INFECTIOUS DISEASES CASE PRESENTATIONS - PowerPoint PPT Presentation

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INFECTIOUS DISEASES CASE PRESENTATIONS

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Afebrile. BP 105/70 mmHg. PR 60 reg. O2 Sat 100% RA. Examination Findings. No photophobia ... Afebrile. BP 145/90 mmHg. PR 55 regular. O2 sat 98% room air ... – PowerPoint PPT presentation

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Title: INFECTIOUS DISEASES CASE PRESENTATIONS


1
INFECTIOUS DISEASES CASE PRESENTATIONS
  • Dr Peter Leung
  • Registrar
  • Immunology Infectious Diseases
  • John Hunter Hospital

2
INFECTIOUS DISEASES CASE PRESENTATION
  • Case 1

3
Ms TG
  • 30-year-old female
  • lives with partner
  • 2 children
  • Non-smoker
  • Non-drinker

4
Ms TG
  • Works with cattle on farm
  • Recent holiday to New Zealand
  • No significant contact history
  • No significant past medical history
  • No regular medication
  • No known allergies

5
Ms TG
  • Nov 2004, 5 week history
  • Headache
  • Entire head, concentrated over frontal and
    occipital regions
  • Severe
  • Minimal relief from simple analgesia
  • Nausea, intermittent vomiting
  • Neck stiffness
  • Mild photophobia

6
Ms TG
  • Drenching night sweats
  • No rigors nor documented fevers
  • Weight loss of 10kg
  • No weakness, no sensory changes, no visual
    disturbance

7
Ms TG
  • Initially presented to MBH
  • CT head normal
  • LP
  • Protein 0.49g/L
  • Glucose 3.0mmol/L
  • India Ink demonstrated cryptococcus
  • Diagnosed cryptococcal meningitis

8
Ms TG
  • MBH
  • respiratory arrest post ictal
  • Found in vomitus and incontinent
  • Supported with bag and mask
  • Patient had no recollection of events
  • Subsequently transferred to JHH

9
Examination Findings
  • Thin
  • Holding head
  • Afebrile
  • BP 105/70 mmHg
  • PR 60 reg
  • O2 Sat 100 RA

10
Examination Findings
  • No photophobia
  • Neck stiffness (unable to flex gt30)
  • Cranial nerves and PNS normal

11
Initial Investigations
  • Hb 106 MCV 68 WCC 6.2 Plt 301
  • Na 134 K 3.7 Cr 59 urea 1.9
  • LFT normal

12
Initial Management
  • Amphotericin B 0.5mg/kg
  • Flucytosine 37.5mg/kg QID
  • PICC line insertion

13
Further Investigations
  • Serum cryptococcal antigen titre gt11024
  • HIV negative
  • Repeat LP
  • Cryptococcal Ag gt11024
  • WCC 10, protein 0.53g/L, glucose 2.8mmol/L
  • India ink positive for cryptococcus
  • Cultured Cryptococcus neoformans var gattii

14
Further Investigations
  • Serial LPs to assess for clearance of
    cryptococcus and to relieve raised ICP
  • multiple visual field tests to monitor for visual
    loss from papilloedema
  • Serial CSF cryptococcal Ag levels
  • MRI brain negative for cryptococcoma

15
Progress
  • GTC seizures
  • Rx Phenytoin
  • Treatment related complications
  • Leucopenia from 5-FC despite in therapeutic
    range, requiring brief cessation of drug
  • Hypokalaemia from Amphotericin B
  • ?Cr secondary to Amphotericin B and 5-FC
  • PICC site cellulitis

16
Progress
  • No further seizures
  • No further ve cultures for cryptococcus on CSF
  • ICP reduced with LPs (opening pressure 17cm
    pre-discharge)
  • Subsequently switched onto Fluconazole and
    discharged home mid December 04 with follow up
    appointments arranged

17
Early Jan 05
  • Re-admission
  • Brief admission after repeat LP by LMO
    demonstrated cryptococcus (India Ink) but
    subsequently shown to be culture negative and CSF
    Cryptococcal Ag titre 116
  • Discharged home

18
Mid-to-late Jan 05
  • Re-presented with intractable headache
  • CT and MRI showed no focal lesions
  • Repeat LP demonstrated raised opening pressure of
    gt38cm H2O
  • Lumboperitoneal shunt inserted with rapid
    resolution of symptoms
  • Patient discharged early Feb

19
Late Feb 05
  • Represented after 3 days of increasing headache
  • Frontal and temporal regions
  • Worse in afternoon
  • ?worse with straining
  • Also some nausea and vomiting the day before
    admission
  • Admitted for Ix and Mx

20
Late Feb 05
  • Examination revealed bilateral papiloedema,
    fullness around LP shunt sites at the lumbar
    spine and abdominal site
  • Taken back to theatre
  • Shunt was working

21
Late Feb to March 05
  • Ongoing worsening headache
  • Repeat LP
  • Opening pressure 21cm H2O
  • India Ink neg for cryptococcus
  • WCC 96
  • Glucose 1.7mmol/L
  • Protein 1.65g/L
  • No growth

22
Late Feb to March 05
  • Repeat MRI V and review of previous MRIs
  • Filling defects seen in both sigmoid sinuses
    suggesting partial thrombosis
  • Rx anticoagulation

23
March 05
  • Depressed, non-engaging, lack of initiation
  • Citalopram commenced
  • Malnourished requiring supplementary NGT feeding
  • Constipated with nausea and vomiting
  • Drowsy from gabapentin (commenced for both
    headache and seizure control)

24
Last 2 Weeks
  • Hyponatraemia Na 123
  • ?CNS disease ? Citalopram
  • ?Extra-cranial cryptococcal deposits
  • Persistently raised serum cryptococcal Ag levels
  • Liposomal Amphotericin B recommenced pending CT
    chest/abdo/pelvis
  • CT
  • Deposits in lungs and liver

25
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26
Last Week
  • Developed receptive dysphasia
  • CT and MRI head showed cerebral cryptococcomas

27
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28
Last Week
  • Dosage of Liposomal Amphotericin B increased
  • 5-FC not commenced as previous problem with
    leucopenia
  • Waiting to see if clinically responding to
    escalated treatment

29
INFECTIOUS DISEASES CASE PRESENTATION
  • Case 2

30
Mr GC
  • 50-year-old male
  • Lives with mother
  • Works as flagman for RTA
  • Non-smoker
  • Occasionally alcohol
  • Admitted at JHH Dec 2004

31
Mr GC
  • HIV infection
  • Diagnosed 1993
  • Claimed to have contracted HIV from heterosexual
    contacts
  • Denied IVDU
  • Previously on antiretrovirals (Efavirenz/Lamivudin
    e/Abacavir) but not last 6 months secondary to GI
    intolerance
  • Relatives unaware of diagnosis

32
Mr GC
  • AVR
  • Severe aortic regurgitation
  • Congenital biscuspid aortic valve
  • Porcine prosthesis

33
Mr GC
  • Initially admitted to PMPH
  • 2-month-history of lethargy
  • 2-week-history of
  • Back pain
  • Neck pain
  • Headache (bitemporal) throbbing
  • Mild photophobia
  • Fevers, rigors, sweats
  • Nausea and vomiting since admission
  • No cough/chest pain/dyspnoea/abdo pain/dysuria

34
Mr GC
  • Transferred to JHH following an abnormal BC
    result ve for yeast

35
Medications
  • Aspirin 100mg daily
  • Carvedilol 6.25mg BD
  • Frusemide 20mg daily
  • Ramipril 10mg daily
  • Bactrim 3 ? per week
  • Fluconazole 400mg daily

36
Adverse Drug Reactions
  • Panadeine forte and morphine caused vomiting

37
Examination Findings
  • Looked unwell
  • Photophobic
  • Pain in neck on movement
  • Afebrile
  • BP 145/90 mmHg
  • PR 55 regular
  • O2 sat 98 room air

38
Examination Findings
  • Neck stiffness
  • Well hydrated
  • Systolic murmur
  • No peripheral stigmata of infective endocarditis
  • Chest and abdo exam unremarkable

39
Initial Investigations
  • Hb 161 MCV 90 WCC 5.7 neut 4.3 lymph 0.9
    plt 192
  • ESR 26 CRP lt4
  • Na 138 K 4.5 Cr 80 urea 3.7
  • TP 74 alb 37 glob 37 GGT 149 ALP 125
    AST 28 ALT 60 bili 13
  • CXR and CT head normal

40
Provisional Diagnosis
  • Cryptococcal meningitis with associated fungaemia
    pending identification and sensitivities from
    original blood cultures

41
Blood Culture Results
  • Cryptococcus neoformans var. neoformans

42
Further Investigations
  • Serum cryptococcal antigen
  • Strongly positive gt11024
  • T cell subsets
  • CD4 count 40
  • HIV viral load
  • gt100 103/mL
  • LP
  • Glucose 1.8mmol/L protein 1.01g/L
  • Cryptococcus neoformans var. neoformans

43
Treatment
  • Initially Fluconazole while waiting for further
    results
  • Amphotericin B and 5-Flucytosine IV commenced
    after definitive diagnosis (had total of about 6
    weeks)
  • Regular LPs to monitor CSF clearance of
    cryptococcus and to relieve raised ICP
  • Antiretrovirals eventually recommenced

44
Progress Last 2 Months
  • Slow to respond to treatment
  • Ongoing headache
  • Delirious
  • Verbally aggressive
  • Refusal to take in oral intake
  • Tendency to pull out IV access and NGT
  • Deconditioning as a result of prolonged illness

45
Progress
  • Complications
  • Acute renal impairment (? Cr)
  • E. coli UTI
  • Central line sepsis
  • Malnutrition requiring initially TPN but
    subsequently PEG insertion and feeding
  • MRSA colonisation

46
However.
  • Has turned the corner the last 2 weeks
  • More alert
  • Able to hold brief conversations
  • Participating in ward physiotherapy

47
What Does the Future Hold for Him
  • Have to wait and see.
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