Clinical manifestations of brucellosis and leptospirosis

Transcription

1 Clinical manifestations of brucellosis and leptospirosis Department of Internal Medicine Division of Infectious Diseases Medical University of Vienna

2 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

3 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

4 Fever after sexual intercourse lab & x-ray WBC 5.3 G/L ESR 17/61 CRP 10.7 mg/dl Urine o.b. C/P normal Abd sonography normal Echocardiogr normal

5 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

6 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

7 Gram-negative, coccoid rods

8 Fever after sexual intercourse microbiological laboratory results BRUCELLOSIS M. Bang Maltafever BC: Brucella abortus Serology: 1:10.000

9 BRUCELLOSIS Transmission paths conjunctives Aerosole, hands INHALATION Slaughterhouse waste Laboratory accidents Veterinary intervention INGESTION Milk products contaminated hands Skin lesions veterinarians butchers

10 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

11 Brucellosis Percentage of Cases Uptodate 2009

12 Brucellosis Percentage of Cases Uptodate 2009

13 BRUCELLOSE Treatment Doxycyclin + Rifampicin Doxycyclin + Gentamicin Levofloxacin + Rifampicin Cotrimoxazol + Rifampicin

14 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

15 Case report Few days after returning patient feels bad Fever, exhaustion, muscle pain, fatigue General practitionercommon cold Symptoms become worse

16 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

17 Case Report Differential Diagnosis? Which diagnostic investigations?

18 Case Report Blood culture Uricult Abdominal sonography Echocardiography Abdominal CT No special cause could be detected

19 Case Report During the following days no amelioration of symptoms Further elevation of bilirubin, liver- and renal parameters Special serology is taken

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21 Case Report Serology: Leptospirosis: 1: 1600 Diagnosis: Leptospirosis (M. Weil) Treatment: Amoxicillin/Clavulanic acid During the following days slow improvement of symptoms

22 However, no Triathlon was possible this year

23 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

24 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

25 Leptospirosis Diagnostics: Direct verification of pathogen: very timeconsuming Serological antibody-detection Therapy: Ampicillin Doxycyclin

26 29-years old Bricklayer with muscle pain, jaundice and weakness

27 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

28 days before admission to hospital swam in danube; no animal bite perceived; no hepatitis vaccination No fever, once diarrhea No medication Profession: bricklayer Medical history

29 Physical Examination Vitals: Subfebrile temperature, increasing respiratory and hemodynamic impairment Abdomen: only palpatory pain Skin/Mucosa: Jaundice, incl. sclera Rest of physical examination: normal

30 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: 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%

31 This men is very ill..

32 X-ray C/P- Radiography: interstitial infiltrations on the right side. DD: atypical pneumonia, alveolar hemorrhage

33 Differential diagnosis? With what kind of antimicrobial therapy would you begin?

34 Initial Therapy IE Penicillin G - Soludacortin 1g - Voluven 500ml - RL 1000ml, - Diazepam total 10mg - Blood transfusion - Quinton Catheter right femoral vein

35 Hematological and infectiological Consultation: suspicion of Leptospirosis IgM positive 5d after admission

36 Patient developed a MOF

37 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

38 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

39 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

40 Case Report 8d after admission: Recent increase of inflammatory parameters with diarrhea: empiric Tygacil Diagnosis: C. difficile Tx: Metronidazol Finally patient improved

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