On March 8, 2017 a collaborative tele-conference occurred between the University of Pittsburgh and Philippines General Hospital. This was the second such meeting and was a great success. The time difference makes coordination of these events more difficult but during the “Standard Time” period of year, it is dinner time in Pittsburgh and early breakfast time in Manila. We will plan to have more of these conferences in the fall and will post the time/place in advance for those who would like to attend.
Please see the case discussions below:
The first case was presented from Philippines General Hospital.
Dr. Harold Chiu, a first year medicine resident, presented a case of a middle aged male who was newly diagnosed with diabetes. He presented with a foot ulcer after stepping on a nail. He tries oral amoxicillin but progressed and was admitted with narcotizing fasciitis with clearly evident air in the tissues on his X-rays of the foot and leg. He had sepsis on admission and required an above-knee amputation. He improved, however 3 days later he developed left eye swelling, chemosis and purulence. His vision on that side was only light perception. His ophthalmologic exam revealed hypopyon and endopthalmitis. He underwent vitrectomy of the Left eye.
The cultures from the eye, foot wound and the blood all grew Klebsiella pneumoniae. The sensitivities showed a wild-type (intrinsically resistant to ampicillin). He was treated with ceftazidime. On the agar plate this isolate had a positive “string sign” which confirmed the hypermucoviscous phenotype.
Important points from the discussion:
- The hypermucoviscous (also known as hypervirulent) K. pneumoniae is identified by the string sign (colony attaches and sticks as per image. This virulence relates to abundant production of its polysaccharide capsule. This makes them more resistant to phagocytosis
- The most common serotypes for this hypermucoviscous phenotype are K1 and K2.
- The most common infection seen with these Klebsiella is liver abscess (the patient in the case had negative US and CT scan of liver)
- Two main risk factors for hypermucoviscous Klebsiella are diabetes and residence in/travel to Asia
- Classically while more virulent, K1 and K2 serotypes of Klebsiella have not been associated with increased resistance, however Dr. Yohei Doi noted that there have been reports from China carbapenem resistant cases. (Zhang et al ACC 2015)
- There have been a few reports in the literature of necrotizing fasciitis due to the hypermucoviscous Klebsiella, but this is not one of the the classic organisms (Pubmed)
(Pitt attendees watching Dr. Chiu’s presentation)
The second case was presented by Mana Rao, 2nd year Fellow in Infectious Diseases at the University of Pittsburgh. Her case also involved occular symptoms. The patient was a middle aged male diagnosed with HIV/AIDS (Cd4 <200) during an admission for poly-microbial bacteremia and pneumonia. After discharge he established care and was started on an anti-retroviral regimen (EVG/c/TAF/FTC).
He was noted to have an elevated RPR and was given 3 doses of penicillin intramuscuarily for presumed late latent syphilis. 1 month later he was admitted for C diff, improved, however soon after he developed right eye floaters. His repeat CD4 count showed improvement (>500) with an appropriate viral load reduction.
Ophthalmologic examination revealed pan-uveitis. He did not have vitreous sampling but underwent lumbar puncture. This revealed 1 WBC, but was positive for VDRL. As such he was treated with 10-14 days of intravenous penicillin G as per the CDC guidelines.
The discussion of centered on the diagnosis and treatment for syphilis, neurosyphilis and ocular syphilis in the setting of HIV and AIDS. Key points included:
- The pharmicokinetics of intramuscular penicillin G are insufficient for CSF penetration and also likely for ocular penetration
- Prior guidelines recommended LP for any patient with HIV and positive RPR, however the recent guidelines give more leeway and recommend “All persons with HIV infection and syphilis should have a careful neurologic exam” .
- It is important to recall the physical exam findings in neurosyphilis (Argyll Robinson pupil, Tabes dorsalis etc- See nice NEJM Image)
- Most clinicians present agreed that with positive RPR and negative neurologic exam treatment for late latent syphilis is appropriate in HIV patients (assuming no prior negative RPR documented within the past 1 year).
- Treatment for ocular syphilis is akin to treatment for neurosyphilis and requires intravenous penicillin.
- While LP (with VDRL) is recommended for patients with ocular (or suspected ocular) syphilis, colleagues in the Philippines noted that they usually defer this as the treatment decision is not changed by a positive or negative LP. This may be the preferred strategy is more resource-limited settings.