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Mayo Clinic Infectious Diseases

4 Feb, 11 tweets, 7 min read

#MayoIDQ 69M was brought to the ED because of weakness. PE: intoxicated disheveled man with multiple skin ulcers / excoriations.
WBC 27. CK 1486. AST 76.
Wound culture: Clostridium botulinum

Which of the following is most consistent with wound botulism?

2/
#Botulism

#Botulinum neurotoxin binds to cholinergic nerve terminals and cleaves intracellular proteins needed for #acetylcholine release —> reduced acetylcholine —> neuromuscular blockade —> bulbar palsies, hypotonia, and symmetric, descending, #flaccid #paralysis.

3/
#Botulism

Clinical features
1. Flaccid paralysis
2. Prominent cranial nerve palsies
3. Descending progression
4. Symmetrical presentation
5. No sensory nerve dysfunction.

43% are correct in MCQ

cdc.gov/botulism/healt…

4/
#Botulism

Prominent cranial nerve palsies!
* Blurred vision
* Diplopia
* Ptosis
* Dysarthria
* Dysphagia

5/
#Botulism
Cause: #Clostridium #botulinum

Clinical types
1. Food borne botulism
2. Infant botulism
3. Wound botulism
4. Iatrogenic botulism

6/
Foodborne #Botulism

Ingestion of #botulinum toxin from poorly prepared home-canned foods

Rapid onset: illness in few hours to days
* Abdominal pain, N V D —> flaccid paralysis

Public health emergency: outbreaks when people consume same food source

doi.org/10.1086/379326

7/
Infant #botulism

Occurs when infants harbor C. #botulinum in intestinal tract

Infant ingests spores of C. botulinum —> intestinal tract colonization —> toxin production

cdc.gov/botulism/infan…

8/
Wound #botulism

Wounds get infected with C. #botulinum —> secrete toxin

Risk groups:
1. IDU - black tar #heroin
2. Traumatic injury, such as motorcycle crashes

jamanetwork.com/journals/jama/…

9/
Iatrogenic #botulism occurs after an overdose of injected #botulinum toxin (Botox) for cosmetic or medical purposes.

ncbi.nlm.nih.gov/pmc/articles/P…

10/
#Botulism Rx

#botulinum antitoxin ASAP. Antitoxin does not reverse paralysis, but arrests progression.

Supportive care / mechanical ventilation, until recovery / regeneration of new nerve connections.

Wound botulism: debridement to remove source + antibiotic therapy

11/
Bonus MCQ: what is the recommended infection control precaution of patients with #botulism?

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Mayo Clinic Infectious Diseases

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6 Feb

Weekend Digest

What happens when a person ingests this “egg packet”?

Name the pathogen and its treatment.

2/
What happens when a person ingests this “egg packet”?

Nothing!
#Dipylidium caninum eggs are NOT infectious to humans.

Then,
How do humans get infected?

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How do humans get infected?

Humans (often children) are infected when they accidentally ingest a flea that contains #Dipylidium larvae (cysticercoid).

Infected fleas in pet dogs and cats

doi.org/10.12980/APJTB…

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19 Dec 20

Weekend Digest

Name the pathogen!

H & E stain of heart tissue of a 27M who developed severe intractable heart failure 2 months after an allogeneic bone marrow transplant for acute leukemia.

Clue: consumption of food / water contaminated with feces of snakes

2/
#Sarcocystosis
1. Sarcocystis hominis, suihominis, nesbetti, others
2. Zoonotic: 2 forms for human infection
3. Intestinal and muscular sarcosystosis
4. Dx: intestinal (O/P), muscular (biopsy)
5. Rx: not well defined; TMP-SMX, albendazole, others

cmr.asm.org/content/28/2/2…

3/
Intestinal #Sarcocystosis
1. Ingestion of sarcocyst (S. hominis / beef, suihominis / pork) in tissue
2. Sarcocyst digested —> bradyzoites —> intestinal infection / gametes —> oocysts / sporocyst detected in stool
3. Self limited. No Rx needed

cmr.asm.org/content/28/2/2…

Read 5 tweets

Mayo Clinic Infectious Diseases

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17 Dec 20

Images of Infectious Diseases

GMS of sinus tissue of 20F with no PMH. She presented with fever and sinus pain. CT pansinusitis. Labs: WBC 1.7 ANC 0. Serum BDG and GM negative.

What is your differential diagnosis and empiric therapy? #MayoIDQ to follow...

2/
Histopath of surgically resected tissue shows fungal elements. You suggested Mucor/Rhizopus, Fusarium, Trichosporon.

Lack of serum BDG suggests Mucor/Rhizopus

The patient was started on AmBisome.

Few days later, the fungal culture of the same sinus sample shows (photo)

3/
#MayoIDQ Surgical debridement of the sinuses was performed plus liposomal Amphotericin B was initiated. Patient lives in rural MN and asks you if an oral option is available as step down Rx.

Read 9 tweets

Mayo Clinic Infectious Diseases

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28 Nov 20

Weekend Digest

Giemsa stain of blood smear of a 50M who returned to the US after a 10-year missionary work in Mali and Senegal. He presented with episodic angioedema and eosinophilia.

Name the pathogen, its treatment and complication of Rx.

2/
#Loa loa

Bite of chrysops deer fly

Larva migrates in tissues; matures into adult worm in 5 months, and live for 20 years.

Adults produce microfilaria that gets into lymphatics / blood —> tissues. Microfilaria does not mature into adult but lives for a year.

3/
#Loa loa migrates in tissues

Most infected people ASYMPTOMATIC

1. Calabar swelling - transient localized, non-tender swellings usually on arms and legs and near joints

2. Eye worm - visible movement of adult worm across the surface of eye

3. Eosinophilia and pruritus

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26 Nov 20

Images of Infectious Diseases

6 mo post-tx: H&E (400x) of cervical biopsy of 46F s/p living unrelated donor kidney tx for adult PCKD.

Belatacept. MMF. Prednisone.
Acute cellular + antibody-mediated rejection.

CMV D+/R-. valganciclovir prophylaxis.

DDx / Rx? #MayoIDQ next

2/
Case diagnosis: breakthrough CMV disease with cervicitis

H&E intranuclear / intracytoppasmic inclusions within endothelial cells in ectocervical stroma.

Immunohistochemistry stain for CMV shows infected endothelial cells with CMV inclusions.

doi.org/10.1111/tid.13…

3/
#MayoIDQ Breakthrough CMV disease, while receiving valGCV prophylaxis, is concerning for over-immunosuppression, under-dosing of val GCV, and/or drug-resistant virus.

If gene sequencing shows the most common CMV gene mutation, what drug would be recommended Rx?

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Mayo Clinic Infectious Diseases

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23 Aug 20

Images of Infectious Diseases

This is GMS stain and culture of a skin biopsy from a patient’s leg.

Who is the host? What is the syndrome? Name the pathogen. How to treat?
#MayoIDQ and case details to follow...

2/
66M. 4 mo after heart Tx: painless leg nodules that spread distally x 5 weeks. No pain. No fever.

PE unremarkable except lesions in left leg / foot + tinea pedis

Biopsy: GMS fungal elements in dermis. Culture: Trichophyton rubrum

What is true of this condition?

3/
Case diagnosis:
#Majocchi’s Granuloma due to #Trichophyton rubrum

Histopath shows fungal elements (GMS) - not sufficient for identification.

Important: Send specimen for culture identification!!!

Treatment: Itraconazole Rx

Read 9 tweets

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