Clinical manifestations of brucellosis and leptospirosis
Heinz Burgmann Department of Internal Medicine Division of Infectious Diseases Medical University of Vienna
Fever after sexual intercourse admissional status
. 25-year old woman, good general conditions . Fever attacks since 6 weeks . Night sweats . Weight loss . Arthralgia,headache . Swelling of cervical lymph nodes
Heinz Burgmann Fever after sexual intercourse Medical history I
. No former diseases . No recent visit abroad . No household pets . No exanthema . No dysuria . No diarrhea
B-Symptomatology
Heinz Burgmann Fever after sexual intercourse lab & x-ray
. WBC 5.3 G/L . C/P normal . ESR 17/61 . Abd sonography normal . CRP 10.7 . Echocardiogr normal mg/dL . Urine o.B.
Heinz Burgmann Fever after sexual intercourse Medical history II
•The patient had a boyfried
•The boyfriend had been in syria
•In Syria he ate unpasteurised fresh goat cheese
Heinz Burgmann Fever after sexual intercourse Medical history III
. Boyfriend, 25 years old
. February: Trip to Syria . Fever NSAID - amelioration . April: Fever Roxithromycin, NSAID . June: Fever in-patient treatment positive Blood culture . fever, headache, arthralgia, fatigue, night sweats, shivering attacks, weight loss
Heinz Burgmann Heinz Burgmann • Gram-negative, coccoid rods Fever after sexual intercourse microbiological laboratory results
BRUCELLOSIS M. Bang – Maltafever
BC: Brucella abortus Serology: 1:10.000
Heinz Burgmann BRUCELLOSIS Transmission paths
conjunctives Aerosole, hands INGESTION INHALATION Milk products Slaughterhouse waste contaminated hands Laboratory accidents Veterinary intervention
Skin lesions veterinarians butchers Heinz Burgmann BRUCELLOSE – M. BANG – MALTA- FEVER "Sexual Transmitted Diseases"
Direct Transmission from human to human very rare Infection through sexual intercourse proven for B. melitensis (Sperma) Goossens, Lancet 1983 Stantic-Pavlinic, Infection 1983 Vandercam, Eur J Clin Microbiol Infect Dis 1990 Mantur, Lancet 1996
Heinz Burgmann Brucellosis
Percentage of Cases
Uptodate 2009
Brucellosis
Percentage of Cases
Uptodate 2009
BRUCELLOSE Treatment
DoxycyclinDoxycyclin ++ RifampicinRifampicin
DoxycyclinDoxycyclin ++ GentamicinGentamicin
LevofloxacinLevofloxacin ++ RifampicinRifampicin
CotrimoxazolCotrimoxazol ++ RifampicinRifampicin
Heinz Burgmann Case Report
• 40 years old man, athletically trained, wants to participate at the IRON MAN • Qualification-Triathlon in the U.S. • At qualification patient swims in sea with warning sign „Swimming forbidden“ • After qualification returns to Austria Heinz Burgmann Case report
• Few days after returning patient feels bad • Fever, exhaustion, muscle pain, fatigue • General practitioner- common cold • Symptoms become worse
Heinz Burgmann Case Report
Admitted to the hospital Status: muscle pain, malaise beginning jaundice C/P normal Elevated CRP, leucocytes and thrombocytopenia, elevated CK Creatinine 2 mg%, AST 80 U/L, ALT 120 U/L
Heinz Burgmann Case Report
Differential Diagnosis? Which diagnostic investigations?
Heinz Burgmann Case Report
• Blood culture • Uricult • Abdominal sonography • Echocardiography • Abdominal CT
No special cause could be detected
Heinz Burgmann Case Report
During the following days no amelioration of symptoms Further elevation of bilirubin, liver- and renal parameters Special serology is taken
Heinz Burgmann
Case Report
• Serology: – Leptospirosis: 1: 1600
• Diagnosis: – Leptospirosis (M. Weil)
• Treatment: Amoxicillin/Clavulanic acid • During the following days slow improvement of symptoms
Heinz Burgmann However, no Triathlon was possible this year
Leptospirosis
• 1886 first description • Often mistaken for yellow fever and malaria • Zoonotic Disease • Worldwide occurence • Gram-negative bacteria • Transmission: contaminated humid soil (Urine) or contact to infected animals • Human to Human plays a minor role
Heinz Burgmann Leptospirose
Incubation period: 5-14d 90% selflimiting systemic disease But possible lethal course with liver/renal failure, pneumonitis,… Course: acute septic begin followed by immunological reaction-phase
Heinz Burgmann Leptospirosis
• Diagnostics: – Direct verification of pathogen: very time- consuming – Serological antibody-detection • Therapy: – Ampicillin – Doxycyclin
Heinz Burgmann 29-years old Bricklayer with muscle pain, jaundice and weakness
Heinz Burgmann Medical history
• 29 years old patient • up to 4 days ago free of any complaints • With suspicion of HUS/TTP admission at emergency department: • During the last 4 days muscle pain, first in legs; increasing jaundice and weakness; • Acute-CT: reactive lymph nodes
Heinz Burgmann Medical history
• days before admission to hospital swam in danube; no animal bite perceived; • no hepatitis vaccination • No fever, once diarrhea • No medication • Profession: bricklayer
Heinz Burgmann Physical Examination
• Vitals: Subfebrile temperature, increasing respiratory and hemodynamic impairment • Abdomen: only palpatory pain • Skin/Mucosa: Jaundice, incl. sclera • Rest of physical examination: normal
Heinz Burgmann Lab-Investigation Creatinine: 6,00 mg/dl BUN: 72,1 mg/dl Bilirubin:38,61 mg/dl a-Amylase: 970 U/L ALT: 676 U/L AST: 243 U/L LDH: 664 U/L CK: 13922 U/L CK-MB: 116 U/L CRP: 16,35 mg/dl; Thrombocytes: 23 G/L Leucocytes: 8,05 G/L Erythrocytes: 1,6 T/L Hb: 4,9 g/dl; Fibrinogen: 566mg/dl, D-Dimer: 2,27 µg/ml Normotest: 83% Heinz Burgmann This men is very ill…..
X-ray
C/P- Radiography:
interstitial infiltrations on the right side. DD: atypical pneumonia, alveolar hemorrhage
Heinz Burgmann Differential diagnosis? With what kind of antimicrobial therapy would you begin?
Heinz Burgmann Initial Therapy
- 10.000 IE Penicillin G - Soludacortin 1g - Voluven 500ml - RL 1000ml, - Diazepam total 10mg - Blood transfusion - Quinton Catheter right femoral vein
Heinz Burgmann Hematological and infectiological Consultation: suspicion of Leptospirosis → IgM positive 5d after admission
Heinz Burgmann Patient developed a MOF
Case Report
– Liverfunction, Bilirubin: • Bilirubin was at max.with 66,44mg/dl 4d after admission • Transaminases constantly decrease; • Hepatitis-Serology was negative – Rhabdomyolysis: • Under PenG-Therapy declining – Acutes renal failure: • Despite adequate treatment 7d after admission anuric
Heinz Burgmann Case Report
Quinton HF catheter in right groin: massive bleeding Thrombocytes, FFP + Prothromplex -- no success Coagulation: prolonged PTT >180 abdominal sonography: no pseudoaneurysma or paravasate CT: spontaneous retroperitoneal hematoma treatment with Novoseven, FFP, thrombocytes, Minrin + at all 17 Ery-packages
Heinz Burgmann Sepsis/Infection-course:
• Development of massive leucocytosis with max. of 43,5G/L 6d after admission • Maximal CRP was 20mg/dl and normalised 7d after admission
Heinz Burgmann Case Report
8d after admission: Recent increase of inflammatory parameters with diarrhea: empiric Tygacil Diagnosis: C. difficile Tx: Metronidazol
Finally patient improved
Heinz Burgmann