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

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Post-Operative Fever

Post-Operative Fever
Presentation lecture by: Jennifer Caffey, D.O.

HPI
* CC: Fever x 2 days
* HPI: 19 months old female with 2 days history of fever, max. 102F. Emesis x2, described as non-bilious, non-bloody. Appetite decreased but tolerating oral fluids. Good urine output. No sick contacts. Status-post Open Reduction, Internal Fixation 5 days prior to admission for developmental dysplasia of the left hip.

Review of Systems
* No URI symptoms
* No pain in extremities
* No dyspnea
* No chest pain
* No diarrhea, no constipation
* No rashes

Past History

* PMH: developmental dysplasia of left hip
* PSH: 2 prior corrective surgeries on left hip, 1st on May 6, 2nd on May 20, 2004
* Birth: term AGA female born via C-section secondary to hand presentation. Pregnancy complicated by transient episodes of maternal hypotension. Normal nursery stay.
* Previous Hospitalizations: 9 mos for febrile illness. Twice in May 2004 for hip surgery.
* Meds: Tylenol prn fever
* Allergies: NKDA
* Immunizations: UTD by history
* Diet: well rounded, age-appropriate
* Family Hx: Maternal grandmother with Type II DM
* Social Hx: Lives with mom, dad, 5y/o brother and 2m/o brother. Dad is a smoker. + Cats outside. No daycare.
* Developmental: Speaks Spanish only, multiple single words

Physical Exam

* V/S: T 37.3 (ax) HR 145 RR 24 BP: 103/53 Wt: 15kg (>95th)
* Gen: Lying on back in SPICA cast
* HEENT: normocephalic, PERRL, red reflex intact, nares patent, TM’s clear Bilaterally, moist mucosa, oropharynx with mild erythema, no cervical lymphadenopathy
* Heart: regular rhythm, no murmurs
* Lungs: Limited exam secondary to cast, upper lobes clear to auscultation bilaterally
* Abd: Limited secondary to cast, + bowel sounds, lower abdomen soft, not tender
* Ext: lower extremities in cast, lower extremity pulses 2+ and symmetrical
* Neuro: Limited exam, no focal deficits
* GU: normal female genitalia, left hip wound dressed and without drainage.

LABS (initial)
* CBC: WBC 15.6 H/H 8.6/27.2
G 69.5 L 19.6 M 10.4 E 0.2 B 0.2
Platelets 459,000
* Blood Culture -- drawn
* CXR: Lungs are clear except for some increased opacity behind the heart that may represent atelectasis.

Labs during Hospital Stay

* ESR 98 (5/26), repeat 78 (5/28)
* CRP 10.2 (5/26), repeat 2.1 (5/28)
* Blood Culture negative at 73 hours

Differential Diagnosis
* UTI
* Wound infection/abscess
* Pneumonia
* Vascular/venous catheters
* Deep vein thrombophlebitis
* Others…?

Postoperative Fever
* Fever > 38° is common in 1st few days after major surgery
* Most early post-op fever caused by inflammatory stimulus of surgery and resolves spontaneously

* Pathophysiology of fever:
- Fever is manifestation of cytokine release in response to stressful stimuli
- Cytokines released include interleukin-1, TNF-alpha, IFN gamma
- Fever-associated cytokines released by tissue trauma and do not necessarily signal infection
* Timing of fever after surgery is important in establishing differential diagnosis:
- Immediate - onset in operating suite or within hours after surgery
- Acute- onset within 1st week after surgery
- Subacute - onset from 1 to 4 weeks after surgery
- Delayed – onset >1 month after surgery

Post-op Fever- Immediate
Differential Diagnosis:
* Medications or blood products,
* Immune mediated reactions to transfused blood products and antimicrobials, and
* malignant hyperthermia
Fever due to trauma of surgery resolves within 2-3 days (fever due to severe head trauma may be persistent and not resolve for days to weeks)

Post-op Fever- Acute
Differential Diagnosis:
* Nosocomial infections
* Community acquired infections
* Surgical site infection
* Intravascular catheters
* Pneumonia
* UTI

Post-Op Fever- Subacute
Differential Diagnosis:
* Surgical site infection
* Central venous catheter related infections
* Thrombophlebitis
* Antibiotic associated diarrhea
* Drug Fever
* Deep Vein Thrombophlebitis
* Pulmonary Embolism

Post-Op Fever- Delayed
Differential Diagnosis:
* Infection
* Viral infections from blood products
* Surgical site infections

Causes of Post-op Fever
* Infectious:
Surgical site infections
Pneumonia
UTI
Catheter infection
Sinusitis
Meningitis
Parotitis
TSS
* Non-Infectious:
Stress of surgery
Medications
Malignant hyperthermia
Deep vein thrombosis
Fat embolism
Transfusion reactions
Atelectasis?

Orthopedic Procedures
Complications:
Spontaneously resolving fever is the rule after major orthopedic surgery
Differential Diagnosis:
* Surgical Site Infections
* Hematoma
* Deep Vein Thrombosis/Thrombophlebitis

Approach to Patient
* Evaluate patient systemically taking into account timing of onset of fever and the various possible causes
* Initial screen:
* Wind: consider pulmonary causes including pneumonia, aspiration, embolism
* Water: consider UTI
* Wound: consider surgical site infection
* What did we do ?: consider treatment interventions including medications, blood product transfusions, and intravascular, urethral, nasal and abdominal
Treatment

* Remove unnecessary treatments including medications and catheters
* Suppress fever with tylenol
* Antibiotics per clinical judgment/culture results

Post-Operative Fever.ppt

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BioImage

BioImage Suite is an integrated image analysis software suite developed at Yale University. BioImage Suite has been extensively used at different labs at Yale since about 2001. The last stable version is 2.6.1 which was released on April 6th, 2009.

BioImage Suite has extensive capabilities for both neuro/cardiac and abdominal image analysis and state of the art visualization. Many packages are available that are highly extensible, and provide functionality for image visualization and registration, surface editing, cardiac 4D multi-slice editing, diffusion tensor image processing, mouse segmentation and registration, and much more. It can be intergrated with other biomedical image processing software, such as FSL, AFNI, and SPM. This site provides information, downloads, documentation, and other resources for users of the software.

Visit Here to Download

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