Dr Philip Asquith (CMT2)

Dr Cecilia Jukka (Consultant Medical Microbiologist)

Dr John Horsley (Consultant Physician)

Southport and Ormskirk NHS Trust

‘A Hunter’s Infection’ Federation of Infection Societies Annual

Conference 2013

Background Autumn 2012

48 year old gentleman, previously fit and well, attends local Emergency Department feeling generally unwell with a two week history of:

Pyrexia

Myalgia

Arthralgia

And: abdominal pain, nausea and vomiting for one day

Had attended GP surgery one week earlier

No history of cough, dysuria, diarrhoea, headaches

Observations on admission

Pyrexia- temperature 40.8oC

Tachycardia- heart rate 126 bpm

Tachypnoea- respiratory rate 22

Relative hypoxia- oxygen saturation 93% on air

Examination in AED:

‘Chest clear, heart sounds normal, abdomen generally

tender but no guarding or organomegaly’

‘No focal neurological signs’

‘No cervical, axillary or inguinal lymphadenopathy

palpable’

Initial Investigations

White cell count 12.5 x109/litre (neutrophils 10.5 x109/litre )

C-Reactive Protein (CRP) 217 mg/litre

Renal and Liver Function Tests normal

Amylase 39, Lactate 2.1 u/litre

Corrected Calcium 2.07 mmol/litre

INR 1.2

Urine dipstick- trace of protein and blood

Blood and urine specimens for culture taken

Chest X-ray on admission

Initial social history

‘Non-smoker’

‘Truck driver who occasionally works in forests’

‘Many tick and mosquito bites’

‘No recent foreign travel’

Clinical Course

Sepsis ?source - IV Cefuroxime 1.5g TDS

commenced

Persistently hypotensive and pyrexial overnight-

given stat dose of Gentamicin

Improved during day, febrile again by evening

Antibiotics changed to IV Tazocin 4.5g TDS and IV

Gentamicin continued

Further history elicited:

Patient travels extensively throughout the UK for pheasant

shooting

Trains gun dogs for a living

Had been staying in Scotland during recent Legionella

outbreak (A red herring – travel was 2 months earlier!!)

Day 2…

Continued deterioration

Delirium, visual and auditory hallucinations

Increasing oxygen demands

Persistent tachycardia

Urgent CT head requested - normal

Lumbar puncture performed

normal opening pressure (<20cmH20), no increased

cells, no organisms seen, normal protein and glucose

Day 3…

Developed dry cough -coarse crackles to mid-zones

bilaterally on chest auscultation

CRP>300mg/litre

Some symptomatic improvement following doses of

Gentamicin. IV Clarithromycin commenced

High resolution CT chest requested

HRCT findings

Significant negative results

Three sets of blood cultures - 09/10/12th Nov

(prolonged incubation)

Mid-stream specimen of urine

Urinary Legionella antigen

Coxiella serology

Brucella serology

Borrelia serology

Paul Bunnell test

HIV 1 and 2 antibody testing

Significant negative results

Avian IgG precipitins to parrot/pigeon/budgerigar

Respiratory Viral PCR panel:

Influenza A/B

RSV

Parainfluenza 1/2/3

Adenovirus

Rhinovirus

Human metapneumovirus

Vasculitic screen (all negative)

Anti SSa/SSb

Anti-centromere

Anti-Scl 70

Anti-Jo1

Anti-GBM

cANCA/pANCA

Double stranded DNA

Immunoglobulins (IgA/IgG/IgM)- within normal range

Day 4...

Reviewed by Consultant Physician and Consultant

Microbiologist

‘Tell us more about this

hunting…’

Pigeons, lots and lots of pigeons…

Pigeons, lots and lots of pigeons…

3 month history of using trapped pigeons for hunting

practice

Regularly in contact with faecal matter and feathers

No protective clothing used

Day 4 continued…

IV Tazocin and IV Clarithromycin stopped

Oral Doxycycline 100mg BD commenced

Hunting partner visits patient

Partner now unwell also with fever and dry cough

Advised to attend Emergency Department…

Attends two days later so as not to miss big hunt in

South of England!

Temperature chart

32

33

34

35

36

37

38

39

40

41

42

Temperature

0 1 2 3

4* 5 6

Days since

admission

*Doxycycline

commenced

Outcome

10 days following admission the patient was well

enough to be discharged (CRP 13, WCC normal)

Gentamicin stopped after 7 days

Doxycycline continued for a further 3 weeks

Hunting partner improved after 5-day hospital stay.

Also treated with long duration oral Doxycycline (plus

IV Amoxicillin for 1st two days of admission)

Follow-up

Reviewed in outpatient clinic 6 weeks later

Rising CFT titres to Chlamydophila group from 12 to

64 on acute and convalescent serology specimens

Specific fluorescent antibody titres to Chlyamdophila

psittaci on acute and convalescent specimens

confirmed diagnosis (1024 rising to 4096)

Complete resolution of symptoms and returned to

training hunting dogs

Now wearing protective overalls…

(and using wild pigenons

…and using wild pigeons

Learning Points

Psittacosis1

Chlamydophila psittaci

Typically found in parrots, parakeets, budgerigars

May also be found in pigeons, turkeys and doves

Transmitted through inhalation of infected avian

material (respiratory secretions, faecal matter or dust)

or direct contact with plumage of infected birds

Learning Points Around 50 cases reported in England and Wales per annum (Public

Health England)1

Typical incubation period 5-19 days following exposure2

Common symptoms3 :

Fever

Dry cough

Myalgia

Headache

Less commonly:

Gastrointestinal disturbance

Polyarthralgia

Horder spots (facial rash)

Potential complications include:

Severe pneumonia requiring HDU/ITU support, endocarditis,

glomerulonephritis, meningoencephalitis, hepatitis,

pancreatitis, disseminated intravascular coagulation

Untreated Psittacosis has a high mortality (15-20%)4

Serological diagnosis is performed by PHE Reference

Laboratory, Bristol

PCR restricted (only available following discussion on tissue

or broncho-alveolar lavage specimens)

Learning Points

An accurate and thorough social history can help aid

diagnosis

If patient’s condition deteriorates despite

conventional antibiotic therapy, consider atypical

organisms

Close collaboration with Infection Specialists is

essential in cases of unusual presentations or

failure to respond to empirical therapy

References 1. Background information on Psittacosis. Public Health

England. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Psittacosis/GeneralInformation/psiBackgroundInformation/

2. Psittacosis. Centers for Disease Prevention and Control. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/psittacosis_t.htm

3. Psittacosis. http://emedicine.medscape.com/article/227025-overview

4. Centers for Disease Control and Prevention Compendium of measures to control Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis), 2000. MMWR Recomm Rep. 2000;49(RR-8):3–17.

References

Clip Art images from Microsoft Office Powerpoint 2010

Springer spaniel

http://commons.wikimedia.org/wiki/File:Springer_Spani

el.jpg.JPG

Pheasant http://themoocher.co.uk/2013/01/07/an-

appreciation-of-pheasant/

Pigeons http://observer.com/2011/06/park-slope-guy-

poisoning-pigeons-damn-the-collateral-damage/

Chlamydophila psittaci

http://www.cpnhelp.org/publicimages/EBsOnRBCs.jpg

References

‘The Simpsons’ produced by Gracie Films in

association with 20th Century Fox, created by Matt

Groening

‘Breaking Bad’ produced by High Bridge Productions

with Gran Via Productions and Sony Pictures

Television for American Movie Classics (AMC)

Acknowledgements and Thanks

Many thanks to the patient for allowing us to share

his story

Radiology Department at Southport DGH for help

acquiring CT/Radiograph images

Public Health England Reference Laboratory, Bristol

(especially Dr David Carrington for discussion

regarding results)

Thank you for listening