Post on 27-Apr-2018
An uncommon route for an uncommon pathogen
Brittany Folks, MD PGY2 Exempla Saint Joseph Hospital
Denver, Colorado
The Patient
• 81 yo Hispanic gentleman • PMH: DM2, osteoarthritis of knees • Meds: diclofenac, ibuprofen, ASA, PPI,
multiple herbs and supplements • Social:
– No smoking, EtOH, or illicits – Resides in the US the majority of year – Travels to Chihuahua Mexico to his cattle ranch
The Presentation
• Chronic knee swelling 2/2 OA • Cough, hemoptysis, and weight loss for 2-3
months • Substernal CP, dyspnea, dizziness for 8 days • Progressive somnolence and fatigue for 2-3
days • ROS: + L hip pain, otherwise negative
The Exam
• VS normal • Bibasilar crackles • Normal heart sounds • No JVD • Pedal edema • Prepatellar L knee swelling • Oriented to self only
The Initial Work Up
• Na 130 • Cr 1.3 • Hb 12, Hct 36 • Trop 0.08 • BNP 200 • Lactate 1.3 • UA with small blood, trace LE, rare bacteria, 8
WBC
The Initial Course
• TTE obtained showed EF 50% with severe apical and septal hypokinesis, mild RV dilatation, grade I diastolic dysfunction
• ECG remained unchanged • Troponins negative x2 • Gently diuresed • Started on antibx for CAP
And Then…
• Antibx were broadened, antivirals were added • Transferred to ICU for worsening septic picture • Amphotericin was added with some
improvement initially • Developed progressive swelling of his knees
bilaterally • Liver enzymes became elevated • Decompensated and was placed on vent • Underwent bronchoscopy, LP, bone marrow bx,
joint fluid aspiration
The Work Up
• Mycoplasma • Hep A • Hep B • Hep C • HIV • Francisella • Parasite screen • Yersinia • Legionella • Leptospira • Chlamydia
• Coccidioides • Hantavirus • AFB • Brucella • Histoplasma • HSV • CMV • Coxiella • ANA • ANCA • Quantiferon
gold
• Sputum cx • Blood cx • Body fluid cx • Body fluid
analysis • MRI L spine • MRI hip • MRI brain • CT chest • CT abd • CT pelvis
AFB from bone marrow bx and bronchial washings returned positive.
Initial sputum samples remained negative.
Who would have thought?!
M. bovis
• Carried by cattle and other mammals • 1-2% of TB cases in US, 10-15% in developing
countries • Risk factors: young age, residing in endemic
areas, Hispanics, immunosuppressed • Typically spread by aerosolized particles or
non-pasteurized dairy products • Has been found in blood samples of cattle
Sample type (total no. of
samples positive by N-
PCR and culture)
No. (%) of bovine samples positive for pathogenic mycobacteria by:
N-PCR Culture
M. tuberculosis
M. bovis
M. tuberculosis
and M. bovis Total Not done
M. tuberculosis M. bovis Total
PSLN (35) 10 15 3 28 (80.0)
4 2 2 4 (11.4)
Blood (30) 12 12 1 25 (83.3)
1 5 2 7 (23.3)
Milk (48) 20 19 7 46 (95.8)
1 3 4 7 (14.2)
Total (113) 42 (37.1) 46 (40.7)
11 (9.7) 99 (87.6)
6 10 (8.8) 8 (7.1) 18 (15.7)
Detection of pathogenic bacteria in cattle-derived samples. Mishra, A, et al. J Clin Microbiol. 2005. Nov; 43(11):5670-8.
M. bovis vs. M. tuberculosis
• Clinically and radiographically indistinguishable
• Extrapulmonary manifestations are more common with M. bovis
• Distinguished by DNA PCR • Differ in treatment regimen
– Both require 4 drug regimen – Levofloxacin instead of pyrazinamide
PCR products of various Mycobacteria DNA. Lanes 2 and 3 are M. tuberculosis; lane 5 is M. bovis. Bayraktar B, et al. J. Clin. Microbiol. 2011;49:3837-3841
The Course Continued
• Reintubated x1 • Tension pneumothorax requiring needle
thoracostomy and chest tube • Anteroapical MI with development of apical
thrombus • Developed atrial fibrillation with RVR • DVT at PICC site • At one point, made DNR and extubated
And Continued…
• PEG tube placed • L psoas fluid collection drained for possible
abscess • Discharged to SNF after 92 days • Rehospitalized x2 later that year
– 13 days for FTT, GIB – 8 days for sepsis with enterococcus bacteremia
And Continued…
• PEG tube placed • L psoas fluid collection drained for possible
abscess • Discharged to SNF after 92 days • Rehospitalized x2 later that year
– 13 days for FTT, GIB – 8 days for sepsis with enterococcus bacteremia
• But was back in Mexico the following spring!