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GOOD MORNING!

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Title: GOOD MORNING!


1
  • GOOD MORNING!

2
MEDICAL GRANDROUNDS
  • Antonio A. Carlos, Jr., MD
  • First Year Resident
  • 12 June 2008

3
THE GREAT IMITATOR
4
OBJECTIVES
  • To present a case of liver abscess with an
    unusual cause
  • To give an overview on the etiology and
    management of liver abscess
  • To discuss melioidosis, its diagnosis and
    management.

5
  • Santiago City, Isabela

6
  • Santiago City, Isabela

7
IDENTIFYING DATA
  • E. B.
  • 58 year-old female
  • Married
  • Farmer
  • Non-diabetic
  • Non-hypertensive

8
CHIEF COMPLAINT
  • Abdominal pain

9
HISTORY OF PRESENT ILLNESS
  • 8 months prior to admission,
  • crampy left upper quadrant abdominal pain
  • occur intermittently
  • no fever, vomiting, and diarrhea

10
  • consulted at a local hospital
  • abdominal ultrasound showed the presence of three
    hepatic nodules
  • no treatment was done due to financial
    constraints
  • lost to follow-up

11
  • 2 months prior to admission,
  • intermittent abdominal pain
  • consulted in another local hospital
  • abdominal CT scan showed the presence of five
    hepatic nodules
  • advised biopsy of the nodules
  • opted to seek second opinion

12
  • 2 weeks prior to admission,
  • consulted a gastroenterologist in Manila
  • EGD was done
  • showed gastric ulcer
  • biopsy of the ulcer showed positive for
    Helicobacter pylori
  • started on H. pylori regimen

13
  • advised admission for the work-up of the hepatic
    nodules

14
PAST MEDICAL HISTORY
  • (-) Hypertension
  • (-) Diabetes
  • (-) Bronchial asthma
  • (-) Tuberculosis

15
FAMILY MEDICAL HISTORY
  • () Hepatitis A
  • () Bronchial asthma
  • (-) Hypertension
  • (-) Diabetes
  • (-) Tuberculosis

16
PERSONAL/SOCIAL HISTORY
  • Farmer
  • Non-smoker
  • Non-alcoholic beverage drinker
  • No known allergies

17
REVIEW OF SYSTEMS
  • (-) weight loss
  • (-) fever
  • (-) cough and colds
  • (-) loss of appetite
  • (-) easy fatigability
  • (-) chest pain
  • (-) palpitations

18
PHYSICAL EXAMINATION
  • GS conscious, coherent, ambulatory,
  • not in respiratory distress
  • VS BP 100/70 HR 82 RR 18 T 36.9
  • HEENT anicteric sclerae, pale palpebral
  • conjunctivae, no nasoaural
    discharge,
  • no CLAD
  • CL symmetric chest expansion,
  • clear breath sounds

19
  • CVS adynamic precordium, normal rate,
  • regular rhythm, distinct S1 and S2
  • ABD flat, normoactive bowel sounds, soft,
  • () direct tenderness on LUQ,
  • no guarding, no organomegaly
  • EXT no edema, no cyanosis,
  • full and equal pulses

20
SALIENT FEATURES
  • 58 year-old female
  • farmer
  • left upper quadrant abdominal pain
  • abdominal CT scan finding of hepatic nodules

21
What is the nature of the hepatic nodules?
22
DAY OF ADMISSION
  • Primary Impression
  • Hepatocellular carcinoma
  • Differential Diagnosis
  • Liver Abscess

23
EB
Abdominal Pain
Hepatic Nodules
Hepatocellular CA
Liver Abscess
Primary
Metastatic
Etiology??
24
  • CBC
  • CT Guided Liver Biopsy

Gram Stain
Culture and Sensitivity
AFB Smear and Culture
Cell Block
25
1st HOSPITAL DAY
  • Patient had febrile episodes, maximum temperature
    of 39.4C
  • Blood culture was done
  • Started on Metronidazole 50mg/IV q8
    Ciprofloxacin 500mg/tab, 1 tablet 2x a day
    Paracetamol 500mg/tab, 1 tablet every 4 hours

26
2nd HOSPITAL DAY
  • Patient still had febrile episodes
  • CBC done
  • Referred to Infectious Disease Service

27
What is the focus of the fever?
28
  • Patient was seen by the Infectious Disease
    Service

Transfer IV site
Urinalysis
Chest x-ray
29
EB
Liver Abscess
UTI
PTB
Phlebitis
Hepatocellular CA
Etiology??
Primary
Metastatic
30
3rd HOSPITAL DAY
  • Patient was still febrile
  • Liver aspirate culture grew gram negative rods,
    T/C Pseudomonas

31
  • Ciprofloxacin was discontinued
  • Piperacillin-Tazobactam 4.5g/IV every
  • 8 hours was started

32
4th HOSPITAL DAY
  • Liver biopsy showed negative for malignant cells
  • Cytomorphologic features consistent with an acute
    suppurative infection

33
  • Liver aspirate culture grew Burkholderia
    pseudomallei
  • Piperacillin-Tazobactam was shifted to
    Ceftazidime 1g/IV every 8 hours

34
EB
Liver Abscess
PTB
Hepatocellular CA
Burkholderia pseudomallei
Primary
Metastatic
35
5th HOSPITAL DAY
  • Blood culture and sensitivity showed no growth
    after 5 days
  • Day 1 afebrile

36
6th HOSPITAL DAY
  • Day 2 afebrile
  • Patient decided that blood transfusion
  • would be done in Isabela
  • Patient was discharged with follow-up
  • after 2 months

37
FINAL DIAGNOSIS
  • Melioidosis
  • Cannot totally rule out
  • Pulmonary Tuberculosis
  • Peptic ulcer disease

38
RECOMMENDATION
  • PTB work-up should be done

39
MELIOIDOSIS
40
HISTORICAL BACKGROUND
  • Named from the Greek melis (distemper of asses)
    and eidos (resemblance)
  • First described by pathologist Alfred Whitmore
    among morphia addicts in Burma in 1911
  • In 1917, Stanton and Fletcher identified the
    bacteria that cause the disease

41
  • 100 cases identified during the French occupation
    of Vietnam in 1948-1954
  • 300 cases identified during the American
    occupation in the 1970s, popularly known as the
    Vietnamese Time Bomb

42
EPIDEMIOLOGY
  • Regarded as endemic to Southeast Asia and
    Northern Australia
  • Corresponds approximately to latitudes between
    20oN and 20oS

43
  • Fig. 1 Worldwide distribution of melioidosis

44
REPORTED CASES
  • In Australia, 40 cases per 100,000 in 2002
  • In Thailand, 1,100 cases between 2004-2005
  • In Malaysia, 50 cases in 2002
  • In Singapore, 57 cases in 2004
  • In Taiwan, 43 cases in 2004
  • In Philippines, not reported in the world
    literature

45
ETIOLOGIC AGENT
  • Burkholderia pseudomallei
  • gram negative bacillus
  • bipolar staining
  • safety pin appearance
  • saprophytic
  • considered a Category 3 pathogen by the CDC

46
  • Resilient organism capable of surviving hostile
    environmental conditions
  • Produces several virulence factors
  • exopolysaccharides and lipase
  • phospholipase C
  • hemolysin
  • protease
  • Often called the Great Imitator

47
RISK FACTORS
  • Exposure to aquatic environments and agricultural
    lands
  • Diabetes mellitus
  • Chronic obstructive pulmonary disease
  • Use of steroids

48
CLINICAL SYNDROMES
  • Sepsis
  • Pneumonia
  • Liver abscess
  • Splenic abscess
  • Skin and soft tissue abscess

49
4 DISEASE CATEGORIES (CDC, 2000)
  • Acute localized infection
  • ? localized as a nodule
  • ? results from inoculation through a break in
    the skin
  • Acute pulmonary infection
  • ? produce a clinical picture ranging from mild
  • bronchitis to severe pneumonia
  • ? radiologic findings include nodule, upper lobe
  • consolidation, cavitary lesions

50
  • Acute bloodstream infection
  • ? patients with underlying illness such as
    diabetes,
  • renal failure are affected by this type
    of disease
  • ? usually results in septic shock
  • Chronic suppurative infection
  • ? involves the liver, lung, spleen, lymph nodes
  • ? may become dormant with exacerbation occurring
  • after primary infection

51
MODES OF ACQUISITION
  • Inoculation
  • ? major mode of acquisition
  • ? wounds to the feet of rice farmers are
  • common sites of inoculation
  • ? 25 in the Darwin study gave a history of
  • an inoculation injury prior to
    presentation

52
  • 2. Inhalation
  • ? based on studies of US soldier helicopter crew
  • in Vietnam
  • ? non-ambulant patients in Singapore acquired
  • the disease without exposure to soil or water

53
  • 3. Ingestion
  • ? contamination of potable water in two
  • outbreaks in Northern Australia

54
INCUBATION PERIOD
  • Incubation period of melioidosis is not clearly
    defined
  • In the Darwin Series, an incubation period of
    1-21 days has been defined
  • Incubation periods of as long as 24 to 29 years
    in ex-servicemen who were in Papua New Guinea and
    Vietnam have been described (hence the Vietnamese
    time bomb)

55
DIAGNOSIS
  • Isolation of B. pseudomallei remains the gold
    standard in diagnosis
  • A modified Ashdown medium with colistin is
    commonly used

56
  • Monoclonal antibody latex agglutination test
  • Shown to agglutinate blood culture fluid positive
    to B. pseudomallei
  • Sensitivity of 95 Specificity of 99.7

57
TREATMENT
  • Characteristics of Antimicrobial
  • It should have a bactericidal effect
  • Should be able to penetrate phagocytic cells
  • Eliminate or inhibit glycocalyx

58
  • Treatment of Melioidosis is divided into two
    stages
  • 1. an intravenous high intensity stage
  • 2. an oral maintenance stage to prevent
    recurrence

59
  • Intravenous Intensive Phase
  • Intravenous ceftazidime is the current drug of
    choice for melioidosis
  • Meropenem, imipenem, cefoperazone-sulbactam are
    also active
  • Amoxicillim-clavulanate may be used if none of
    the above are available

60
  • Maintenance Phase
  • Treatment with cotrimoxazole and doxycycline be
    used for 12 to 20 weeks to reduce the rate of
    recurrence
  • Co-amoxiclav is an alternative for those who are
    unable to take cotrimoxazole or doxycycline

61
PROGNOSIS
  • Without access to antibiotics, the septicemic
    form of melioidosis has a mortality that exceeds
    90
  • With appropriate antibiotics, mortality rate is
    about 10 for uncomplicated cases
  • Relapse rate occurs in 10 to 20 of patients

62
BIOLOGIC WEAPONS AGENT
  • CDC classified melioidosis as Category B
    biological weapons agent
  • Good candidate as a bioweapon because it is
    easily available in the tropics, easy to
    cultivate, sturdy, high potential to become
    bacteremic
  • Countries studying melioidosis as a bioweapon are
    USA, Russia, and Egypt

63
ACKNOWLEDGMENT
  • Dr. Miguel Fores
  • Dr. Tarcela Gler
  • Dr. Jodor Lim
  • Dr. Mabel Aloc
  • Dr. Sasa Samson
  • Dr. Ronnie Benitez
  • Dr. John Jarin
  • Dr. JC Sevilla
  • Arianne
  • Ivy
  • Abbey
  • Mara
  • Gelo
  • Ed B.
  • MM

64
  • THANK YOU!

65
CBC April 23, 2008
Hemoglobin 9.3
Hematocrit 30.9
WBC 9.91
Neutrophils 84
Lymphocytes 10
Eosinophils 1
Monocytes 5
Basophils 0
Platelet 263,000
66
CBC April 25, 2008
Hemoglobin 8.6
Hematocrit 28.6
WBC 5.91
Neutrophils 65
Lymphocytes 19
Eosinophils 4
Monocytes 12
Basophils 0
Platelet 220,000
67
Urinalysis
Color Yellow
Transparency Clear
pH Acidic
Specific Gravity 1.025
Sugar Negative
Proteins Negative
Ketones Negative
Nitrites Negative
Leukocyte Esterase Negative
Blood 0
RBC 0
WBC 0 1
Epithelial Cells 2
Bacteria 3
68
  • Consider calcified
  • granuloma in the left
  • apex.
  • The rest of the lungs are
  • clear.
  • Heart and other chest
  • structures are within
  • normal limits

69
Site of Collection Post Liver Biopsy April 23, 2008
Results Identified Organism/s Burkholderia pseudomallei Light growth
Sensitivities Amikacin 6 R Ticarcillin/Clavulanic acid 28 S Piperacillin/Tazobactam 29 S Cotrimoxazole 32 S Ceftazidime 25 S Cefepime 18 S Ciprofloxacin 24 S
70
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