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Raymond P. Podzorski, Ph.D, D(ABMM) St. Mary’s Hospital Laboratory and Wisconsin Region SSMHealth 608-258-6393 [email protected]
Case Study
2016 – Wisconsin Mycobacteriology
Laboratory Network Annual Conference November 17, 2016
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Disclosure
Raymond P. Podzorski, Ph.D., D(ABMM) November 17, 2016
No relevant financial relationships to disclose.
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What Week Is This?
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1. National Radiologic Technology Week? 2. National Nurses Week? 3. Gun Hunting in Wisconsin? 4. CDC – Get Smart About Antibiotics Week? 5. Medical Laboratory Professionals Week?
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New & Progressing Lesions on Left Foot and Abdomen
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• 37 y/o ♂ presents to an urgent care center • Smoker, ½ pack per day • Construction worker – roofer • Works outside in all kinds of weather • Plays competitive soccer most weekends • Typically in very good health
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Past Medical History
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• Broken left ankle 3 years ago • Eye injury from nail gun “several years back” • Rarely even gets a cold
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Patient Examination
• No fever • No chills • No weight loss • No cough • No change in routine • No medications • Vitals all normal • Lesions on foot and abdomen noted
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Patient Examination
Lesions on left foot, first noticed about 9 months ago
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Patient Examination
Lesions on abdomen
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Patient Workup
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• Chest X-ray • BMP • CBC
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Chest X-ray
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Patient Workup
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• Chest X-ray - normal • BMP - normal • CBC - normal
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Patient Diagnosis/ Treatment/Follow Up
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• No diagnosis determined • Given one IM dose of gentamicin • Over 4-6 weeks there was a transient
improvement of all skin lesions
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……As Time Goes By…..
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Three Months Later
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• Patient presents to hospital ED • Complains of 3-week history of progressive
scrotal lesions, started with single lesion • Lesions are red, inflamed, painful, with
scrotal ulcerations
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Patient Examination
• No fever • No chills • No weight loss • No cough • Painful scrotal lesions • Lesions noted on foot and abdomen • No medications • Vitals all normal
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Patient Examination
17 Patient admitted to hospital
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ED Patient Workup
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• Chest X-ray • CAT scan chest, abdomen, pelvis • BMP • CBC • UA • HIV serology
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Which of These Tests Do You Think Will Be Flagged As Abnormal?
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1. Chest x-ray/CT scan of the chest? 2. BMP? 3. CBC? 4. HIV serology? 5. None of them?
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ED Patient Workup
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• Chest X-ray - normal • CAT scan chest – normal , abdomen - normal,
pelvis – scrotal cellulitis and soft tissue inflammation
• BMP - normal • CBC - normal • UA – normal • HIV serology - negative
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Hospital Course
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• Started on Vancomycin and Pip/tazo –no improvement observed after 72 hours
• Shave biopsy of scrotum obtained; H&E, Ziehl-Neelsen, and GMS stains performed
• Specimens for bacteria, AFB, and fungus cultures collected
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H&E Stain
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Ziehl-Neelsen Stain
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Hospital Course
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• Residual shave biopsy tissue of scrotum was tested using the Hologic amplified M. tuberculosis complex test – the result was positive
Patient started on rifampin, isoniazid, pyrazinamide, and ethambutol
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What Nucleic Acid Amplification Technology Is Used In The Hologic Assay?
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1. Polymerase Chain Reaction (PCR)? 2. Transcription Mediated Amplification (TMA)? 3. Strand Displacement Amplification (SDA)? 4. Nicking Enzyme Amplification Reaction (NEAR)? 5. Loop-Mediated Isothermal Amplification (LAMP)?
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Transcription Mediated Amplification
RT
RT
RT
RNA Pol RT
RT
8. Production of 100-1000 copies of RNA transcript
RNA
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Hospital Course
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• Three sputum specimens were collected for AFB stain and culture • All three sputum specimens were negative for AFB by Auramine-Rhodamine staining • All three sputum specimens grew M. tuberculosis complex after 14 - 17days • After 21 days of incubation the scrotal lesion MGIT tube incubated at 37° C grew M. tuberculosis complex
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Which One Of These Mycobacterium Is Not A Member of M. tuberculosis complex?
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1. M. microti? 2. M. africanum? 3. M. caprae? 4. M. arupense? 5. M. pinnipedii?
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M. arupense
• Belongs to M. terrae complex • Associated with cases of
tenosynovitis/osteomyelitis of fingers/wrist • Formally referred to as Mycobacterium sp.
MCRO 6 • Non-chromogenic • Grows rapidly on LJ at 30° C and slowly at 37° C • Type strain isolated from a human tendon
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Diagnosis/Conclusions
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• Patient has cutaneous tuberculosis • Very uncommon in US, only 1-2% of TB cases • Patient’s lung and cutaneous involvement suggest
hematogenous spread rather than primary inoculation
• A 2014 study of 103 cases of extra-pulmonary TB found that 26% of patients had a normal CXR*
• Reason(s) for cutaneous involvement in this patient is unknown
• Additional questioning of the patient elicited a history of past exposure to tuberculosis
*Herath et.al. 2014. J. Prim. Health Care, 1;6:64-68
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The End