Journal of the Louisiana State Medical Society
CorynebacteriumBacteremia - Not Always a Contaminant A.S.J. Chandranesan, A. Khan, and M. Choudhary LSU-Health Sciences Center, Shreveport Case: A 56-year-old African-American male with past medical history of HIV presented to an outside hospital with hemoptysis and fatigue for two weeks. He denied fever, shortness of breath, recent travel, and sick contacts. He was non-compliant withHAART for three years. He quit smoking two years ago. He was afebrile and cachectic in appearance. Chest exam revealed decreased breath sounds, and dullness to percussion in the right-posterior field. WBC count was 8.9 x 10 9 /L with 85% neutrophils and 6% bands. Blood culture grew gram-positive coccobacilli. Chest X-ray showed a right upper lobe cavitary lesion. The patient was started on empiric vancomycin and ceftriaxone. CD4 count was 3. CT chest showed a thick-walled cavitary mass with air-fluid level in the right mid-upper lobe. Sputum AFB smears were negative. Sputum culture isolated normal respiratory flora. Fungal and mycobacterial blood cultures were negative. Repeat blood cultures grew the same gram- positive rod that was identified as Corynebacterium species. The isolate was sent to a reference lab where it was identi- fied as Rhodococcus equi (formerly Corynebacterium equi ). The patient was treated with vancomycin, imipenem/cilastin, rifampin, and levofloxacin. Resolution of symptoms was noted in 10 days. Bacteremia resolved in a month. HAART was restarted. Outpatient follow-up in two months showed resolution of lung abscess, improvement in CD4 count, and undetectable HIV viral load. Levofloxacin and rifampinwas planned for additional six months. Discussion: Rhodococcus equi is a gram-positive, aerobic, non-motile intracellular weakly acid fast coccobacilli. It is often overlooked or discarded as non-pathogenic coryne- form. It causes lung infection in horses and cattle. Most human infections are noted post-animal exposure or in immunocompromised. It causes subacute to chronic bron- chopneumonia complicated by abscess and suppurative involvement of distant sites - brain and skin. Blood cultures are positive in 25%-50% cases. It is treated with more than two antimicrobials until clinical improvement. This is fol- lowed by two oral antibiotics for at least sixmonths. HAART therapy should be initiated in HIV positive patients.
with a Hgb of 6.2 g/dL and an MCV of 90 fL. His platelet count was normal, 300K/µL. ACT scan of the pelvis showed a large right-sided retroperitoneal hematoma and subcuta- neous hematoma. Coagulation studies revealed a PT of 11.2 s, INR of 1.0, and a PTT elevated at 113 s. The patient was unaware of any bleeding disorders in his or his families’ past medical history. D-dimer and fibrinogen were elevated so DIC seemed less likely. He received fresh frozen plasma and prothrombin complex concentrate, each improved his PTT temporarily. A mixing study did not correct. Further coagulation studies showed a low Factor VIII activity level of 8 IU/dL and an elevated Factor VIII inhibitor level of 28 BU/mL. The patient was diagnosed with an acquired factor VIII inhibitor. He was started on rituximab and received recombinant factor VIIa after a bleeding episode. His PTT improved and dropped as low as 71 s; however, he became unstable after developing abdominal compartment syndrome from the large pelvic hematoma and went into cardiopulmonary arrest and died. Discussion: Differential diagnosis of a prolonged PTT with normal PT includes deficiencies of factors VIII and IX, as well as inhibitors of these factors. Amixing study is used to confirm the presence of an inhibitor. Confirmation of a factor VIII inhibitor is made with low factor VIII activity levels and elevated factor VIII inhibitor levels. Treatment involves attempts at raising factor VIII levels with DDAVP and factor VIII concentrates and to bypass factor VIII with activated prothrombin complex concentrates or recombinant factor VIIa in cases of bleeding. Agents used to eliminate the inhibitor include rituximab, cyclophosphamide with prednisone, IVIG, and cyclosporine. Stressed, Stiff, and Spastic - More Than Just Graves’ Hyperthyroidism V. Narendra and G. Sun LSU-Health Sciences Center, Shreveport Introduction: Stiff-Person syndrome (SPS) is a rare neuroimmunologic disorder characterized by elevated glutamic acid decarboxylase antibody (GADA) titers and progressive rigidity, stiffness, and painful spasms of the axial muscles. It is associated with other autoimmune conditions, including type 1 diabetes mellitus and rarely, autoimmune thyroid disease. We describe SPS in a patient presenting with thyrotoxicosis. Case: A 23-year-old woman presented with two weeks of bilateral lower extremity pain. She was tachycardic (130 bpm), tremulous, and hyperreflexic with left leg spasms. Increased muscle tone, decreased range of motion, pedal edema, left foot tenderness, and lumbar lordosis were also noted. Autoimmune-mediated hyperthyroidism was con- firmedwith thyrotropin <0.01 [0.4-4.0 IU/mL], total thyrox- ine 18.1 [4.5-11.5 ug/dL], total triiodothyronine 141.88 ng/ dL [60-180 ng/dL, thyroperoxidase antibodies 131.5 [<6 IU/ mL], and thyroid stimulating immunoglobulin 423 [<140%]. Creatinine kinase and aldolase were 2682 [20-180 U/L] and 19.7 [<7.5 U/L], respectively. Impending thyroid stormpre-
Hemophilia A is Not a Disease Just For Kids V. Patel, R. Ramirez, and R. McCarron LSU-Health Sciences Center, New Orleans
Introduction: Acquired factor VIII inhibitors (also re- ferred as Acquired Hemophilia A) is a rare bleeding diathe- sis caused by autoantibodies directed against clotting factor VIII and is associated with bleeding involving soft tissues. Case: A 79-year-old Caucasian male presented to the emergency room with complaints of right hip pain and left elbow pain for two weeks after falling. On physical exam, he had a large edematous area with significant ecchymosis over his right gluteal area and left elbow. He was anemic
90 J La State Med Soc VOL 166 March/April 2014
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