Clinical manifestations of brucellosis and leptospirosis 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
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
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
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
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
Gram-negative, coccoid rods
Fever after sexual intercourse microbiological laboratory results BRUCELLOSIS M. Bang Maltafever BC: Brucella abortus Serology: 1:10.000
BRUCELLOSIS Transmission paths conjunctives Aerosole, hands INHALATION Slaughterhouse waste Laboratory accidents Veterinary intervention INGESTION Milk products contaminated hands Skin lesions veterinarians butchers
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
Brucellosis Percentage of Cases Uptodate 2009
Brucellosis Percentage of Cases Uptodate 2009
BRUCELLOSE Treatment Doxycyclin + Rifampicin Doxycyclin + Gentamicin Levofloxacin + Rifampicin Cotrimoxazol + Rifampicin
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
Case report Few days after returning patient feels bad Fever, exhaustion, muscle pain, fatigue General practitionercommon cold Symptoms become worse
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
Case Report Differential Diagnosis? Which diagnostic investigations?
Case Report Blood culture Uricult Abdominal sonography Echocardiography Abdominal CT No special cause could be detected
Case Report During the following days no amelioration of symptoms Further elevation of bilirubin, liver- and renal parameters Special serology is taken
Case Report Serology: Leptospirosis: 1: 1600 Diagnosis: Leptospirosis (M. Weil) Treatment: Amoxicillin/Clavulanic acid During the following days slow improvement of symptoms
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
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
Leptospirosis Diagnostics: Direct verification of pathogen: very timeconsuming Serological antibody-detection Therapy: Ampicillin Doxycyclin
29-years old Bricklayer with muscle pain, jaundice and weakness
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
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
Physical Examination Vitals: Subfebrile temperature, increasing respiratory and hemodynamic impairment Abdomen: only palpatory pain Skin/Mucosa: Jaundice, incl. sclera Rest of physical examination: normal
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%
This men is very ill..
X-ray C/P- Radiography: interstitial infiltrations on the right side. DD: atypical pneumonia, alveolar hemorrhage
Differential diagnosis? With what kind of antimicrobial therapy would you begin?
Initial Therapy - 10.000 IE Penicillin G - Soludacortin 1g - Voluven 500ml - RL 1000ml, - Diazepam total 10mg - Blood transfusion - Quinton Catheter right femoral vein
Hematological and infectiological Consultation: suspicion of Leptospirosis IgM positive 5d after admission
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
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
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
Case Report 8d after admission: Recent increase of inflammatory parameters with diarrhea: empiric Tygacil Diagnosis: C. difficile Tx: Metronidazol Finally patient improved