JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
MIMICKING LUNG CANCER: A MOLDY PROBLEM
RAT BITE FEVER IN A DUMPSTER DIVER
A. Syed, MD; H. Fervaha, MD; R. Marvin, MD; D. Daberkow, MD; A. Espinoza, MD Department ofMedicine, Leonard J ChabertMedical Center, Houma Case: A 74-year-old woman with a history of HTN, HLD, type 2 diabetes, tobacco use (50 year) and CKD IIIb presented complaining of cough with thick brown sputum and right posterior chest wall pain of greater than 6 weeks. She had been treated 10 days prior for community acquired pneumonia without significant improvement. She also complained of 10lb weight loss along with night sweats and fevers. She had SIRS criteria on admission along with a consolidation in the right upper lobe that had worsened compared to the CXR from 10 days prior. She was started on broad-spectrum antibiotics as she had failed outpatient treatment for CAP. She had minimal improvement over the next 48 hours and the majority of her microbiological workup was negative. Consequently, a CT chest showed significant consolidation in the right upper lobe, including ground-glass areas and a non-calcified nodular density. The patient underwent a bronchoscopy that showed cobblestoning and friable tissue throughout the trachea along with various areas of bleeding from the right bronchus. Biopsies and cultures were collected and there was high suspicion of an endotracheal tumor with a post-obstructive pneumonia. Subsequently, the patient’s BAL returned with numerous septate hyphae showing 45 o angle branching. The patient’s respiratory culture resulted with Aspergillus Fumigatus, and she was started on Voriconazole 200mg BID. A CT scan 2 months later demonstrated improvement in consolidations in the right upper lobe with formation of multiple apical and upper lobe cavities. Discussion: Aspergillus infections, which are frequently associated with immunocompromised states, are primarily found in the pulmonary system, but infection of the cutaneous, cardiac and gastrointestinal systems frequently occur. This patient’s cancer workup was negative but she had poorly controlled diabetes. Tracheobronchial aspergillosis is commonly found in lung transplant patients with pulmonary aspergillosis being a late manifestation. Our patient had a clear CXR 4 months prior and developed an invasive infection in a relatively short period of time. This case highlights the importance of tight glycemic control as the hyperglycemic environment created by poorly controlled diabetes results in immune dysfunction.
S. Clark, MD 1 ; J. Anderson, MD 1 ; S. Jani 2 ; D. Yang 2 ; B. Johnson 2 ; M. Shaw 2 ; L.A. Naccari 3 1 LSU Health Sciences Center -Baton Rouge, 2 Lsu Health Sciences Center – New Orleans, 3 LSU Health Sciences Center – Shreveport Case: A 56-year-old African American man with a past medical history of pre-diabetes, HLD, HTN, and intellectual disability presented with right arm pain as well as 2-3 weeks of generalized weakness, subjective fevers, poor appetite and “loose stools.” Review of systems was significant for recent left knee pain as well as a 9 pound weight loss. Upon obtaining further history, the patient reported that he had been dumpster diving and collecting aluminum cans in the recent months and sustained multiple cuts from various items of garbage. At the time of presentation he was febrile (101.5 o F), ill-appearing, and underweight. He exhibited an erythematous macular rash of his palms and soles with no associated penile or perineal lesions. Joint exam did not reveal any effusions, warmth or erythema. His labs were significant for a leukocytosis of 19.3 with 17.9% neutrophils, negative RPR, HIV, urine gonorrhea and chlamydia. CXR and CT head provided no source for infection. Blood cultures were positive for a gram negative anaerobe, and he was started on pipercillin/tazobactam for a total of 11 days until final speciation resulted as Streptobacillus moniliformis . He was transitioned to Augmentin to complete 14 days total of antibiotic therapy. Rat bite fever can be caused by both Streptobacillus moniliformis or Spirillum minus (though S. minus is found predominantly in Asia). Streptobacillus moniliformis is filamentous, gram negative, non-motile, microaerophilic, highly pleomorphic bacillus which can cause two main clinical syndromes: rat bite fever and Haverhill fever. Transmission is usually via direct inoculation, handling rodents, or ingestion of contaminated food or water. Clinical symptoms occur 3-10 days after a bite or scratch by an infected rodent, but can occur up to 3 weeks later. Treatment includes bite wound care followed by systemic antibiotics with penicillin being the agent of choice. Long-term complications are rarely seen if patients are treated appropriately; however, if treatment is not initiated then long- term effects can include endocarditis, myocarditis, pericarditis, meningitis, pneumonia, abscesses in internal organs, and rarely, death. Discussion:
J La State Med Soc VOL 170 MARCH/APRIL 2018 61
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