Clinical Case Conference

1
Clinical Case Conference

• Vera P. Luther, MD
• October 3, 2005

2
DisclosuresSection of Infectious Diseases

• Kevin High, M.D.
• Grant/Research Support Cubist Pharmaceuticals,
  Astellas Pharma US, Inc.
• Consultant Merck Co., Inc.
• Speakers Bureau Pfizer Pharmaceuticals
• James Peacock, M.D.
• Ownership in Common Stock Pfizer
  Pharmaceuticals
• Sam Pegram, M.D.
• Grant/Research Support Roche, Bristol-Myers
  Squibb, Gilead, Schering-Plough, Tibotec
  Pharmaceuticals
• Consultant Abbott Laboratories,
  GlaxoSmithKline, Boehringer Ingelheim, Gilead,
  Roche
• Speakers Bureau Abbott Laboratories,
  GlaxoSmithKline, Boehringer Ingelheim, Merck,
  Pfizer Pharmaceuticals

3
Disclosure (continued)Section of Infectious
Diseases

• Aimee Wilkin, M.D.
• Grant/Research Support Abbott Laboratories,
  GlaxoSmithKline, Tibotec Pharmaceuticals,
  Bristol-Myers Squibb Company, Gilead
• Christopher Ohl, M.D.
• Grant/Research Support Cubist Pharmaceuticals,
  Gene-Ohm Sciences, Merck Pharmaceuticals
• Speakers Bureau/Consultant Ortho-McNeil
  Pharmaceuticals, Cubist Pharmaceuticals,
  Sanofi-Aventis Pharmaceuticals, Pfizer
  Pharmaceuticals, Bayer Pharmaceuticals

4
Disclosure (continued)Section of Infectious
Diseases

• Tobi Karchmer, M.D.
• Grant/Research Support Gene-Ohm Sciences
• Speakers Bureau Pfizer Pharmaceuticals, Cubist
  Pharmaceuticals, Cepheid,
• Gene-Ohm Sciences
• Consultant C.R. Bard
• Robin Trotman, D.O.
• Speakers Bureau Pfizer Pharmaceuticals

5
Case 1

• 43 y/o African-American male admitted to the
  hospital July 6, 2005 with fever, headache, neck
  stiffness, photophobia
• Physical Examination
• T 101.6
• drowsy
• nuchal rigidity
• Laboratory Data
• wbc 18.1 with 79 segs, 4 bands

6
Case 1

• Lumbar Puncture findings
• cloudy CSF
• 9700 wbc (90 polys, 10 monos)
• protein 287
• glucose 40 (serum glucose 126)

7
MRI
8
Case 1

• Started on
• ceftriaxone 2 grams IV q 12h
• vancomycin 1 gram IV q 12h
• Infectious Disease Consult Obtained

9
Case 1 Infectious Diseases Consult

• Past Medical History
• Meningitis
• 1/05 H. influenzae, non-typeable
• 1/01 CSF culture negative
• s/p cholesterol granuloma removal from petrous
  apex
• 3/98
• Found 2º to c/o double vision, retro-orbital
  pain, and left 6th nerve palsy
• Intraoperatively pus found extending from
  mastoid air cells to air cells in petrous apex.
• Mastoidectomy performed
• Air cell tract was stented open
• A small CSF leak was repaired with bone wax

10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
Case 1 Infectious Diseases Consult

• Past Medical History
• Meningitis
• 1/05 H. influenzae, non-typeable
• 1/01 CSF culture negative
• s/p cholesterol granuloma removal from petrous
  apex
• 3/98
• Found secondary to c/o double vision and
  retro-orbital pain, and left 6th nerve palsy
• Intraoperatively pus found extending from
  mastoid air cells to air cells in petrous apex.
• Mastoidectomy performed
• Air cell tract was stented open
• A small CSF leak was repaired with bone wax

14
(No Transcript)
15
(No Transcript)
16
Peacock JE, et al. Persistent Neutrophilic
Meningitis. Medicine. 1984 Nov63(6)379-95.Ell
ner JJ, Bennett JE. Chronic meningitis.
Medicine. 1976 Sep 55(5) 341-369.Jones HM.
The problem of recurrent meningitis. Proc roy
Soc Med. 1974 Nov 67 1141-54.

• Chronic meningitis
• continued symptoms (gt 1 week)
• associated with ongoing signs of meningeal
  inflammation

• Recurrent meningitis
• acute symptoms with symptom-free intervals
• aseptic vs bacterial

17
Durand ML et al. Acute bacterial meningitis in
adultsa review of 493 episodes. N Engl J Med
1993 Jan 7328(1)21-8

• 493 patients from 1962-1988 (age 16)
• 9 had recurrent meningitis
• 16 of those had CSF leak
• 16 had more than one recurrence

18
Kline MW. Review of recurrent bacterial
meningitis. Pediatr Infect Dis J. 1989
Sept8(9)630-4.

• Reviewed case reports and collections of cases
  from the literature 1978-1988
• 47 patients (ages 5 mos-74 yrs)
• Roughly 50 had only 1 recurrence
• 94 had predisposing condition identified
• Congenital fistulae (21 adults)
• Traumatic fistulae (36 adults)
• Immunodeficiency (21)
• Others bone defects, abscesses

19
Kline MW. Review of recurrent bacterial
meningitis. Pediatr Infect Dis J. 1989
Sept8(9)630-4.

• Recurrent N. meningitidis infections associated
  with immunodeficiency
• terminal complement component deficiencies
• Recurrent S. pneumoniae or H. influenzae
  infections associated with
• Fistulae
• Bone defects
• ethmoid
• temporal
• CT of the petrous bone should be initial study
• Recurrent staphylococcal or enteric gram-negative
  bacteria associated with
• Congenital dermal sinus tract

20
Recommendations

• Workup
• Treatment

21
Case 1

• CSF culture
• Haemophilus influenzae, non-typeable,
• ß-lactamase negative

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
Petrous apicitis

• Infection of the petrous apex
• Causative organisms Streptococcus spp,
  Pseudomonas spp., Staphylococcus spp., H.
  influenzae
• Common (commonly fatal) in preantibiotic era
• In the late 1950s, Dr. DeWeese cautioned
  physicians to remain vigilant of petrous
  apicitis, "Lest we forget that this condition
  still occurs."

33
Petrous apicitis

• Gradenigos syndrome
• Clinical triad of headache, abducens nerve
  (cranial nerve VI) palsy, and suppurative otitis
  media
• In 1904, described 57 cases of petrous apicitis
  in a manuscript
• Uber circumscripte Leptomeningitis mit
  spinalensymptomen und über Paralyse des N.
  Abducens otitischen Ursprungs," in the Archiv für
  Ohrenheilkunde
• 42 had the triad
• 51 had addtl cranial nerve deficits
• 7 had meningitis ? death

34
Horn KL. Suppurative petrous apicitis osteitis
or osteomyelitis? An Imaging Case Report. Am J
Otol 199617(1) 54-7.

• Eagleton (1931) described petrous apicitis as
• osteomyelitis of medullary bone of the petrous
  apex
• Infection blood-borne through thrombophlebitis
• required extensive surgery for cure
• Lempert (1937) described petrous apicitis as
• osteitis of pneumatized temporal bone (petrous
  air cells)

35
Petrous apicitis

• Pneumatization plays important role in spread of
  disease through mastoid ? petrous bone
• Spread to non-pneumatized petrous bone via direct
  extension or venous channels occurs as well

36
(No Transcript)
37
Virapongse C, et al. Computed tomography of
temporal bone pneumatization 1. normal pattern
and morphology. AJR. Sep 1985 145173481

• Pneumatization of 141 normal temporal bones
  evaluated by CT scan in pts age (6-85y)
• Scored extent of pneumatization (vs diploic)
• Extensive pneumatization found in 35 of patients

38
(No Transcript)
39
(No Transcript)
40
Petrous apicitis

• Complications
• Meningitis
• Cranial nerve palsies
• Labyrinthitis
• Intracranial abscess formation
• Retropharyngeal abscess
• Venous sinus thrombosis

41
Chole RA et al. Petrous apicitis. Clinical
considerations. Ann Otol Rhinol Laryngol
198392544-51.

• Series of 8 cases of petrous apicitis
• 2/8 patients had meningitis as complication of
  petrous apicitis
• S. pneumoniae
• Pseudomonas

42
Petrous apicitis

• Jackler RK. Radiographic differential diagnosis
  of petrous apex lesions. Am J Otol Nov
  199213(6)561-74.
• Initial workup
• CT scan of temporal bones preferred screening
  evaluation
• MRI
• May have false positive results physiologic
  asymmetry of petrous apex pneumatization, marrow
  formation, and vascular anatomy
• Useful in assessing soft tissue involvement

43
Case 1

• Completed course of ceftriaxone
• Started on long-term oral antibiotic therapy
• ciprofloxacin 750mg po bid
• Immunizations updated
• Underwent surgery
• Left revision mastoidectomy/apicectomy
• Removal of left petrous apex stent
• Temporalis fascia graft reconstruction of left
  tegmen defect
• No CSF leak

44
(No Transcript)
45
Case 2

• 46 y/o African-American female admitted with
  fever, chills, abdominal pain
• Treated with IV antibiotics, but symptoms
  persisted
• On hospital day 3, pt had fever to 1043, sudden
  drainage of purulent foul-smelling discharge per
  vagina ? improvement in abdominal pain

46
Case 2

• PMH h/o stage IIIb cervical CA
• s/p chemo
• s/p XRT 1.5yr prior
• Physical Examination
• T1019 vss
• Abdomen soft
• Purulent discharge from vagina
• Laboratory data
• wbc 17.0 with 85 segs, 5 bands

47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
ID consulted

• Initial thoughts?
• Recommendations?

67
Pyometra

• Accumulation of pus in the uterine cavity
• Result of interference of natural drainage

68
Muram D, et al. Pyometra. Can Med Assoc J. 1981
Sep 15125(6)589-92.

• Retrospective chart review of 18 cases seen in
  Canada b/t 1974-1978
• All but one patient was postmenopausal
• One death (peritonitis)
• 72 associated with radiotherapy or malignant
  disease of the uterus

69
Muram D, et al. Pyometra. Can Med Assoc J. 1981
Sep 15125(6)589-92.
70
Muram D, et al. Pyometra. Can Med Assoc J. 1981
Sep 15125(6)589-92.

• Anaerobic bacteria isolated in 56
• More than one bacteria isolated in 60

71
Karpathios S. Pyometra. Int J Gynaecol Obstet.
197614477-9.

• Chart review of 13 cases of pyometra treated in
  Greek hospital b/t 1969-1974
• 4 senile changes (cervical stenosis)
• 8 benign tumors
• 1 cervical carcinoma

72
Shierholz JD. Pyometra complicating radiation
therapy of uterine malignancy. J Reprod Med
197719(2)100-2.

• The records of all patients with uterine
  malignancy admitted to University of Iowa
  1970-1975 reviewed to determine prevalence of
  pyometra
• 12 patients identified (out of 733)
• 10 continued external beam XRT
• 2 had worsening sx
• No deaths

73
Pyometra

• Rx drainage
• dilate cervical os
• D C
• hysterectomy
• Broad spectrum antibiotic therapy

74
Case 2

• 2/2 blood cultures positive
• Alpha-hemolytic streptococci
• Unasyn ? ceftriaxone x 2 weeks
• Doing well at follow-up visit

75
(No Transcript)