五院區聯合視訊會議 - cgmh.com.cn · meningeal sign: brudzinski sign: negative; kernig...

五院區聯合視訊會議五院區聯合視訊會議A 11A 11--yearyear--99--month old boy with fever and month old boy with fever and

conscious disturbanceconscious disturbance

R3 R3 楊韻璇醫師楊韻璇醫師 / MA / MA 花曼津醫師花曼津醫師

基隆長庚醫院小兒科基隆長庚醫院小兒科

20092009--44--2222

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General dataGeneral data

nn Name: Name: 高高XX源源nn Chart number:Chart number: 71002227100222nn Age: 11Age: 11--yearyear--99--monthmonth--old old nn Gender: maleGender: malenn BW: 40 kg (50BW: 40 kg (50--75th percentile)75th percentile)

BH: 150cm (50BH: 150cm (50--75th percentile)75th percentile)

nn Admission date: 2009/01/29~2009/3/1Admission date: 2009/01/29~2009/3/1




Chief complaintsChief complaints

nn Fever for 2 daysFever for 2 daysnn Conscious disturbance with sudden onset Conscious disturbance with sudden onset

of seizure attack at 1/29 nightof seizure attack at 1/29 night




Present IllnessPresent Illness

nn This 11This 11--yearyear--99--monthmonth--old boy suffered from old boy suffered from mild cough with mild cough with rhinorrhearhinorrhea for one week. for one week.

nn Spiking fever up to 40.1C for 2 daysSpiking fever up to 40.1C for 2 daysnn Depressed consciousness was found transient in Depressed consciousness was found transient in

the 1/29 morning. Nausea, vomiting, and the 1/29 morning. Nausea, vomiting, and headache were also complained. headache were also complained.




Present illnessPresent illness

nn Seizure attack at 1/29 night (7pm) with clinical Seizure attack at 1/29 night (7pm) with clinical presentations ofpresentations ofnn Lost of consciousness Lost of consciousness nn TonicTonic--clonicclonic type seizure ( Left lower limb weakness)type seizure ( Left lower limb weakness)nn Duration : less than 10 Duration : less than 10 minsmins ((relieved spontaneouslyrelieved spontaneously))

nn Consciousness was not fully recovery ( E2V2M4)Consciousness was not fully recovery ( E2V2M4)nn Admitted to PICU for further careAdmitted to PICU for further care




Past and Personal HistoryPast and Personal History1. 1. Admission history: Admission history:

Acute lymphoblastic leukemia (transitional preAcute lymphoblastic leukemia (transitional pre--B subtype) post B subtype) post status chemotherapy at 2status chemotherapy at 2--yearyear--old, complete remission old, complete remission

2.2. Allergy history: deniedAllergy history: denied3. Operation history: no 3. Operation history: no 4. Chronic illness: no4. Chronic illness: no5. Current medication: no5. Current medication: no6. Travel history: none6. Travel history: none7. Contact history: 7. Contact history: mother and brother had common cold mother and brother had common cold

recentlyrecently




Physical ExaminationPhysical Examinationnn T:38.1/T:38.1/℃℃ P:83/minP:83/min R:27/min R:27/min BP:115/84 mmHgBP:115/84 mmHgnn General appearance: acute illGeneral appearance: acute ill --lookinglookingnn Consciousness: drowsy, GCS:E2V2M4Consciousness: drowsy, GCS:E2V2M4nn HEENT:HEENT:

nn Lips: no cyanosis, Lips: no cyanosis, laceration wound(+)laceration wound(+)lip swelling (+)lip swelling (+)oral ulcers( oral ulcers( -- ) gum swelling ( ) gum swelling ( -- ))throat: injectedthroat: injected

nn Chest / Heart :Chest / Heart : BS coarse , BS coarse , rhonchirhonchi ++ , RHB, , RHB, no murmurno murmur

nn Abdomen : soft and flat, no tendernessAbdomen : soft and flat, no tendernessBowel sound : Bowel sound : normoactivenormoactive

nn EXTREMITIES:EXTREMITIES:No pitting edema, Peripheral pulse: symmetricNo pitting edema, Peripheral pulse: symmetric

nn SKIN:SKIN:No rash; no No rash; no petechiaepetechiae or or ecchymosisecchymosis; no vesicle; no desquamation; no vesicle; no desquamationIntact without woundIntact without wound




Physical examinationsPhysical examinationsnn Neurological examinations: (1/30)Neurological examinations: (1/30)

Neck suppleNeck supplePupil light reflex: +/+Pupil light reflex: +/+Muscle power: Muscle power:

○○4 4 ∣∣ 4 4

44＼／▽＼／＼／▽＼／4 4 4 4 ∣∣ 4 4 44／＼／＼3 3 ∣∣4 34 3∣∣

44─┘─┘ └─└─4 4 DTR :++/++DTR :++/++BabinskiBabinski sign: plantar flexion/plantar flexionsign: plantar flexion/plantar flexionMeningealMeningeal sign: sign: BrudzinskiBrudzinski sign: negative; sign: negative; KernigKernig sign: negativesign: negative




0.1%BASOPHIL

0.0%EOSINOPHIL

4.7%MONOCYTE

6.7%LYMPHOCYTE

88.5%SEGMENT

2101000/cmmPLATELET

12.0%RDW

34.9g/dLMCHC

28.3pg/CellMCH

81.1ummMCV

35.2%HCT

12.3g/dLHGB

4.34milon/cmmRBC

20.01000/cmmWBC

血液組(CBC)

980129單位檢驗項目

45U/LAST

0.76mg/dLCR(B)

9.0mg/dLCA(B)

98U/LCK

190.55mg/LCRP

4.34meq/LK(B)

118.7meq/LNA(B)

210mg/dLGLU

生化組(B)

980129單位檢驗項目




2009/1/29:

PA view of chest shows: Normal heart size and configuration. Peribronchial infiltrationGaseous dilatation of bowel loops .

Consolidation over the retro-cardiac region




Radiography of Chest Lateral View L’T Show:Infiltration in left lower lung field.Normal heart size and configuration.




No bacteria seenNo bacteria seenGRAM STAINGRAM STAIN100:0100:0RBC F:ORBC F:O

00MONOCYTEMONOCYTE00LYMPHOCYTELYMPHOCYTE00NEUTROPHILNEUTROPHIL154154uLuLRBCRBC00uLuLWBCWBC21.821.8mg/mg/dLdLPROTEINPROTEINCOLORLESSCOLORLESSCOLORCOLOR

CLEARCLEARAPPEARENCEAPPEARENCE

(1/30)(1/30)CSF studyCSF study

Glucose: 103 mg/dL Total protein: 21.8 mg/dL

Lactate: 27.0 mg/dL




nn Brain CT scan (1/30)Brain CT scan (1/30)Imp: Imp: No definite evidence of intracranial lesion

n EEG exam (2/2)Imp: No epileptic form discharge, normal report




Initial ImpressionInitial Impression

1. Left lower lung pneumonia 1. Left lower lung pneumonia 2. Sepsis2. Sepsis3. Seizure and conscious change3. Seizure and conscious change

suspect bacterial suspect bacterial meningoencephalitismeningoencephalitissuspect herpes simplex encephalitis suspect herpes simplex encephalitis suspect septic encephalopathysuspect septic encephalopathy

4. 4. HyponatremiaHyponatremia




PICU coursePICU course

nn Consciousness improved graduallyConsciousness improved graduallynn Study and treat about the pneumonia and sepsisStudy and treat about the pneumonia and sepsisnn Empiric antibiotics and antiEmpiric antibiotics and anti--viral agent : viral agent :

nn VancomycinVancomycin (60mg/kg/day Q8h) + (60mg/kg/day Q8h) + RocephinRocephin(100mg/kg/day Q12h) (100mg/kg/day Q12h) (meningitis dose) (1/30(meningitis dose) (1/30--2/2)2/2)

nn AzithromycinAzithromycin PO QD for 3 days PO QD for 3 days ( 1/30( 1/30-- 2/1)2/1)nn Acyclovir (500mg/mAcyclovir (500mg/m22/dose) IVF Q8h /dose) IVF Q8h (1/30(1/30-- 2/4)2/4)

nn Survey bacterial and viral etiology Survey bacterial and viral etiology n Follow up electrolyte and correct hyponatremia




45U/LAST

0.76mg/dLCR(B)

0.12ng/mLTROPONIN-I

2.2ng/mLCK-MB

5mg/dLBUN(B)

8.58.49.0mg/dLCA(B)

15U/LALT

278258262mosm/KgH2OOSMO(B)

19698U/LCK

281.95190.55mg/LCRP

3.363.914.103.944.34meq/LK(B)

136.2132.1122.4120.1118.7meq/LNA(B)

164163175210mg/dLGLU

生化組(B)

980131980130980130980130980130980129單位檢驗項目




nn CSF culture: negative (1/30)CSF culture: negative (1/30)nn Blood cultures (1/29, 1/31)Blood cultures (1/29, 1/31)

Staph.aureusStaph.aureus 11 --------------------------------------------------------------------------------------------------------------------------------------------------藥敏試驗藥敏試驗____________________ClindamycinClindamycin . R ,. R ,Erythromycin . RErythromycin . R ,,FusidicFusidic acid______ _________ S ______,acid______ _________ S ______,OxacillinOxacillin . R ,. R ,Penicillin . RPenicillin . R ,,SufamethoxazoleSufamethoxazole--Trimethoprim__STrimethoprim__S ______,______,TeicoplaninTeicoplanin . S ,. S ,VancomycinVancomycin . S. S ,,

Antibiotics shift to : • Vancomycin ( 40mg/kg/day)

Q6h IVF (2/2--)




After consciousness recovery After consciousness recovery (1/31)(1/31)……....

nn Patient complained about left thigh pain with Patient complained about left thigh pain with movement limitationmovement limitation

nnCRP elevated : 190.55 (1/29)CRP elevated : 190.55 (1/29)àà 281.95 (1/31) mg/L 281.95 (1/31) mg/L nnTransfer to ordinary ward Transfer to ordinary ward




Patient self describedPatient self described……..

nn Left knee was hit by his brother 3 days before Left knee was hit by his brother 3 days before admission admission

nn Progressive left lower limb weakness, pain and Progressive left lower limb weakness, pain and swelling change were found thereafter. swelling change were found thereafter.




左大腿表皮有erythema, local heat左腿圍比右腿圍大




2009/1/31:

Left hip , femur AP and lateral view shows:No bony pathologic change.




Bone scan(2/2)Bone scan(2/2)

The flow study of bilateral lower limbs region The flow study of bilateral lower limbs region revealed revealed increased blood flow and blood pool to increased blood flow and blood pool to left knee area and thighleft knee area and thighThe whole body bone scan revealed 1 focal area of The whole body bone scan revealed 1 focal area of increased uptake of radioactivity involving the increased uptake of radioactivity involving the lateral lateral epicondyleepicondyle of left femur.of left femur.Impression:Impression:Active bone lesion in the lateral Active bone lesion in the lateral epicondyleepicondyle of left of left femur,femur, either either postpost--traumatic effect or focal traumatic effect or focal osteomyelitisosteomyelitis may show this picture. may show this picture.




Femur CT ( 2/3)There is abnormal low density lesion in the medial aspect of the left femur, just in the vastus intermediausmuscle, measured about 191mmx26mmx24mm .Abscess formation is considered.

There is no gross bony changes in the left femoral cortex and intramedullarspace. No evidence of osteomyelitis in the left thigh




1. There is increased in strands in the subcutaneous layer of the left thigh, and skin thickening .Compatible with cellulitis in the left thigh.

minimal air density inside the muscle.




Fluid collection in the left knee joint space and suprapatellarbursa, as well as in the poplitealaspect of lower thigh.Suspect left knee Pyoathrosis




CT guided drainage (2/4) CT guided drainage (2/4) ----> 128cc pus was > 128cc pus was drained at the 1st day drained at the 1st day

nn Pus culturePus culture11 Staph.aureusStaph.aureus Moderate Moderate --藥敏試驗藥敏試驗__________________ 1( __________________ 1( 濃度濃度 ))ClindamycinClindamycin . R ,. R ,Erythromycin . R ,Erythromycin . R ,FusidicFusidic acid___________. S ______,acid___________. S ______,OxacillinOxacillin . R ,. R ,Penicillin . R ,Penicillin . R ,SufamethoxazoleSufamethoxazole--TrimethoprimTrimethoprim . S . S TeicoplaninTeicoplanin . S ,. S ,TigecyclineTigecycline . S ,. S ,VancomycinVancomycin_________. S ______,_________. S ______,




Ultrasound-guided aspiration of the left knee joint spaceà Left knee septic arthritis was excluded




2009/1/29 admission

Vancomycin

3/2 discharged

Acyclovir

2/10

2/4 CT guided drainage

2/10 Skin rash

Teicoplanin

Rocephin

2/11

Gentamicin

2/23 2/25

2/2 bone scan

2/3 femur CT

2/24 Skin rash

2/19




1/29

1/301/31 2/1 2/2

2/3

2/4

2/5 2/6 2/7

Vancomycin

Rocephine

Vancomycin




Skin rash over trunk on 2/10Skin rash over trunk on 2/10Fever was still persistedFever was still persisted

ALP U/L

3151CK U/L

51.54181.82CRP mg/L

19ALT U/L

20AST U/L

0.52CR mg/dL

13BUN mg/Dl

2/112/82/4

1.01.00.0EOS%

3.04.04.7MON%

12.04.06.7LYM %

82.089.088.5SEG %

463353210PLA1000/cmm

10.612.312.3HGBg/dL

12.418.820.0WBC 1000/cmm

2/82/41/29




Suspect Drug Eruption Suspect Drug Eruption and Drug Feverand Drug Fever

nn DC DC VancomycinVancomycin on 2/11( since 1/30; Day 13)on 2/11( since 1/30; Day 13)nn Shift to Shift to TeicoplaninTeicoplanin (8mg/kg/day IVF QD) since (8mg/kg/day IVF QD) since

2/112/11àà fever subside dramatically fever subside dramatically nn Stable condition during 2/12Stable condition during 2/12--2/182/18




2/8 2/9 2/10 2/11 2/12

VancomycinTiecoplanin

2/132/14 2/15 2/16

1/29

2/17

Tiecoplanin




Fever flared up again since 2/19Fever flared up again since 2/19~ ~ TeicoplaninTeicoplanin Day 9Day 9

nn Mild cough with Mild cough with rhinorrhearhinorrheann Arrange soft tissue echo for evaluationArrange soft tissue echo for evaluationnn Septic workupSeptic workupnn Arrange pus culture from vacuum ball, Arrange pus culture from vacuum ball,

remove drainage tube (D20) with culture on 2/23remove drainage tube (D20) with culture on 2/23àà suspect gram negative bacilli infection suspect gram negative bacilli infection

add add gentamicingentamicin IVF for 3 days (2/23IVF for 3 days (2/23--2/25)2/25)Finally, tip culture without bacterial growth Finally, tip culture without bacterial growth




Rash developed again on 2/24Rash developed again on 2/24Suspect Suspect TeicoplaninTeicoplanin drug eruption and drug eruption and

fever fever nn DC DC TeicoplaninTeicoplanin on 2/25 ( since 2/11; Day 14 )on 2/25 ( since 2/11; Day 14 )nn Laboratory data showed Laboratory data showed neutropenianeutropenia and AST, ALT and AST, ALT

elevation on 2/26elevation on 2/26àà no more fever since 2/26, data improved laterno more fever since 2/26, data improved later

nn Discharge on 3/1Discharge on 3/1àà no no sequelasequela and well condition at presentand well condition at present




2/18 2/19 2/20 2/21 2/22

Teicoplanin

2/23 2/24 2/25 2/26 2/27

Teicoplanin

GentamicinP D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com



0.04.00.6

17.020.05.8

46.057.030.0

37.019.063.3

331211184

82.581.682.2

10.29.610.3

3.723.543.81

3.72.23.4

3/12/262/23

EOS%

MON%

LYM %

SEG %

PLA 1000/cmm

MCV Umm

HGB g/dL

RBC mil/cm

WBC 1000/cmm

33.65CRP mg/L

4860ALT U/L

53AST U/L

0.50CR mg/dL

9BUN mg/Dl

3/12/26




Serology survey

n MYCO-IgM Borderline 16MYCO-IgG 1:80(+) 1:160(-)

COLD AGGL 1:32(+) 1:64(-)n HSV-IgM Negative

HSV-DNA Negativen INFA-Ab 1:2 (+)

INFB-Ab 1:2 (-)n EBEA-Ab 1:20 (weakly)

EBNA-Ab Positive EB-VCAG 1:160 (+) EB-VCAM Negative

2/26




Immunology surveyImmunology survey

nn IgGIgG mg/mg/dLdL 2430.00(0211) 2430.00(0211) (680(680--1530)1530)IgAIgA mg/mg/dLdL 391.00(0211) 391.00(0211) (74.7(74.7--373.5)373.5)IgMIgM mg/mg/dLdL 108.00(0211) 108.00(0211) (40.2(40.2--167.5)167.5)TT--CD3 78.1(0212) (49.9CD3 78.1(0212) (49.9--84.7)84.7)BB--CD19 11.1(0212) (7.8CD19 11.1(0212) (7.8--22.8)22.8)CD4 T Cell 34.4(0212) (23CD4 T Cell 34.4(0212) (23--53%)53%)CD8 T Cell 24.7(0212) (19CD8 T Cell 24.7(0212) (19--49%)49%)NKNK--Cell 9.4(0212) (1Cell 9.4(0212) (1--35%)35%)

nn CD4+ CD45RACD4+ CD45RA-- : 14.5(0212) : 14.5(0212) CD4+ CD45RA+ : CD4+ CD45RA+ : 20.0(0212)20.0(0212)CD4CD4-- CD45RA+ : 41.5(0212)CD45RA+ : 41.5(0212)CD4+ CD45ROCD4+ CD45RO-- : 21.4(0212): 21.4(0212)CD4+ CD45RO+ :13.3(0212)CD4+ CD45RO+ :13.3(0212)CD4CD4-- CD45RO+ : 22.9(0212)CD45RO+ : 22.9(0212)CD27+ CD19CD27+ CD19-- : 68.4(0212): 68.4(0212)CD27+ CD19+ : 0.9(0212)CD27+ CD19+ : 0.9(0212)CD27CD27-- CD19+ : 10.2(0212)CD19+ : 10.2(0212)HLADR+ CD2HLADR+ CD2-- : 17.3(0212): 17.3(0212)HLADR+ CD2+ : 26.1(0212)HLADR+ CD2+ : 26.1(0212)HLADRHLADR-- CD2+ : 51.4(0212CD2+ : 51.4(0212




Final DiagnosisFinal Diagnosis1. 1. PyomyositisPyomyositis, , vastus intermediaus muscle2. Left thigh 2. Left thigh cellulitiscellulitis3. 3. OxacillinOxacillin--resistant Staphylococcus resistant Staphylococcus aureusaureus

bacteremiabacteremia4. Septic encephalopathy with seizure attack4. Septic encephalopathy with seizure attack5. Left lower lung Pneumonia5. Left lower lung Pneumonia6. 6. HyponatremiaHyponatremia7 .Drug 7 .Drug hypersentivityhypersentivity reaction to reaction to VancomycinVancomycin

and and TeicoplaninTeicoplanin




DiscussionDiscussion

Part I. Part I. PyomyositisPyomyositis and and Community –acquired (CA)-MRSA




DefinitionsDefinitions

nn PyomyositisPyomyositis is a bacterial infection of skeletal is a bacterial infection of skeletal muscle with a predilection for large muscle muscle with a predilection for large muscle groups, and it often results in localized abscess groups, and it often results in localized abscess formation. formation.

nn In children, the peak incidence is between 5 and In children, the peak incidence is between 5 and 9 years of age9 years of age

~ Ann Trop ~ Ann Trop PaediatrPaediatr 19991999




~J Pediatr Orthop 2008

Children with musculoskeletal infection, treated between January 2002 and December 2004. There were total 3254 children and 554 had deep musculoskeletal infections.à Pyomyositits (3.6%) is a rare condition in children




MicrobiologyMicrobiologynn S. S. aureusaureus is the most commonly identified organism; it accounts is the most commonly identified organism; it accounts

for approximately 90% of cases of for approximately 90% of cases of pyomyositispyomyositis in tropical areasin tropical areasand approximately 70% of cases in North Americaand approximately 70% of cases in North America ..

Our patient: CA- MRSA




nn Staphylococcal (Staphylococcal (““tropicaltropical””) ) pyomyositispyomyositis most frequently affects most frequently affects the quadriceps, hamstring, or the quadriceps, hamstring, or glutealgluteal muscles but can also affect muscles but can also affect the the paraspinousparaspinous, shoulder girdle, , shoulder girdle, psoaspsoas, and other muscles, and other muscles




Clinical Manifestations of Clinical Manifestations of PyomyositisPyomyositis

nn Symptoms generally appear insidiously, with lowSymptoms generally appear insidiously, with low--grade fever, muscle aches, and cramping evolving grade fever, muscle aches, and cramping evolving over several days. over several days.

n Multiple sites are involved in 11% to 43% of patients n More rapidly necrotizing infections of muscle also

have been described. . nn Tropical Tropical pyomyositispyomyositis is occasionally complicated by is occasionally complicated by

metastatic disease such as metastatic disease such as empyemaempyema, , pericarditispericarditis, or , or lung abscess. In rare cases, lung abscess. In rare cases, fulminantfulminant septicemia or septicemia or toxic shock syndrome can occur.toxic shock syndrome can occur.




PathogenesisPathogenesisnn Staphylococcal muscle abscesses appear to be a Staphylococcal muscle abscesses appear to be a

complication of complication of transient transient bacteremiabacteremia and typically and typically develop without penetrating injurydevelop without penetrating injury or other clear portal or other clear portal of entry. of entry.

nn Blood cultures are usually negative. Blood cultures are usually negative. ~~ PediatrPediatr Infect Infect DisDis JJ 2000 2000

nn Predisposing factors: Predisposing factors: nn A history of trauma A history of trauma nn Vigorous exercise, presumably a cause of muscle strainVigorous exercise, presumably a cause of muscle strainnn An antecedent viral infectionAn antecedent viral infectionnn OthersOthers ——immunodeficiency, HIV infection, DM, injection immunodeficiency, HIV infection, DM, injection

drug use, and malnutrition drug use, and malnutrition




Defining Community Defining Community AssoicatedAssoicatedMRSAMRSA

nn Infections are classified as Hospital acquired (HA)Infections are classified as Hospital acquired (HA)--MRSA MRSA nn If MRSA is isolated 48 or more hours after hospitalization If MRSA is isolated 48 or more hours after hospitalization nn If the patient has a history of hospitalization, surgery, dialysIf the patient has a history of hospitalization, surgery, dialysisisnn RresidenceRresidence in a longin a long--term care facility within 1 year before term care facility within 1 year before

the MRSA culture datethe MRSA culture datenn Presence of an indwelling device at the time of culture, Presence of an indwelling device at the time of culture, nn A previous history of MRSA infection or colonizationA previous history of MRSA infection or colonization

nn Community Community ––acquired (CA)acquired (CA)--MRSAMRSA has been has been defined as an MRSA infection with defined as an MRSA infection with onset in the onset in the community in a patient lacking established HAcommunity in a patient lacking established HA--MRSA MRSA risk factorsrisk factors

~~The Pediatric Infectious DiseaseThe Pediatric Infectious Disease 20082008




HAHA--MRSA MRSA vsvs CACA--MRSAMRSA

healthy young hosts healthy young hosts (no predisposing (no predisposing comorbiditiescomorbidities))

an opportunistic an opportunistic pathogenpathogen

PatientPatient’’s groups group

more commonmore commonseldomseldomSevere invasive Severe invasive diseasedisease

SCCmecSCCmec tpyestpyesIV, VIV, V

SCCmecSCCmec types types I, II, IIII, II, III

GenotypeGenotype

CACA--MRSA strains MRSA strains (Community acquired)(Community acquired)

HAHA--MRSA strainsMRSA strains(Hospital acquired)(Hospital acquired)

~N Engl J Med 2005

** SCCmec: staphylococcal cassette chromosome mec




nn CA-MRSA is more and more prevalent in the environment

~~PediatrPediatr Infect Infect DisDis JJ. 2006. 2006

nn In 1 study of 812 U.S. Army soldiers presenting In 1 study of 812 U.S. Army soldiers presenting for Health Care Specialist training in 2003, for Health Care Specialist training in 2003, nasal nasal colonization with MRSAcolonization with MRSA, as compared with , as compared with MSSA, MSSA, was associated with a was associated with a significantly significantly increased risk of subsequent increased risk of subsequent S. S. aureusaureus skin and skin and soft tissue infectionsoft tissue infection (38% versus 3%, (38% versus 3%, P P <0.001) <0.001)

~~ClinClin Infect DisInfect Dis. 2004. 2004




nn CACA--MRSA was responsible for 59% of all skin MRSA was responsible for 59% of all skin and soft tissue infectionsand soft tissue infections (SSTI)(SSTI) at a network of at a network of 11 emergency departments located across the 11 emergency departments located across the United States.United States.

~N ~N EnglEngl J Med 2006J Med 2006n Most SSTIs are mild to moderate, CA-MRSA

may less commonly cause serious invasive infections, including necrotizing pneumonia, osteomyelitis, pyomyositis, bacteremia, and toxic shock syndrome

~ARCH PEDIATR ADOLESC MED 2008ARCH PEDIATR ADOLESC MED 2008




CACA--MRSA compared with CAMRSA compared with CA--MSSA MSSA in skin and softin skin and soft--tissue infections tissue infections

nn Ochoa et al. found patients with CAOchoa et al. found patients with CA--MRSA infections MRSA infections were were significantly youngersignificantly younger than patients with CAthan patients with CA--MSSA MSSA infections. infections.

nn Patients with CAPatients with CA--MRSA tended to have MRSA tended to have longer longer duration of duration of bacteremiabacteremia and required more surgical and required more surgical interventionsinterventions (incision, aspiration, drainage, or (incision, aspiration, drainage, or debridement).debridement).

nn MartinezMartinez--Aguilar et al. found that Aguilar et al. found that duration of fever and duration of fever and hospitalizationhospitalization were great in children with CAwere great in children with CA--MRSA MRSA compared with CAcompared with CA--MSSA infection. MSSA infection.




Diagnosis and Evaluation of Diagnosis and Evaluation of PyomyositisPyomyositis

nn Plain radiographs are usually normalPlain radiographs are usually normalnn Computed tomography (CT) or Computed tomography (CT) or ultrasonographyultrasonography may delineate a may delineate a

lowlow--density (or density (or hypoechoichypoechoic) fluid collection, thereby facilitating ) fluid collection, thereby facilitating diagnostic aspiration or diagnostic aspiration or percutaneouspercutaneous drainage.drainage.

nn MRI MRI helped in making the diagnosis and delineating the extent helped in making the diagnosis and delineating the extent of the muscle involvement in all patients. of the muscle involvement in all patients. nn The high signal intensity of the pathological process (T2)The high signal intensity of the pathological process (T2) can be easily can be easily

distinguished from the relative low signal intensity of normal mdistinguished from the relative low signal intensity of normal muscle ( T2). uscle ( T2). nn MRI provides excellent anatomical detail of each muscle group anMRI provides excellent anatomical detail of each muscle group and d

precisely located the site of diseaseprecisely located the site of disease~ Med J Aust. 2008~ Med J Aust. 2008




Diagnosis and Evaluation of Diagnosis and Evaluation of PyomyositisPyomyositis

nn Laboratory studies tend to be nonspecific.Laboratory studies tend to be nonspecific.nn LeukocytosisLeukocytosis with left shiftwith left shiftnn The erythrocyte sedimentation rate is often elevated The erythrocyte sedimentation rate is often elevated nn Muscle enzymes, such as Muscle enzymes, such as creatinecreatine kinasekinase is generally is generally

normal. normal. nn Blood cultures yielded positive results in 29% of cases Blood cultures yielded positive results in 29% of cases nn Fluid aspirated from the site of infection is more likely to Fluid aspirated from the site of infection is more likely to

yield an organism.yield an organism.




Management of Pyomyositis~(1)Management of Pyomyositis~(1)

nn Effective surgical drainage of all Effective surgical drainage of all pyogenicpyogenicmuscle abscesses is paramount. muscle abscesses is paramount. nn This can often be accomplished This can often be accomplished percutaneouslypercutaneously with with

ultrasound or CT guidanceultrasound or CT guidancenn an open surgical procedure may be required.an open surgical procedure may be required.

nn Definitive antibiotic therapy will be guided by Definitive antibiotic therapy will be guided by results of Gram stain, culture, and susceptibility results of Gram stain, culture, and susceptibility testing of material obtained during surgery. testing of material obtained during surgery.




Management of Management of PyomyositisPyomyositis ~(2)~(2)nn S. S. aureusaureus has remained the most common in all has remained the most common in all

age age nn A semiA semi--synthetic synthetic penicillinasepenicillinase resistant penicillin (resistant penicillin (egeg, ,

oxacillinoxacillin) is the traditional choice for empiric therapy. ) is the traditional choice for empiric therapy. nn ClindamycinClindamycin is an alternativeis an alternativenn In patients with penicillin allergies or MRSA was founded, In patients with penicillin allergies or MRSA was founded,

VancomycinVancomycin, , TeicoplaninTeicoplanin, or , or LinezolidLinezolid should be should be consideredconsidered

nn The optimal length of therapy is not well described. In The optimal length of therapy is not well described. In general, intravenous antibiotics should be continued general, intravenous antibiotics should be continued until clinical improvement is evidentuntil clinical improvement is evident




OutcomesOutcomes

nn In most large series of people with In most large series of people with pyomyositispyomyositiswere complete cure, with minimal residual were complete cure, with minimal residual symptoms. symptoms.




Part II. Part II. Drug Hypersensitivity Reaction to Drug Hypersensitivity Reaction to

VancomycinVancomycin and and TeicoplaninTeicoplanin




Drug Hypersensitivity ReactionDrug Hypersensitivity Reactionnn The diagnosis of drug hypersensitivity reaction was The diagnosis of drug hypersensitivity reaction was

made on the basis of signs and symptoms associated made on the basis of signs and symptoms associated with with the syndrome which rapidly resolved after the syndrome which rapidly resolved after withdrawal of the drugwithdrawal of the drug

nn The adverse drug reactions caused by The adverse drug reactions caused by VancomycinVancomycin and and TeicoplaninTeicoplanin are rare are rare

nn Allergic crossAllergic cross--reactions can occur between reactions can occur between vancomycinvancomycinand and teicoplaninteicoplaninnn Treatment with Treatment with vancomycinvancomycin or or teicoplaninteicoplanin results in a results in a

similar incidence of rash and fever but not necessarily in similar incidence of rash and fever but not necessarily in the same patientsthe same patients




VancomycinVancomycin

nn VancomycinVancomycin causes several different types of causes several different types of hypersensitivity reactions, ranging from localized hypersensitivity reactions, ranging from localized skin reactions to generalized cardiovascular skin reactions to generalized cardiovascular collapse. collapse. nn Red man syndrome ( RMS)Red man syndrome ( RMS) : most common : most common

adverse effectsadverse effects: It is a rate: It is a rate--dependent infusion dependent infusion reaction, and not a true allergic reaction. reaction, and not a true allergic reaction.




nn Skin manifestationsSkin manifestations: : nn MaculopapularMaculopapular or or urticarialurticarial skin eruptions: fever or rash usually skin eruptions: fever or rash usually

developed in the first 2 weeks of treatment. developed in the first 2 weeks of treatment.

nn VancomycinVancomycin--related linear "related linear "IgAIgA bullousbullous dermatosisdermatosisnn StevensStevens--Johnson syndrome ,Johnson syndrome ,exfoliativeexfoliative dermatitis ,and toxic dermatitis ,and toxic

epidermal epidermal necrolysisnecrolysis

nn RenalRenal:: The potential of The potential of vancomycinvancomycin to cause to cause nephrotoxicitynephrotoxicity is controversial.is controversial.nn It had been reported when It had been reported when vancomycinvancomycin was used together with was used together with

aminoglycosidesaminoglycosides..

nn Liver and the gastrointestinal tractLiver and the gastrointestinal tractnn Neither Neither teicoplaninteicoplanin nor nor vancomycinvancomycin cause severe liver toxicity. cause severe liver toxicity.




nn HematologicHematologic :Hematologic manifestations of :Hematologic manifestations of vancomycinvancomycin--related reactions include related reactions include leukocytosisleukocytosis, , eosinophiliaeosinophilia, , neutropenianeutropenia, and immune , and immune thrombocytopenia thrombocytopenia nn Drug induced Drug induced neutropenianeutropenia occurs as an adverse occurs as an adverse

idiosyncratic reactionidiosyncratic reactionnn The true incidence of drugThe true incidence of drug--induced induced neutropenianeutropenia is not is not

known. known. The white blood cell count recovers quickly once The white blood cell count recovers quickly once vancomycinvancomycin is stoppedis stopped. .

nn Drug have been administered within four weeks of the Drug have been administered within four weeks of the onset of onset of neutropenianeutropenia. .

nn Mechanism: either by Mechanism: either by immuneimmune--mediated destructionmediated destruction by by drugdrug--dependent or drugdependent or drug--induced antibodies or by induced antibodies or by direct direct toxic effectstoxic effects upon marrow granulocytic precursors. upon marrow granulocytic precursors.




Drug feverDrug fever

nn DrugDrug feverfever should be considered in the differential should be considered in the differential diagnosis of all febrile illnesses . diagnosis of all febrile illnesses .

nn Any drug can cause fever, especially those used to Any drug can cause fever, especially those used to mediate neurologic disorders, cardiovascular conditions, mediate neurologic disorders, cardiovascular conditions, and and neoplasianeoplasiann Aspirin, Aspirin, nonsteroidalnonsteroidal antianti--inflammatory agentsinflammatory agentsnn Among antimicrobial agents, Among antimicrobial agents, vancomycinvancomycin, , ββ--lactamlactam agents, agents,

isoniazidisoniazid, and sulfa drugs are most likely to cause fever,, and sulfa drugs are most likely to cause fever,whereas whereas aminoglycosidicaminoglycosidic agents and agents and macrolidesmacrolides are least likely are least likely

~ ~ Long: Principles and Practice of Pediatric Infectious Long: Principles and Practice of Pediatric Infectious Diseases, Diseases, 3rd ed3rd ed




nn DrugDrug feverfever may be low or high grade and sustained or may be low or high grade and sustained or intermittent and sometimes is disproportionate to the intermittent and sometimes is disproportionate to the degree of systemic toxicity. degree of systemic toxicity.

nn Typical onset of fever is 7 to 10 days after Typical onset of fever is 7 to 10 days after commencement of therapy, but the onset is variable. commencement of therapy, but the onset is variable.

nn Diagnosis: Clinical improvement is generally noted Diagnosis: Clinical improvement is generally noted within 24 to 48 hours of discontinuation of the within 24 to 48 hours of discontinuation of the causative agent. Recrudescent fever occurs within a few causative agent. Recrudescent fever occurs within a few hours after the drug is restartedhours after the drug is restarted

nn DrugDrug feverfever may present with rash, may present with rash, hemolysishemolysis, bone , bone marrow suppression, or marrow suppression, or eosinophiliaeosinophilia. .

~Long: Principles and Practice of~Long: Principles and Practice of Pediatric Infectious Pediatric Infectious Diseases, Diseases, 3rd ed3rd ed




TeicoplaninTeicoplanin

nn TeicoplaninTeicoplanin has the same spectrum of has the same spectrum of antimicrobial activity as antimicrobial activity as vancomycinvancomycin, and it , and it has a similar structure to has a similar structure to vancomycinvancomycinnn TeicoplaninTeicoplanin seldom causes seldom causes ‘‘red manred man’’ syndrome, syndrome, nn TeicoplaninTeicoplanin has less has less nephrotoxicitynephrotoxicitynn Routine serum assays are not necessary. Routine serum assays are not necessary. nn Patients treated with high doses of Patients treated with high doses of teicoplaninteicoplanin

for prolonged periods are most likely to for prolonged periods are most likely to experience adverse events. experience adverse events.




nn Overall, the incidence of adverse effects with Overall, the incidence of adverse effects with teicoplaninteicoplanin is lower is lower nn A metaA meta--analysis of 11 comparative trials found significantly analysis of 11 comparative trials found significantly

higher number of adverse events in patients given higher number of adverse events in patients given vancomycin(21.9%) than vancomycin(21.9%) than teicoplaninteicoplanin (13.9%)(13.9%)

~ J ~ J AntimicrobAntimicrob ChemotherChemother 19961996

n In a series of 3377 patients given teicoplanin, the most common reported adverse events werenn Local intolerance (55 patients,1.6%)Local intolerance (55 patients,1.6%)nn Abnormal liver function (57 patients, 1.7%),Abnormal liver function (57 patients, 1.7%),nn Fever (27 patients, 0.8%)Fever (27 patients, 0.8%)nn Abnormal renal function (22 patients, 0.7%) Abnormal renal function (22 patients, 0.7%) nn OtotoxicityOtotoxicity (11 patients, 0.3%) (11 patients, 0.3%)

~~ AntimicrobAntimicrob ChemotherChemother 1991.1991.




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