南區感染科 聯合討論會

高雄長庚 感染科Fellow1 許睿琪 2018/10/18 General data

• Name: 張葉O O • Age/gender: 64-year-old female • Admission date: 2018/07/30 Present Illness

• Admit to Ophthalmology department for elective surgery for rhegmatogenous retinal detachment with macula off (OS)

• Past history: Hypertension, HBV, HCV Clinical Course

Amoxycillin 1g+Clavulanic acid 200mg IVF Q8H

Consult ID Present Illness

• Dysuria, rhinorrhea, right hip pain, left shoulder pain, no local heat, no limited ROM • Back pain for months • Physical examination – Systolic murmur over sternal border TOCC

• Travel history: 無境外, 外島旅遊史 • Occupation: 冷凍魚屠宰業(海水魚) – Injury of left thumb in 2018/4, • Contact history: 流浪貓 • Cluster history: 無 LAB data

Hemogram Biochemistry Urinalysis WBC 12700 /ul BUN 28 mg/dL Color Yellow Hb 9.3 g/dl Cr. 1.10 mg/dL Turbidity Clear Hct 28.2 % Na 131 meq/L SP. Gravity 1.013 Platelet 83 K/ul K 4.6 meq/L pH 6.5 Segment 83.0 % Cl 108 mg/dL Leukocyte Negative Monocyte 7.0 % AST 81 U/L Nitrite Negative Lymphocyte 9.0 % ALT 54 U/L Protein Negative Eosinophil 1.0 % Total Bil. 1.3 mg/dL Glucose Negative Basophil 1.0 % Alb 2.5 g/dL Ketone Negative Culture CRP 37.4 mg/L Bilirubin Negative Blood culture pending Influenza A+B Negative Blood 1+ Sputum smear acid-fast bacillus not found Sputum mycobacterium culture: pending

Clinical Course

Amoxycillin 1g+Clavulanic acid 200mg IVF Q8H

Consult ID Blood culture

• 8/1 GPB ------(2/2) PATHOGEN? Blood Culture

• Erysipelothrix rhusiopathiae Clinical Course

8/5 8/10 8/13 8/14 8/15 9/4

Transfer to L-spine X ray 2D Echo T.E.E study WBC 2600/uL ID ward Hb 9.4g/dL Fever Bone scan Gallium scan Plt 73K/uL

Dapyomycin Ceftriaxone 1gm IVF Q12H Peniillin G 3MU IVF Q4H 500g IVF QD Clinical Course

9/26 10/3

2D ECHO: OP: Severe MR due to P1 Still vegetation at ant. mitral chordae rupture s/p MV leaflet, 0.55 cm ; at aortic repair valve, 0.8 cm in diameter →Consult CVS

Sputum mycobacterium culture: Mycobacterium tuberculosis

Dapyomycin 500g IVF QD Final diagnosis

• Infective endocarditis with Erysipelothrix rhusiopathiae septicemia, severe MR due to posterior chordae rupture s/p mitral valve repair on 2018/10/3 • L2, L3 osteomyelitis • Pulmonary tuberculosis • Gout arthritis • Rhegmatogenous retinal detachment (OS) • Chronic hepatitis B and C • Hypertension Discussion

Erysipelothrix Infection Erysipelothrix rhusiopathiae

• Gram-positive bacillus • Widespread in nature, also infects domestic and marine animals • Estimated 30-50% healthy swine harbour the organism • Swine • Occupationally related infection in humans – Contact with contaminated animals, their products, wastes or soil – Butchers, veterinarians, farmers, fishermen, fish-handlers, housewives • Infection is initiated by an injury to the skin with infective material or when a previous injury is contaminated Clinical manifestation

• Localized cutaneous infection • Diffuse cutaneous infection • Systemic infection Localized cutaneous infection

• of Rosenbach, subacute cellulitis • Fingers of fisherman, pork fingers • Incubation period: 2-7 days • Symptoms begin with pain at the site of inoculation, progresses slowly • Well-defined, slightly elevated, violaceous zone • Self-limiting and resolves in 3 weeks Diffuse cutaneous infection

• Same types of exposures as those with localized cutaneous infection; eating seafood/uncooked pork • Proximal progression of involvement from the inoculation site or additional sites • Urticarial or bullous lesions • Fever, arthralgia • Blood culture are usually negative Systemic infection

• Antecedent or concurrent Erysipeloid/ Ingested contaminated foods • Bacteremia is relatively uncommon – Often complicated by endocarditis – 1/3 of patients died, additional 1/3 required valve replacement • Chronic liver disease is a predisposing factor Other manifestation

• Brain , meningitis, endophthalmitis • Intra-abdominal abscess, psoas abscess, • Osteomyelitis, septic arthritis • Epidural and paravertebral • Pneumonia • Peritoneal dialysis-related peritonitis with bacteremia Diagnosis

• History & characteristic physical findings • Suspected in cutaneous or systemic gram-positive infection that fail to respond to vancomycin • Gram stain & culture of aspirated material are often negative • MALDI-TOF Treatment

• Penicillin is the drug of choice • In vitro, penicillin and imipinem are the most active agents • Other active agent include cephalosporins, fluoroquinolones, clindamycin, daptomycin and linezolid • Resistance to vancomycin is a clinically relevant characteristics Thanks for your attention