Infectious Diseases Conference

Infectious Diseases Conference
Presentation by:Charles de Comarmond MD

History of present illness
Past medical Hx, FHx, SHx, ROS
* Multiple sclerosis
* Seizure disorder
* Pernicious anemia
* Chronic back syndrome
* Migraine headache
* Depression

Medications
* Betaseron
* Ampicillin-sulbactam
* Vancomycin
* Tegretol
* Librium
* Paxil
* Risperidal
* Trazodone
* Vicodin
* Phenergan
* FHx: Non-contributory
* SHx: 20 pack/year smoker, occasional ETOH
* ROS: chronic low grade temp, repeated admission for hyponatremia

Physical exam
* Vitals: Tmax. 101.5° F, HR:86, RR:20, BP: 111/79.
* Appeared comfortable at time of exam.
* Skin: no rash or jaundice
* HEENT: PERLA, ears, nose, mouth normal
* Neck: supple
* Chest: Clear
* Heart: S1S2 regular rate and rhythm
* Abdomen: Soft, no hepatosplenomegaly
* Extremities: Grossly erythematous swelling of the cubital fossa, with erythema extending to the palmar aspect of left wrist. No evidence of drainage.
* Neuro: AAOx3

Labs

* WBC: 5.3 segs; 84%
* bands; 5%
* lymphs; 7%
* monos; 4%
* Hemoglobin; 12.2 mg/dL
* MCV; 102.8 FL
* Platelets;
* Na 130
* K 4.2
* Cl 9.2
* BUN 8
* Creatinine 0.8
* Glucose 107
* Calcium 8.4
* UA: normal
* 12/25/02 BC: gram +ve cocci (1 of 1)
* Cardiac echo;
* Overall normal valvular appearance and function with mild mitral regurgitation and tricuspid regurgitation. No pericardial effusion.

Differential diagnosis

* Op note; The cephalic vein was dissected out and was noted to be thrombosed. There was an abscess cavity right at the antecubital fossa. The vein was tied off distally, and the entire cephalic vein and a portion of the basilic vein were completely excised.
* Pathology; Acute phlebitis with necrosis and organizing thrombus. There is focal necrosis of the intima. Neutrophils infiltrate the wall of the vessel.
Follow-up cultures
Differential Diagnosis

* Infectious
* Multiple abscesses —Bacteremic patients may develop multiple lung abscesses, which are more common in dependent areas of the lungs. Typically the lesions are between 0.5 and 3 cm in diameter, round, and well-defined.
* Septic emboli — Septic thrombophlebitis may generate septic emboli which produce multiple 0.5 to 3 cm round or wedge-shaped nodules with a predilection for peripheral areas of the lower lobes Cavitation is common, usually producing thin-walled lesions. On CT, subpleural lesions can display a feeding vessel.

* Fungi
* Histoplasmosis
* Coccidioidomycosis
* Aspergillosis
* Cryptococcus
* In these cases, the lesions tend to range from 0.5 to 3 cm in diameter without a clear predilection for a specific area of the lungs
* Neoplastic
* Metastatic solid organ malignancies
* the most common cause of multiple pulmonary nodules and account for 80 percent of such cases.
* The lesions are variable in size and location, with a proclivity for the better perfused lung bases
* The lesions are usually round with sharply demarcated borders
* Cavitation of metastatic lesions occurs in less than 5 percent of cases.
* Non-Hodgkin's lymphoma: These are more common in the lower lobes.
* Intrapulmonary lymphoma nodules usually originate from the bronchial-associated lymphoid tissue (BALT), and occasionally exhibit a halo of ground glass attenuation
* HIV: Kaposi's sarcoma can present with multiple pulmonary nodules in a peribronchovascular distribution.
* The size of these nodules tends to exceed 1 cm at the time of diagnosis
* Noninfectious
* Inflammatory conditions;
* Wegener's granulomatosis: Can produce multiple round, sharply or poorly demarcated lesions varying in size from 0.5 to 10 cm.
* Areas of consolidation may be associated with nodules, and cavitation occurs in slightly less than one-half of patients, generally producing a thick wall with an irregular inner lining
* Lymphomatoid granulomatosis
* Sarcoidosis
* PULMONARY ARTERIOVENOUS MALFORMATIONS
* Present radiographically as either solitary or, in 30 percent of cases, multiple pulmonary nodules.
* Lesions are usually well-defined, round or oval opacities ranging from 1 to 5 cm in diameter
* The presence of a shunt fraction of >5 percent when breathing 100 percent oxygen in the absence of an intracardiac shunt strongly favors the diagnosis of pulmonary arteriovenous malformations.
* PNEUMOCONIOSES
* Coal workers' pneumoconiosis
* Silicosis
* May evolve to progressive massive fibrosis or conglomerate masses, yielding a radiographic appearance of multiple pulmonary nodules
* These may range in size from 1 to 10 cm and usually are located in the upper lobes
* Calcification and cavitation are unusual, but can occur and raise the possibility of superimposed tuberculosis.

Thrombophlebitis
* Thrombophlebitis represents a spectrum of disease processes and includes:
* Nonspecific, nonsuppurative thrombophlebitis or "bland phlebitis" manifested by pain, tenderness and redness over the vein course
* Nonsuppurative thrombophlebitis caused by infection of an intraluminal thrombus
* Suppurative thrombophlebitis with intraluminal purulent exudate, necrosis of the vein and periphlebitic abscess

Suppurative superficial thrombophlebitis
Epidemiology
Pathogenesis
Pathology
Microbiology
Clinical Manifestations
Diagnosis
Treatment

Infectious Diseases Conference.ppt