Post on 19-Dec-2015
Necrotizing FasciitisNecrotizing Fasciitis
HistoryHistory 66 y female66 y female
PMH : DM , HTN , IHD , Hypothyroidism PMH : DM , HTN , IHD , Hypothyroidism Pernicious anemia , ETOHPernicious anemia , ETOH
Med: Atenolol , ASA , Nitrospray , Med: Atenolol , ASA , Nitrospray ,
Thyroxin , B12 & AtrovastatinThyroxin , B12 & Atrovastatin
HistoryHistory Presented to Seven Oaks HospitalPresented to Seven Oaks Hospital
1/12 SOBE , Anasarca & decreased UOP1/12 SOBE , Anasarca & decreased UOP
1/7 angina & melena ( 2 minimal )1/7 angina & melena ( 2 minimal )
No orthopnea , PND , wheeze , coughNo orthopnea , PND , wheeze , cough
No palpitation , LOCNo palpitation , LOC
No heartburn , vomiting or hematemisisNo heartburn , vomiting or hematemisis
No blood in urineNo blood in urine
HistoryHistory In ER : hemodynamicaly stableIn ER : hemodynamicaly stable
Sat 94% RA A & OSat 94% RA A & O
Generalized edemaGeneralized edema
No chronic liver disease signsNo chronic liver disease signs
? Hypovolemic? Hypovolemic
Chest : clearChest : clear
DRE +ve bloodDRE +ve blood
HistoryHistory WBC 2.1 poly 1.3 Hb 65 MCV20WBC 2.1 poly 1.3 Hb 65 MCV20 INR 1.7 PTT 54INR 1.7 PTT 54
Creat , BUN & lytes NCreat , BUN & lytes N
AST 110 ALT 70 Albumen 20 AST 110 ALT 70 Albumen 20 Billirubin total 70 direct 40Billirubin total 70 direct 40
UA 0.3- 1 protein NO active sediment UA 0.3- 1 protein NO active sediment
HistoryHistory
Admission Dx Admission Dx pancytopenia pancytopenia ? Malignancy? Malignancy
Rx PRBC , FFP & HASRx PRBC , FFP & HAS
Within hours of admission Within hours of admission Fever , SOB & Hypotension Fever , SOB & Hypotension
No response to IVF , Bronchodilator No response to IVF , Bronchodilator
HistoryHistory Transferred to ICU Transferred to ICU
Worsening work of breathingWorsening work of breathing
On 15 l O2 NRBM On 15 l O2 NRBM
PH 7.3 PCO2 33 PO2 76 HCO3 16PH 7.3 PCO2 33 PO2 76 HCO3 16
Intubated , Neosenphrine Intubated , Neosenphrine
Swan Ganz Swan Ganz septic septic
CXR CXR Lt effusion Lt effusion
HistoryHistory Pleural tapping Pleural tapping LDH 2995 Glucose 0.3 Protein 38LDH 2995 Glucose 0.3 Protein 38
Transferred to ICM St.BTransferred to ICM St.B Shock , Acute renal failure Craet 200 Shock , Acute renal failure Craet 200 Lactaic acidosis 13 MelenaLactaic acidosis 13 Melena Rhabdomyolysis Myogolbin 5000Rhabdomyolysis Myogolbin 5000 ACS TnT 0.05 t wave inversionACS TnT 0.05 t wave inversion
Hospital CourseHospital Course In ICMIn ICM
Seen by 3 services on the same time Seen by 3 services on the same time
(reading the chart together) (reading the chart together)
ID ID meropenem & Vanco meropenem & Vanco
Renal Renal CRRT CRRT
GI GI were scoping the pateint next door were scoping the pateint next door
they didn’t mind scoping this patient !they didn’t mind scoping this patient !
Hospital CourseHospital Course Pleural fluid & Blood C/S Pleural fluid & Blood C/S Group C Beta streptGroup C Beta strept
Abx switch to Penicillin G continuous infusion Abx switch to Penicillin G continuous infusion
Cortisol 1750Cortisol 1750
Not candidate for activated protein CNot candidate for activated protein C
Hospital CourseHospital Course Upper GI scope Upper GI scope diffuse gastritis diffuse gastritis started on pantprazolestarted on pantprazole
Not candidate for activated protein CNot candidate for activated protein C
Recovered from shock Recovered from shock
Transferred to medicine Transferred to medicine
Group C Strept.Group C Strept. G +ve cocci , facultative anaerobesG +ve cocci , facultative anaerobes
Vast majority are pathogenicVast majority are pathogenic
Uncommon cause of bacteremiaUncommon cause of bacteremia
Predisposition Predisposition old age , animal exposure old age , animal exposure
, immunosupression, immunosupression
Group C Strept.Group C Strept. Dx Dx hemolytic pattern on blood agar medium hemolytic pattern on blood agar medium
In case in the absence of overt focal disease& +ve In case in the absence of overt focal disease& +ve Blood C/SBlood C/S search for an abscess, endocarditis or search for an abscess, endocarditis or
a suppurative process in an obscure area a suppurative process in an obscure area
Usually it is part polymicrobial infectionUsually it is part polymicrobial infection
it is important for the microbiology lab to identify it is important for the microbiology lab to identify
all species in a specimen from a closed space all species in a specimen from a closed space
or bacteremic process. or bacteremic process.
Group C Strept.Group C Strept. 5 y retrospective study5 y retrospective study
GCBHS caused 0.05 / 1000 admissionsGCBHS caused 0.05 / 1000 admissions
Data from 10/13 patientsData from 10/13 patients primary bacteremia (4 cases),primary bacteremia (4 cases), pneumonia (2cases), endocarditis (2 cases) pneumonia (2cases), endocarditis (2 cases) meningitis, intraabdominal infection & pericarditismeningitis, intraabdominal infection & pericarditis
6 Streptococcus equisimilis; 3 S. equi; 6 Streptococcus equisimilis; 3 S. equi; 2 S. dysgalactiae; and 1 S. zooepidemicus 2 S. dysgalactiae; and 1 S. zooepidemicus
Diagn Microbiol Infect Dis. 1992 FebDiagn Microbiol Infect Dis. 1992 Feb
Group C Strept.Group C Strept. 8 y retrospective study in 5 hospitals8 y retrospective study in 5 hospitals
78 cases 78 cases 16 bacteremia 16 bacteremia sources primary bacteremia,sources primary bacteremia, cutaneous , meningitis and pneumonia cutaneous , meningitis and pneumonia Higher rates of underlying diseases,Higher rates of underlying diseases, ETOH abuse, liver diseases, and cutaneous ETOH abuse, liver diseases, and cutaneous
infections, and lower rates of exposure to animals or infections, and lower rates of exposure to animals or raw products raw products
Morbidity and mortality were 20% to 30% Morbidity and mortality were 20% to 30% Arch Intern Med. 1995 Jun Arch Intern Med. 1995 Jun
Group C Strept.Group C Strept. Exquisitely susceptible to penicillin Exquisitely susceptible to penicillin
MIC should be performed in life-threatening MIC should be performed in life-threatening infections infections
meningitis, brain abscess, endocarditismeningitis, brain abscess, endocarditis
An aminoglycoside, for synergyAn aminoglycoside, for synergy
Group C Strept.Group C Strept. In penicillin allergic patients In penicillin allergic patients
clindamycin & macrolideclindamycin & macrolide
In high resistance or immunocompromised patients In high resistance or immunocompromised patients
vancomycinvancomycin
Drainage of abscesses is essential Drainage of abscesses is essential
IVIG & GCBHSIVIG & GCBHS
Multicenter randomized Plc control Multicenter randomized Plc control
Jan 1999 Jan 1999 May 2001 May 2001
streptococcal toxic shock syndrome STSS pateintsstreptococcal toxic shock syndrome STSS pateints
Patients could be included before lab confirmation Patients could be included before lab confirmation site of infection or family history strept infectionsite of infection or family history strept infection
Rapid antigen test from throat or skinRapid antigen test from throat or skin CID 2003CID 2003
IVIG & GCBHSIVIG & GCBHS
IVIG 1mg/kg day 1 & 0.5 mg/kg day 2&3IVIG 1mg/kg day 1 & 0.5 mg/kg day 2&3 or Albumen 1%or Albumen 1%
All patients received clindamycin 600mg TIDAll patients received clindamycin 600mg TID & Penicillin 12 gm / day& Penicillin 12 gm / day
Primary outcome 28 days mortalityPrimary outcome 28 days mortality
Secondary outcomes time to shock resolutionSecondary outcomes time to shock resolution 180 days survival & organ dysfunction180 days survival & organ dysfunction
IVIG & GCBHSIVIG & GCBHS
Small number of patients ?may be the reason Small number of patients ?may be the reason for non significance resultsfor non significance results
low incidence of STSSlow incidence of STSS
53% +ve BC & 41% tissue culture53% +ve BC & 41% tissue culture
NO side effects NO side effects