PHARMACOLOGY CONFERENCE

Andal, Ang, J, Ang JM, Ang, K., Aningalan, A.

General Data

• C.R.• 1 y/o• Male

Chief Complaint:

Swelling of the L arm

History of Present Illness• 2 x 2 cm solitary plaque on the L

forearm; erythematous, smooth, raised border; tender, warm, firm to touch

• Lesion increased in size: 4x 4cm • consult at a local clinic

– Prescribed to take Cloxacillin (unrecalled dose), 3mL every 6 hours for 7 days

• The lesion decreased in size to about 3 x 3cm, soft to touch

3 weeks PTA

2 weeks PTA

History of Present Illness• Lesion became a 3x3cm fluctuant

abscess, tender, well defined border• Consult at another local clinic

– I & D: discharge was noted to be bloody and with pus, approximately 10 mL

– Clindamycin was discontinued, and was prescribed Co-amoxiclav (Augmentin) (unrecalled dose) 5mL every 8 hours

• Mother did not give the said medication because she believed that the incision and drainage was enough to heal the lesion

9 days PTA

History of Present Illness• 4 x 4 cm plaque of the same character

appeared adjacent to the previous lesion.• lesion evolved into an 4x4 cm abscess,

with erythmatous, well-defined margin, tender to touch

• Co-amoxiclav(unrecalled dose) 5 mL every 8 hours was given– noted appearance of maculopapular

rashes on the neck, back, abdomen and legs so the medication

– discontinued after 2 days.

7 days PTA

3 days PTA

History of Present Illness• Undocumented fever (patient

was warm to touch)• Ibuprofen (Dolan FP)

100mg/5mL suspension 3 mL every 4 hours was given

• Persistence of symptoms

1 day PTA

ADMISSION

Review of Systems(-) wt loss, anorexia, weakness, (-) blurring of vision, eye redness, eye itchiness, Iacrimation(-) deafness, tinnitus, aural discharge(-) anosmia, epistaxis, sinusitis, nasal discharge(-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion(-) breast masses, discharge, trauma

Review of Systems(-) dyspnea, alar flaring, cough, hemoptysis(-) easy fatigability, chest pain,edema(-) phlebitis, varicosities, claudication(-) dyshpagia, nausea, vomiting, hematemesis,

melena, hematochezia, diarrhea, constipation(-) urinary frequency, urgency, hesitancy,

dysuria, hematuria, nocturia(-) joint stiffness, joint pain, muscle pain, cramps

Review of Systems

(-) heat-cold intolerance, polydipsia, polyphagia, polyuria

(-) headache, speech disturbance, seizures(-) anxiety, depression, confusion

Personal History

Gestational History, Birth and Neonatal History

• born to a 29-year old, G3P2, housewife, living with a 54-year old government employee.

• regular prenatal check-up • took Folic Acid and FeSO4 • 2 shots of Tetanus toxoid. • no illicit drug use, alcoholic intake, exposure to viral

exanthems, teratogenic drugs, cigarette smoke and radiation.

Personal History

• Gestational History, Birth and Neonatal History• No illnesses during the pregnancy• Patient was born live, term, singleton, male, via

CS secondary to cephalopelvic disproportion in Jose Reyes MM

• unrecalled birth weight and birth length. • good cry at delivery, spontaneous respiration,

and not meconium-stained.

Personal History

Feeding History• exclusively breast fed during the first 3 months and was

then shifted to Bonna milk• shifted to Bonamil at 6 months and then to Nido fortified at

1 year• Complementary food was introduced at 6 months, starting

with mashed fruits and vegetables • Currently takes Nido fortified; 1:1 dilution, 8-9

feedings/day, 7 oz/feeding• Patient is not a picky eater; usually eats fruits, vegetables,

chicken liver, fish and rice

24-Hour Food RecallCHO CHON Fats Total Calories

Breakfast Oatmeal (1/2 cup) 11.5 1 61LunchMilk biscuit (2 pcs.) 23 2 100MeriendaKalamansi juice (4oz.)Ice cream (1/3 cup)

1023

2 40100

DinnerMilk (9 bottles – 8oz. each)

84 56 70 1190

ACI 1490RENI 1070% Intake 139 %

Developmental History:

Patient is at par with age Walks alone with one hand held Stands alone Begins to feed with fingers Kisses on request Releases object on request Obeys commands with gestures

Past Medical History:

• No previous hospitalizations/major illnesses• No previous surgeries• No previous blood transfusions

Immunizations:

• incomplete immunization; unrecalled dates• BCG1

• DPT123

• OPV123

• HepB 123

• Measles• HiB1

Family History:

• (+) Diabetes Mellitus – maternal great grandmother, maternal aunt

• (+) Hypertension – maternal grandmother• (+) asthma – maternal grandfather • (-) PTB, Cancer, Hematologic diseases, Goiter

Family Profile

Family

MemberAge Relationship Ed. Attainment Occupation Health

StatusCR 55 Father College graduate –

AB HistoryGovernment

employeehealthy

IR 30 Mother College undergrad Housewife healthy

AR 10 Sister Grade 4 Student healthy

ER 9 Brother Grade 3 Student healthy

RR 46 Uncle High School graduate

Unemployed healthy

Personal, Socioeconomic and Environmental History

• lives with her parents, 2 siblings and uncle • well-spaced, well-ventilated and well-lit • two-storey house made of cement• Drinking water is mineral water• Garbage is burned every day• Does not live near a factory and has no pets. • Exposed to cigarette smoke (Uncle)

Physical ExaminationGeneral: Alert, awake, irritable, not in cardiorespiratory

distress, well-nourished, well-hydratedVital Signs: CR:105 bpm, regular RR:25 cpm, regular T:36.5°C

Ht: 78 cm (z-score: 0, normal), Wt: 14 kg (z-score: 3, obese),

BMI= 23.3 (z-score: above 3, obese)Skin: Warm, moist skin, (+) maculopapular rash on bilateral

thigh, palms and solesHead: No gross head deformities, HC = 53 cm (z-score: +3), no

lesions on the head, equally distributed fine black hair, closed fontanels

Physical ExaminationPink palpebral conjunctivae, pupils 2-3 mm ERTL, anicteric

scleraeNo tragal tenderness, no ear discharge, non-hyperemic

external auditory canal, intact tympanic membrane, with retained cerumen

Midline septum, no nasal discharge, turbinates not congested, no alar flaring

Moist buccal mucosa, no oral ulcers, nonhyperemic posterior pharyngeal wall, tosils not enlarged

Supple neck, no palpable cervical lymph nodes, no masses, thyroid gland not enlarged

Physical Examination

Heart: Adynamic precordium, AB at 4th LICS MCL, S1>S2 at apex, S2>S1 at base, no heaves, no lifts, no thrills, no murmurs

Lungs: Symmetrical chest expansion, no retractions, no use of accessory muscles, clear breath sounds

Abdomen: Globular, soft, with normoactive bowel sounds, no tenderness, no masses

External Genitalia: Grossly male genitalia

Physical Examination

Extremities: No limitations in range of motion, no joint swelling or tenderness; pulses full and equal, no cyanosis, no clubbing, (+) warm, tender, erythematous, fluctuant, 4x4cm mass on the left forearm with well-defined border.

Neurologic Exam on Admission

• Alert, awake, aware of surroundings• No asymmetry, no gross deformities, no bulging of fontanels, no

hydrocephalus• Spontaneous muscle movements, no involuntary movements,

no tremors• Cranial Nerves: CN2- visual tracking, blinks with bright lightCN3, 4, 6- no ptosis, pupils 2-3 mm ERTL; CN5- blinks upon gentle

air blowing; CN7- no facial asymmetry; CN8- turns head to stimulus; CN9, 10- normal suck and swallowing; CN 11- symmetry of SCM muscle bulk

• (-) Involuntary movements• (-) Nuchal rigidity, (-) Babinski

Salient Features• 1 y/o M• (+) warm, tender, erythematous, fluctuant,

4x4cm mass on the left forearm with well-defined border

• (+) maculopapular rash on bilateral thigh, palms and soles

• Irritable• Undocumented fever

Symptom, signs and laboratory finding found in the least number of disease

• Fluctuant Mass

Differential Diagnosis• V—Vascular conditions of the skin like postphlebitic ulcers that cause a

discharge• I—Inflammatory conditions of a noninfectious nature like erythema

multiforme, pyoderma gangrenosum, and pemphigus that produce weeping. Specific infections are listed above.

• T—Traumatic conditions such as third-degree burns• A—Autoimmune and allergic disorders associated with weeping vesicles

and ulcers, such as periarteritis nodosa and contact dermatitis• M—Malformations such as bronchial clefts and urachal sinus tracts• I—Intoxicating lesions such as a vesicular or bullous drug eruption• N—Neoplasms such as basal cell carcinoma and mycosis fungoides that

produce weeping ulcers

Infectious Disorders (Specific Agent)

• Immune deficiency, acquired (AIDS/HIV)

• Infestations/fleas/mites/lice • Sporotrichosis • Cryptococcosis • Glanders (malleomyces mallei) • Loiasis/Loa loa infestation • American

leishmaniasis/cutaneous • Angiomatosis, bacterial

Bartonellosis • Blastomycosis • Cytomegalic virus, congenital

• Glanders abscess • Histoplasmosis, African • Milkers nodules• Mycobacterium

marinum/granuloma skin • Skin infections/Pyoderma • Toxoplasmosis, congental • Whipples disease • Chromoblastomycosis/

chromomycosis • Farcy/Cutaneous Glanders • Cutaneous fungal infection

Infected organ, Abscesses

• Adenitis/lymph node • Furunculosis • Abscess, subcutaneous • Carbuncle • Pyoderma granuloma (vegetans)

Granulomatous, Inflammatory Disorders

• Panniculitis

Neoplastic Disorders

• Hemangioma• Lipoma• Leukemia, acute • Melanoma, malignant • Hodgkin's disease • Kaposi Sarcoma

Allergic, Collagen, Auto-Immune Disorders

• Juvenile rheumatoid arthritis/Stills d • Erythema nodosum • Juvenile chronic arthritis (rheumatoid) • Neonatal subcutaneous fat necrosis • Panniculitis, nodular nonsuppurative • Polyarteritis nodosa • Rheumatoid arteritis/vasculitis • Rheumatoid nodule • Polyarteritis nodosa, infantile

Metabolic, Storage Disorders

• Gout • Tophi/Gouty tophi • Pseudogout syndrome • Amyloidosis, primary nonhereditary

Congenital, Developmental Disorders

• Arteriovenous malformations• Cavernous lymphangioma• Angioma/cutaneous• Dermoid cyst

Hereditary, Familial, Genetic Disorders

• Ehlers-Danlos syndrome• Gardner syndrome• Neurofibromatosis• Tuberous Sclerosis• Lipodystrophy, generalized

Anatomic, Foreign Body, Structural Disorders

• Sebaceous cyst• Soft tissue foreign body/subcutaneous • Keloid• Joint ganglion

Approach

• Smear and culture • skin biopsy • Serologic tests • cultures on special (fungi and parasites)

Others

• CBC (systemic infection)• Sedimentation rate (systemic infection, collagen

disease)• Tuberculin test• VDRL test (primary or secondary syphilis)• X-ray of area involved (abscess, osteomyelitis)• ANA analysis (collagen disease)• Skin test and serology for fungi• Biopsy• Muscle biopsy (collagen disease, trichinosis)

COURSE IN THE WARD

1ST Hospital Day• IVF: D5 IMB 500mL to run at 12-13 gtts/min• Request for:

– CBC with platelet– Gram stain of wound discharge– Culture and sensitivity of wound discharge

• Medications:– Clindamycin 150mg/slow IV infusion (32.1mg/kg/day) over 30

mins. now then every 8 hrs. ANST– Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins.

every 8 hrs.– Paracetamol 250mg/5mL, 4 mL every 4 hours for Temp. > 38.5°C or

for pain (14 mg/kg/dose )– Refer to Pediatric Surgery for further evaluation and management

1st Hospital Day

• Incision and Drainage of Abscess– 20cc purulent discharge– Specimen sent for GS/CS

• For daily COD

Complete Blood Count

Hgb 110

RBC 4.11

Hct 0.33

MCV 79.90

MCH 26.80

MCHC 33.50

RDW 14.00

MPV 6.20

Platelet 281

WBC 12.10

Neutrophils 0.54

Lymphocytes 0.41

Monocytes 0.03

Eosinophils 0.02

Microbiology Examination

Gram (+) Cocci in Pairs Few

Pus Cells ++++

2nd Hospital Day• D1-2 – Clindamycin 150mg/slow IV infusion (32.1mg/kg/day)

over 30 mins. now then every 8 hrs. ANST– Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30

mins. every 8 hrs.• Decreased to D5 IMB 500mL to run at 9-10 gtts/min• Patient was transferred to malward• IVF to consume• Increase oral fluid intake

Culture and Sensitivity: Wound Discharge

Staphylococcus aureus Heavy Growth

*MRSA Positive

Sensitive to:

Azithromycin Chloramphenicol ClindamycinErythromycin Gentamycin Co-trimoxazole

Vancomycin

Resistant to:

Penicillin

5th Hospital Day

• D5-6– Clindamycin 150mg/slow IV infusion

(32.1mg/kg/day) over 30 mins. now then every 8 hrs. ANST

– Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins. every 8 hrs.

• 0.65% NaCl Nasal drops 2-3 gtts/nostril then suction Q6

14th Hospital Day

• Day 14– Clindamycin 150mg/slow IV infusion (32.1mg/kg/day) over 30 mins.

now then every 8 hrs. ANST– Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins. every 8

hrs.• Disharged

– Final Diagnosis: Abscess secondary to MRSA – Take Home Medications:

• Co-trimoxazole 400mg 180mg/5mL, 4mL Q12 to complete for 2 weeks• Mupirocin ointment, apply on affected area TID

– Anticipatory Guidance– Immunization update– For follow up at OPD on Oct 10, 2010

Antibacterial activity of honey against community-associated methicillin-resistant Staphylococcus aureus

(CA-MRSA)Maedaab et. Al

Complementary Therapies in Clinical Practice (2008) 14, 77–82

Introduction

• There has been increasing reports of community acquired MRSA amongst healthy individuals, who have no hospital association

• Predominant presentation is associated with skin and soft tissue infections, particularly folliculitis, pustular lesions and abscesses.

• Risk factors for its acquisition include close physical contact, abrasion injuries and activities associated with poor communal hygiene (e.g. sharing towels).

Introduction

• Although honey has historically been known to have antimicrobial activity, to date, no reports have examined such activity against CA-MRSA.

• Previous literature have indicated honey as an effective treatment of HA-MRSA-related wound infection

• The aim of this small study to examine the potential antimicrobial activity of natural honey against a collection of CA-MRSA organisms.

Materials and Methods

• Natural honey samples (n ¼ 3; approx. 0.5 kg) were obtained from amateur bee-keepers in Northern Ireland, from the Mourne Mountains??

• Commercial French honey from the Suisse Normande was also included as a comparator honey.

• Honey was sterilized with gamma irradiation using cobalt-60 at an environmental temperature of 41oC

• 6 CA-MRSA isolates were included, including CA-MRSA ST35, 5134, 4388, 4266, 4526 and 5090

• Isolates were initially cultured on CBA for 24 h at 37.1oC

Materials and Methods• CA-MRSA inocula were thoroughly mixed into each honey and the honey was stored in the

dark for 24 h at ambient room temperature (approx. 18–200C). • Timepoints, t ¼ 0, 4, 8 and 24 h, • quantitative counts expressed as log10 cfu/g honey.• Following this, and in order to confirm when no CAMRSA• remained culturable, each CA-MRSA inocula/• honey combination underwent a non-selective• enrichment in nutrient broth (Oxoid CM1) (225 ml)• at 37 1C for 24 h, followed by plating of 100 ml• enrichment broth on CBA which was incubated at• 37 1C for 24 h. Any resulting colonies were confirmed• as MRSA by conventional phenotypic assays.• Appropriate controls were established which included• examining the persistence of each CA-MRSA• strain in 0.1% PS, as detailed above, in the absence• of honey.

Statistical Analysis

• Student t-test• probability value = p:0.05 (5%) ; significant

Results

Discussion• Recent emergence of CA-MRSA within the community, in

combination with multiresistance and evolving antibiotic resistance, respectively, merits an examination of alternative treatment regimens for these organisms making the current study timely and of interest to healthcare practitioners involved with in wound management.

• Previously, a small number of case studies have examined the antimicrobial activity of honey against MRSA organisms. Although these reports describe Manuka honey, as an active component in the resolution of wounds, no in vitro susceptibility data were presented to demonstrate the in vitro activity of the honey preparations against the MRSA isolated in situ

Discussion• Gamma-irradiated honey was employed – To perform the bacteriological analyses in pure

culture, using non-selective media– food-grade honey produced for human consumption,

although a shelf-stable product, is not a sterile product

• Analyses of these honey products demonstrated the presence of various Bacillus spp. In this study, seven samples of honey and related were examined microbiologically and were demonstrated to have total viable counts (TVC) ranging from 100 to 1700 cfu/g

Discussion

• Most frequently identified species were:– Bacillus pumilus– B. licheniformis– B. subtilis– B. fusiformis

• Practitioners should consider the employment of honey preparations that have been sterilised employing g-irradiation

Conclusion

• In vitro, natural products of honey had an antimicrobial activity against the CA-MRSA organisms tested.

• Further studies are now required to demonstrate the mechanism and components of such activity and whether this antimicrobial activity has any clinical application for the treatment of CA-MRSA skin and soft tissue infections.