Case 1

1
Case 1

• 43 y.o. BF, progressive HIV, was admitted for
  swelling over right periorbital area
• recently started on Combivir/Nevirapine with
  excellent response
• CD4 520, viral load 165
• no OIs except candidiasis

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History

• 2 weeks PTA, fell and had minor abrasions over R
  forehead ? papular eruptions over area ? lesions
  started to become pruritic, oozing, and crusting
  symptoms worse after washing with soap and water
  used Neosporin
• around the same time, remembers being bitten by
  a bug over right lower eyelid
• () new perfume use about 1 week PTA

3
History

• Reynolds Health Center diagnosed periorbital
  cellulitis, given Augmentin
• improved slightly at first, but later without
  benefit
• ID clinic 1/30 periorbital swelling, no visual
  changes
• admitted for IV antibiotics

4
History

• started on Cefazolin
• no improvement in 48 72 hours
• mild local itching and swelling, no pain
• (-) fever, () chills
• denied cutaneous exposure to allergens
• no similar previous episodes

5
History

• PMHx HIV, HCV, () chickenpox
• PSHx s/p hysterectomy
• Family Hx () CAD
• Social Hx () tobacco, ETOH, h/o IVDA
• Meds
• Combivir, Nevirapine, Cefazolin, Fluconazole
• Allergy sulfa ? rash

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PE

• middle aged BF, NAD
• Temp 98.9 BP 109/63 HR 73
• well-demarcated area of dry, scaly rash over R
  eye, R forehead, R cheek () cervical,
  submandibular lymphadenopathy
• rest of exam unremarkable

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Labs

• WBC 4.1
• 54 segs
• BUN 14
• Creatinine 1.0
• AST 63
• ALT 40

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Hospital Course

• ID Consult
• unlikely infectious
• d/c Cefazolin
• Derm consult
• Dermatology Consult
• likely allergic contact dermatitis
• Desowen topically BID
• no soap to face

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Case 2

• 63 y.o. WM, diabetic, multiple medical problems
  had new onset nausea/vomiting since 1/18
• ER visit _at_ Wilkes showed acute on chronic renal
  failure CxR showed widened mediastinum ? CT
  chest showed pneumomediastinum ? WFUBMC (2/1)

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History

• gastrograffin swallow ? esophageal perforation ?
  OR
• mediastinal abscess ? drained
• R thoracotomy, intercostal muscle flap
• esophageal tear closure, gastrostomy, feeding
  jejunostomy
• empirically started on zosyn/cipro

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History

• PMHx
• DM, CRI, dilated cardiomyopathy, CHF, COPD, gout,
  cirrhosis with ascites
• Family Hx
• non-contributory
• Social Hx
• heavy ETOH use in past
• recently quit tobacco

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History

• Medications
• Zosyn, Cipro, ranitidine, prns
• Timentin at OSH
• Allergy
• sulfa

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PE

• Temp 99 BP 107/71 HR 100
• sedated, intubated
• lungs clear bilaterally
• () thoracotomy scar, chest tube, PEG tube/
  J-tube
• wounds clean, (-) discharge
• Otherwise unremarkable

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Labs

• WBC 11.4 (from 25.4)
• 10 bands
• Creatinine 3.4
• CxR
• L lung effusion, LLL ATX/infiltrate
• widened superior mediastinum
• CT/gastrograffin study as mentioned

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Microbiology Data

• Sputum culture (-)
• Urine culture (-)
• Blood culture (-) (2 of 2)
• OR swab
• 2 yeast, 1 GPC on culture
• 1 yeast, 2 WBC on Gram stain

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• Andersen et al 1992
• prevalence study of esophageal candida
  colonization in Danish population
• 164 subjects stratified according to /- COPD
• questionnaire probing for symptoms of esophageal
  disease
• PFTs, EGD, LES pressure measurement
• surface material from esophageal plaques,
  erosions, exudates, or normal-appearing mucosa
  obtained plated on agar plate
• considered () if at least 50 colonies C.
  albicans grew within 72 hours

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• Andersen et al 1992
• prevalence ranges from 12 25
• overall estimate in Danish population 20
• no statistically significant difference in
  prevalence between following subject groups
• benign esophageal disease
• esophagitis
• GERD
• COPD
• no significant clinical correlation between
  esophageal symptoms () C. albicans

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• Bauer et al 1996
• 2 case reports of invasive candidiasis
  complicating Boerhaave Syndrome
• Risk factors for secondary fungal infection
• preexistent Candida colonization
• incomplete mediastinal drainage
• broad-spectrum antibacterial therapy
• prolonged ICU stay

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• Candida as a cause of mediastinitis very rare,
  accounting for 5
• Clancy et al 1997
• review of 9 cases, all s/p thoracic surgery, 1 as
  complication of esophageal leak
• median time to disease onset of 11 days
• clinical manifestations
• purulent drainage from sternum (56)
• fever, sternal instability, chest wall erythema
  (44)
• shock (33)
• sternal click (22)
• resp. distress, subcutaneous emphysema, wound
  dehiscence, and sternal tenderness (11)

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• Clancy et al 1997
• 89 had Candida isolated in pure culture
• all specimens from mediastinum () Candida
• () blood cultures 44
• () sternal bone cultures 44
• () pleural fluid 22
• () pericardial fluid 22
• () urine culture 22
• () thrombus culture 22
• () wound site culture 11
• () hardware 11

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• Clancy et al 1997
• Overall mortality 56 80 (4/5) of which
  directly attributable to candidal mediastinitis
• clinical manifestations not distinguishable from
  bacterial mediastinitis
• optimal therapy still unclear
• aggressive surgical debridement with antifungal
  therapy is the preferred approach
• duration of antifungal unclear, but at least 6
  weeks recommended

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Case 3

• 51 y.o. WM, OSA presented to OSH with
• 2 3 week h/o polyuria, polydipsia, anorexia,
  weight loss, bloody stool, vomiting, confusion
• work-up revealed glucose of 1,467 AG 29
• admitted with HONC, ARF, fever of 102
• reportedly (-) head CT
• became hypotensive ? pressors
• Temp ? to 107, started on CTX ? further clinical
  decline ? transferred to WFUBMC

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History

• PMHx OSA, depression, gout
• Social Hx (-) tobacco/ETOH/IVDA
• Meds none
• Allergy NKDA

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Hospital Course

• On arrival, BP 68/40, temp 101.3
• aggressively hydrated, electrolytes replaced
• started on levophed/dopamine gtt
• started on heparin gtt (troponin 7)
• empirically started on CTX/EES/ACV
• CT head, LP, EEG performed
• ID consulted for MS changes

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PE

• Temp 102.7 BP 110/72 HR 103
• overweight middle ages WM
• intubated, sedated
• PERRL, anicteric
• lungs clear, tachycardic, RRR, (-) m/r/g
• soft abdomen, () BS
• (-) skin lesions/rash

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Labs

• WBC 24.8 ?12.7
• 85 segs, 2 bands
• BUN/Creatinine 39/5.5
• Na 160 ? 146 CO2 13
• CK 4,080 (peaked _at_ 5,728)
• lactic acid 4.4 ? 1.3
• UA () ketones, 5 8 WBC, 50 RBC

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Labs

• LP
• OP 36 CSF red and cloudy
• WBC 150 RBC 22,100
• 76 segs
• glucose 118 protein 94
• Crypto Ag (-) HSV-PCR (-)
• Gram stain (-) organism, 2 WBC
• bacterial Ag (-)

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Labs

• Blood urine cultures (-) to date
• CxR NAD
• Head CT
• possible Chiari I malformation, mild cerebral
  edema, () infarct over R posterior limb of
  internal capsule

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Extreme Pyrexia Simon 1976, JAMA 2362419-21

• 28 cases of extreme pyrexia, patients with temps
  between 41.1 42.2 C (106 108 F)
• retrospective study in MGH, 1970-75
• ages 6 74, mean 39
• 23 males, 5 females
• grouped into 4 categories based on etiologic
  diagnosis

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Extreme Pyrexia

• Group 1 11 patients (39)
• infection as sole cause of fever
• 7 px with GNR sepsis 1 had TB lymphoma
• 1 px with Staphylococcal line sepsis
• 1 px with pneumonia
• 1 px with pyelonephritis, blood cultures (-)
• 1 px with malaria

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Extreme Pyrexia

• Group 2 9 patients (34)
• infection impaired thermoregulation as cause
• 4 severe burn patients with extensive occlusive
  dressings sepsis (3 GNR, 1 fungal)
• 3 paraplegia/quadriplegia infection (2 pyelo, 1
  mediastinal abscess)
• 1 massive ICH pneumonia
• 1 viral encephalitis

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Extreme Pyrexia

• Group 3 5 patients (18)
• thermoregulatory failure as cause
• 3 with heat stroke (11)
• 2 with massive ICH
• Group 4 3 patients (11)
• etiology unclear
• ? JRA
• ? viral infection
• ? drug/pyrogen reaction

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Extreme Pyrexia

• 18/28 (64) occurred June September
• ? influence from ambient temperature
• 8/28 (29) died
• only 2/28 (7) died from severe pyrexia
• mortality otherwise dependent on underlying dx
• no change in neurological function could be
  attributed to the fever itself in any of the cases

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Extreme Pyrexia

• height of fever not helpful in establishing
  etiologic cause
• thermoregulatory failure
• excessive heat production
• thyroid storm malignant hyperthermia
• impaired heat dissipation
• heat stroke, burn patients with extensive
  occlusive dressings
• disordered hypothalamic function