

39
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

40
Delusional Disorder
41
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

42
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

43
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

44
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

45
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.

46
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

47
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

48
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.

49
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.

50
No. 7 Baseball sweeps series with 11-1 victory in
eight innings over Kansas and can clinch B12
title with one more conference win.
51
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

52
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.

53
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.

54
Case 2
BXC grew?
55
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

56
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

57
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.

58
Case 2
  • MEDS atenolol, Unasyn D0, ciprofloxacin D4
  • NKMA

59
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.

60
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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65
Case 2
  • Called on HD1 to see the patient.
  • Tell me what you would recommend, Ill tell you
    what I did.

66
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

67
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

68
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

69
Streptococcus constellatusMicrobiology Powderly
70
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

71
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.

72
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

73
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

74
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

75
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

76
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

77
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

78
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

79
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.
80
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

81
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.

82
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.

83
Streptococcus constellatusSplenic Abscess?
  • What do we do with this pt if the surgeon does
    not want to perform splenectomy?
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