An uncommon route for an uncommon pathogen

Brittany Folks, MD PGY2 Exempla Saint Joseph Hospital

Denver, Colorado

Q: What do a cow and a knee have in common?

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.

Q: What do a cow and a knee have in common? A: A needle.

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!

Thank you.