FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

Posters

CLINICAL CASE REPORTS – Poster Nos. 001-025

001
Case report of NDM–producing Klebsiella pneumoniae complex upper urinary tract infection treated with ceftazidime-avibactam and aztreonam combination therapy
Abstract - 001
Poster 001

Case report of NDM–producing Klebsiella pneumoniae complex upper urinary tract infection treated with ceftazidime-avibactam and aztreonam combination therapy

Robert Shorten1, Frances Garraghan2, Phillipa Burns1, Iain McIntyre2, Kirsty Dodgson2, Louise Sweeney2
1Public Health England, Manchester. 2Manchester University Foundation Trust

Introduction: We describe the use of ceftazidime-avibactam and aztreonam in combination for the treatment of a complicated urinary tract infection caused by New Delhi metallo-betalactamse (NDM)-producing Klebsiella pneumoniae in a 57 year old man with longstanding obstructive renal failure.

Results: The patient has chronic high pressure retention as a result of benign prostatic hyperplasia, bilateral nephrostomies, a urinary catheter and recurrent urinary tract infections. He had received multiple courses of antimicrobials and was admitted for flexible diagnostic cystoscopy. The patient was known to be colonised with an NDM carbapenemase-producing Klebsiella pneumoniae and became unwell six days after this procedure. The same organism was isolated from multiple urine samples. Susceptibility to the antibiotic combination was determined by a non-validated disc-diffusion synergy method. Due to limited antimicrobial options the patient completed a five-week course of ceftazidime-avibactam and aztreonam in combination with nephrostomy change for source control prior to being discharged.

Discussion: This complex infection caused by a multi-drug resistant organism was successfully treated with this antimicrobial combination. The risk of using two beta lactams in a patient with poor renal function was considered alongside the potential side effects, toxicity and scarcity of other options. The patient has not experienced a further infection with this organism but has been given the same combination as prophylaxis for two subsequent nephrostomy changes. It is likely that the patient acquired this organism on one of many visits to Pakistan. No adverse effects, in particular deterioration in renal function, were identified during this treatment course.

Antimicrobial resistance necessitated an infrequently used combination of antibiotics to successfully treat this complex, deep-seated infection with a multi-drug resistant organism. In vitro susceptibility was determined by a non-validated methodology and suggested activity against this organism. There is a requirement to establish reliable testing as infections with resistant organisms become more prevalent.

002
An unusual case of meningitis – thirsty for the diagnosis
Abstract - 002
Poster 002

An unusual case of meningitis – thirsty for the diagnosis

Fiona McGill1,2,3, Jon Folb1, Gareth Roberts1, Paul Roberts1, Caroline Corless1, Nick J Beeching4,2

1Liverpool Clinical Laboratories, Royal Liverpool University Hospital. 2Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital. 3Institute of Infection and Global Health, University of Liverpool. 4Liverpool School of Tropical Medicine

Introduction: A 64-year-old hotel manager was admitted with an acute severe headache, confusion and fever. He was entirely well 24 hours beforehand. On admission his temperature was 38.7ºC and he was confused with a GCS of 11. He had no photophobia or neck stiffness and no obvious focal neurological abnormality. He was initially treated with IV ceftriaxone, amoxicillin, dexamethasone and aciclovir.

CT of his head showed prominent lateral ventricles. Lumbar puncture could not be performed initially due to agitation. Twelve hours after admission the patient had required multiple doses of lorazepam to control his agitation. He had an acute respiratory deterioration, was intubated and ttransferred to the intensive care unit (ICU).

Methods: Lumbar puncture (LP) in ICU revealed an opening pressure of 24 cm H2O, a leucocyte count of 9650/mm3 (90% polymorphs) and a red cell count of 2330/mm3. Cerebrospinal fluid (CSF) protein was 3.02g/L, glucose 2.5mmol/L (serum glucose 6.4 mmol/L).

The following day a blood culture flagged positive and antibiotics were adjusted accordingly. However, the blood culture isolate was later thought to be a probable contaminant. CSF culture had no growth. Meningococcal and pneumococcal PCR were negative in CSF and blood. 16S rRNA gene PCR of the CSF eventually revealed the causative organism.

The patient received 14 days of ceftriaxone and made a good recovery before being discharged in good health.

Discussion: This is an unusual case of bacterial meningitis. We retrospectively looked back through the last ten years of our laboratory records and have not identified any previous cases of meningitis in our hospital with this organism. 16S rRNA gene PCR was crucial in this case to confirm the diagnosis and should be utilised in cases of suspected bacterial meningitis where none of the more common organisms are found.

003
Taking the mickey
Abstract - 003
Poster 003

Taking the mickey

Helen Casey, Rebecca Annis, Zoe Riches, O. Martin Williams
Bristol Royal Infirmary

Introduction: A 50-year-old man presented with a swollen right knee and reduced mobility. His GP had diagnosed gout but the patient felt that his symptoms were worsening. He was afebrile on initial assessment but self-discharged soon after presentation. Of note, his C-reactive protein (CRP) was elevated (345mg/L (normal range <6.0)).

Three days later the patient represented with a temperature of 38.5°C, and a hot and erythematous right knee with effusion. Repeat investigations showed a CRP of 375mg/L and total white cell count (WCC) of 12.95×109/L (normal range 4.0-11.0). His past medical history included schizophrenia and personality disorder. He smoked tobacco and cannabis but denied alcohol or current intravenous drug use. His knee was aspirated but no crystals were seen under polarised light microscopy and he was admitted under orthopaedics. He was commenced on intravenous (IV) flucloxacillin for a possible septic arthritis.

Methods: His CRP rose to 472mg/L, and he became progressively more unwell. His knee aspirate had numerous white cells seen but no organisms on Gram stain. The cultures were subsequently negative. On further questioning he reported that two days prior to the onset of his symptoms he caught a field mouse, jarring his knee and elbow in the process. The mouse bit his hand before being released. On examination the bite looked well healed with no sign of infection.

He continued to be febrile with ongoing knee pain and was now developing widespread myalgia and arthralgia. An ultrasound scan of his right thigh showed a large and complex collection along the femur with evidence of myositis. A diagnosis of infective endocarditis was now queried. A trans-thoracic echocardiogram demonstrated a small mobile structure on the aortic valve which could be calcium, a vegetation or artefact and trans-oesophageal echocardiogram was recommended. The CRP remained static at 343mg/L.

Discussion: The patient was then reviewed by the Microbiology/Infectious Diseases team who noted a past history of intravenous drug use, although the patient denied injecting for over 10 years. He reported keeping two snakes, and a lizard that had been previously colonised with a Salmonella spp. He had a long term partner and denied any new sexual contacts. On examination the main findings were multiple swollen painful joints and ongoing pyrexia but no rash or stigmata of endocarditis. At this point an alternative diganosis was proposed and his antibiotics were switched.

004
An interesting case of E. coli induced urosepsis complicated by acute myopericarditis
Abstract - 004
Poster 004

 

An interesting case of E. coli induced urosepsis complicated by acute myopericarditis

Rhea O’Regan, Elaine O’Connell, Susanne O’Reilly, Tarah Cullen, Michelle Madden
Mater Misericordiae University Hospital, Dublin, Ireland

Introduction: We present an interesting case of acute myopericarditis following Escherishia coli urosepsis.

A previously fit and well 57 year old gentleman presented to the Acute Medical Unit with two day history of dysuria, left sided flank pain and general malaise.

Patient was hypotensive, tachycardic and febrile on admission with left renal angle tenderness on examination.

Patient had no past medical history of note and was on no regular medications.

Initial bloods demonstrated markedly raised inflammatory markers and urine microscopy was positive for leucocytes. He was commenced on IV antibiotics for pyelonephritis. Urine culture later grew E. coli bacteria with numerous sensitivites.

Two days later, patient appeared much improved and discharge planning was commenced. Unfortunately, he developed sudden onset severe central chest pain that evening and became clinically unstable. High sensitivity troponin and creatinine kinase returned as markedly raised and there were widespread ST-segment elevation changes on ECG. Patient was rushed to cardiac catheterisation lab for urgent CT coronary angiogram.

CT angiogram demonstrated patent coronary arteries. Serial ECGs demonstrated changes in keeping with acute myopericarditis and patient was commenced on high dose aspirin and NSAIDs.

He improved steadily following introduction of NSAIDs and had no further episodes of chest pain. ECGs returned to baseline, as did cardiac biomarkers.

He was discharged home after several days observation and has had no complications.

Methods: Data was collected from the patient’s chart and from radiology and laboratory systems in our institution.

Discussion: This case highlights a rare presentation of E. coli urosepsis complicated by acute myopericarditis in a previously fit and well individual. While cardiac biomarkers can be raised in entities other than acute coronary syndrome such as sepsis, ECG changes are not as well described in such cases.

ST-segment elevation changes are rare and have only previously been noted in a handful of case reports involving patients with E. coli urosepsis.

Myopericarditis is most commonly caused by viral infection in developed countries but some bacteria have also been identified as causal agents.

This case highlights the importance of considering other differentials when confronted with a patient who’s symptoms mimick an acute coronary syndrome following treatment for urosepsis.

005
Is it a lung cancer or pulmonary TB?
Abstract - 005
Poster 005

Is it a lung cancer or pulmonary TB?

Bana Hawramy, Janine Carter, Zelma Hall, Amy Robinson
Bradford Teaching Hospitals NHS Foundation Trust

Introduction: We discuss a case of a 48 year old Bangladeshi gentleman who is an ex-smoker of 7 packs per year having stopped 7 years ago. His only medical history is hypercholesterolemia and gastro-oesophageal reflux for which he takes Atorvastatin and Ranitidine. He has no known tuberculosis (TB) contacts or previous history of TB. His mother had ovarian cancer and his cousin and grandfather had cancer of unknown origin.

Having moved to the UK in 2009, he last travelled to Bangladesh in 2017. He lives with his wife and three children who are all well.

He presented in November 2017 to the Emergency Department with a history of persistent cough and haemoptysis Varying from streaks to small amounts of fresh blood whenever he coughed, shortness of breath on minimal exertion and lethargy. The symptoms had been present since his return from Bangladesh nine months earlier. There was no history of weight loss.

Examination was unremarkable. Blood tests showed normal inflammatory markers and blood borne virus screen was negative.

Methods: Initial chest X-ray (CXR) showed a large hilar mass which was suspicious for pulmonary TB. He proceeded to thoracic CT which showed a large area of right upper lobe (RUL) consolidation with necrosis, and right hilar and mediastinal lymphadenopathy (subcarinal and right paratracheal). A calcified granuloma was seen in the right lower lobe.

Sputum samples cultures respiratory flora and three sputa were both Ziehl Neelsen smear and culture negative for mycobacteria. A bronchoscopy was then performed. No malignant cells were seen in endobronchial washings and again these were mycobacterial smear and culture negative. Bacterial culture was positive for Streptococcus anginosus.

Repeat CT thorax after 10 weeks showed stable appearances. Further characterisation with a PET scan revealed the right upper lobe lesion to be hypermetabolic with a standardised uptake value (SUV max) of 11.9 and subcarinal and paratracheal lymph nodes reaching an SUV max of 4.5. This was reported to favour a primary lung malignancy and provisional staging was T2bN2M0.

However, histological staining of tissue collected via Endobronchial Ultrasound (EBUS) showed only inflammatory nodules with no evidence of granuloma or malignancy and ZN stain was negative.

The patient subsequently underwent CT-guided lung biopsy which showed non -specific inflammation and fibrosis; again there was no evidence of malignancy or granuloma. Gram stain and Grocott staining of the tissue by the histopathology department revealed Gram positive filamentous bacterial colonies. 16S PCR was negative on paraffin section.

He was referred to the infectious disease (ID) clinic where a trial of amoxicillin 1gm TDS was commenced in March 2018.

Results: He continues to improve with amoxicillin both clinically and radiologically. Based on the histological findings there were two initial differentials in his diagnosis, however, the improvement seen with amoxicillin favoured one organism and allowed us to make a presumptive diagnosis.

He remains under ID follow-up with planned treatment duration of 12 months of amoxicillin. Serial CXR show the RUL lesion to be slowly reducing in size to 5cm diameter.

Discussion: This case highlights that this diagnosis is a clinical challenge as it is similar in radiological appearance to other benign and malignant intrapulmonary diseases. Pulmonary involvement is rare especially in immunocompetent patients and the presentation is variable. It is important to remember that not every pulmonary mass with mediastinal lymphadenopathy is malignancy or TB and to bear in mind more unusual diagnoses.

006
Outpatient parenteral antibiotic therapy (OPAT) for non-orthopaedic surgical infections
Abstract - 006
Poster 006

Outpatient parenteral antibiotic therapy (OPAT) for non-orthopaedic surgical infections

Anu Rajgopal, Janine Carter, Jayne Woodhead, Lyndsay Worthington
Calderdale and Huddersfield Foundation NHS Trust, Halifax

Introduction: The OPAT service at Calderdale and Huddersfield NHS Foundation Trust (CHFT) is currently provided by two community teams and overseen by microbiology. A look-back exercise was undertaken to identify patients utilising this service for non- orthopaedic surgical infections, their clinical indications, outcomes, any adverse effects and in-patient bed-days saved.

Methods: A retrospective review of clinical electronic records of patients treated by the OPAT service for the period April 2017- March 2018 was carried out. The following data was collected using a standardised proforma: patient demographics, indication for antibiotics, duration of antibiotics, any admissions avoided and number of bed-days saved. Patients identified as being treated for non-orthopaedic surgical infections also had data collected regarding antibiotic choice, venous access device, whether treatment was targeted or empirical, and whether antibiotic choice was discussed with the clinical microbiologists. Patients were followed up for between 1-12 months. Clinical outcome was evaluated with patients being categorised as ‘cured’, ‘improved’ or ‘failed’. Complications and incidents related to OPAT therapy were recorded. A patient and user satisfaction survey was also undertaken.

Results: 548 patients received antibiotics via the OPAT service between April 2017- March 2018. Of these, 285 admissions were avoided with 4596 inpatient bed –days saved.

For the non-orthopaedic surgical infection subset, 24 patients received antibiotics via the OPAT service between April 2017- March 2018. 579 inpatient bed-days were saved.

Six patients were treated for diabetic foot infection, three patients for intra-abdominal abscess, three patients for intra-pelvic abscess, two patients for liver abscess, two for hernia mesh infection, two for post-operative wound infection and one for each of: gallbladder empyema, infected breast implant, infected renal cyst, infected vascular graft, mycotic aneurysm, malignant otitis externa.

17 patients had a peripherally inserted central catheter (PICC) line whilst 7 used peripheral venous cannulae. Seven patients received ertapenem, nine ceftriaxone, five tigecycline, one meropenem, one tazocin and one teicoplanin. Seven patients received targeted antibiotics, seventeen were treated empirically. All were discussed with microbiology.

18 patients were deemed to be cured, four improved and three met criteria for failure. Of the four patients who were categorised as improved, one was readmitted for definitive drainage and mesh removal, one was admitted with new collections, one was discharged on oral antibiotics and one was readmitted with fluctuant breast swelling thought to be due to implant infection.

All patients completed the full course of antibiotics. Three patients developed complications with their intra-vascular access device, namely; possible PICC line infection, leaking PICC line and PICC line fracture. Three patients had microbiological complications: one developed Clostridium difficile associated diarrhoea and two became colonised with beta-lactamase producing bacteria (extended-spectrum Beta-lactamase (ESBL) and Amp-C Beta-lactamase).

There were two further datix incidents related to OPAT during this period. Both were due to inadequate communication between the clinical teams

Discussion: Historically in CHFT the OPAT service has been utilised for mainly medical patients, in particular cellulitis. The service has been broadened to include surgical indications and promoted to the surgical teams with reasonable take-up. Survey feedback from both patients and the surgeons demonstrate this has been well-received. There have been few adverse effects but 3 out of 24 patients failed therapy. This could be explained by the high rates of empirical therapy and inadequacy of source control.

The OPAT model is unusual in CHFT as there is no infectious diseases department to clinically review patients. Instead the referring consultant takes clinical responsibility and the OPAT microbiologist acts as an intermediary, flagging up the need for clinical review to the referring consultant. This model has been successful in the views of the authors and this is supported by patient and user feedback.

007
Beware, beware, of walking barefoot out there!
Abstract - 007
Poster 007

Beware, beware, of walking barefoot out there!

Blair Merrick1, Thomas Jones2, Uli Schwab3
1Hospital of Tropical Diseases, London. 2Newcastle Medical School. 3Infection and Tropical Medicine, Royal Victoria Infirmary

Introduction: We describe a series of three patients treated in the Infection and Tropical Medicine department at the Royal Victoria Infirmary, Newcastle upon Tyne, between December 2016 and December 2017. Although their clinical presentations were diverse, each notably had a recent travel history to Thailand, and ultimately the same organism was found to be the cause for their symptoms. We aim to highlight a potentially fatal disease of multifarious presentation, which must be considered in travellers returning from endemic areas such as Southeast Asia.

Methods: The first patient was a 52-year-old female with no significant past medical history. She presented to medical attention in septic shock, which required critical care admission for vasopressor support. Her illness initially began with coryzal symptoms one week prior to admission, whilst still on holiday in Thailand. CT chest revealed a large mediastinal abscess and multiple cavitating nodules within both lung fields. Cultures of pus drained from the abscess grew the implicated organism.

The second patient was a 69-year-old female with a history of type 2 diabetes. She developed malaise and shortness of breath whilst away in Thailand. She presented to medical attention two weeks later with fevers, confusion and a productive cough. CT chest was significant for a right-sided necrotising pneumonia. Blood cultures taken on admission grew the responsible organism.

The third patient was a 38-year-old female with a history of type 1 diabetes. She presented with a complex partial seizure and expressive dysphasia on a background of a several month history of unilateral headache. The headache started shortly after returning from a trip to Thailand. An MRI brain revealed a dural-based lesion in the left temporal area. A craniotomy was performed to remove the mass. Intra-operatively this was found to contain pus, cultures of which grew the offending organism.

Discussion: The responsible organism in all three infections was a gram-negative bacillus, which is found predominantly in the tropical and subtropical regions of Southeast Asia and Northern Australia, although cases have been seen across Central and South America, the Middle East and even Africa. Classically infection occurs due to inoculation through skin abrasions, but may also be acquired through inhalation or ingestion of the bacteria. Clinical disease usually occurs within a few weeks of exposure; however, as the bacteria have the capacity to remain dormant for years, presentation can be decades later. Affected individuals frequently have an underlying immunosuppressive condition such as diabetes mellitus or chronic renal insufficiency. Mortality in untreated infection exceeds 90%. 

All three patients were treated with meropenem due to the antimicrobial resistance profile associated with this pathogen. This was followed by a prolonged course of co-trimoxazole or doxycycline (depending on antimicrobial sensitivities) to reduce the risk of relapse (6% in first year and 13% by 10 years). They all went on to make a full recovery and were well at the time of last follow-up. These cases highlight the diversity of presentations seen in this condition. A high index of suspicion is necessary when assessing individuals with a suspected infection and a travel history to an endemic area for the organism, to ensure the diagnosis is considered, and appropriate antimicrobial therapy initiated in a timely fashion.

008
One of the causes for permanent blindness in HIV patients in resource-limited settings, Myanmar
Abstract - 008
Poster 008

One of the causes for permanent blindness in HIV patients in resource-limited settings, Myanmar

Ni Ni Tun1,2, Yee Yee Aung1, Thida Yamin Pyone1, Frank Smithuis1,2
1Medical Action Myanmar, Yangon, Myanmar. 2Myanmar Oxford Clinical Research Unit, Yangon, Myanmar

Introduction: In resoure poor settings, where HIV diagnosis and treatment is limited, many HIV patients usually come with advance presentation. One of the presenting features in advanced AIDS patients is vision impairement. Many cliicians have been struggling in finding out the cause of the blindness in HIV patients. Because of limited diagnosis and treatment facility, it has been a miracle until 2006.

Methods: In 2006, American uveitis specialist came to Myanmar and started training for HIV clinicians to do early diagnosis of CMV retinitis by using indirect ophthalmoscopy and intraocular ganciclovir injection. Regular training and monitoring happened since by that time with Médecins Sans Frontières (MSF-Holland) and Medical Action Myanmar.

Results: A young women aged 24 years was diagnosed as HIV positive on 12thMarch, 2016 with baseline CD4 count of 15cells/ml. Screening for CMV retinitis by indirect ophthalmoscope was done on 25thMarch 2016, and no abnormal finding was detected. On 24th April, 2016, ART was started with Tenofovir, lamivudine and efaverance combination. Follow up screening of CMV eye infection was done on24th May due to low baseline CD4 and CMV was diagnosed (figure 1). Eye vision was 6/6 on both eyes. Intraocular gancyclovir injection to left eye was given (valgancyclovir was unavailable at that time) and ART was continued. After 3 times of weekly intraocular gancyclovir injection, the retinal lesion became inactive and the injection was stopped. Now the patient is more than two years on ART. Her last CD4 count was 332 cells/ml and the retinal lesion remain inactive.

Discussion: Cytomegalovirus (CMV) is a member of the herpes virus family, acquired in childhood and over 90% of adults living in resource-limited settings in middle and low income countries are positive. CMV remains latent for life, but can become active if the immune system becomes significantly impaired. In the setting of HIV infection, cytomegalovirus (CMV) can affect both the central and peripheral nervous systems. It can also cause colitis, esophagitis, adrenalitis, hepatitis and pneumonitis. This usually occurs in patients with severe immunodeficiency: CD4+ lymphocyte counts typically are less than 50/mm3.

CMV retinitis caused over 90% of AIDS-related blindness in developed countries before ART therapy was introduced, and now causes over 90% of AIDS-related blindness in Myanmar, as well as the rest of South East Asia, China, India and Eastern Europe (Russia and the Ukraine). Untreated, CMV retinitis is relentlessly progressive and will destroy the entire retina in 4-6 months. In resource-limited settings, the patient generally does not complain of symptoms until vision loss has occurred, when the damage is already permanent and not reversible. Clinical symptoms may include blurred vision, floaters, scotoma (holes in the vision or blind areas) or flashing lights in the eye. The “gold standard” for diagnosis is indirect ophthalmoscopy through a fully dilated pupil by a trained clinician. Successful treatment of CMV in patients with AIDS requires both, ART and specific medication against CMV. Valganciclovir, an oral version of ganciclovir is the ideal systemic CMV treatment, covering both ocular and extra-ocular disease, but is at the moment unavailable to us. At this time the most cost-effective treatment is intraocular ganciclovir injections. This treatment in combination with ART will effectively stop the progression of CMV, and therefore also limit the occurrence of secondary blinding complications (retinal detachment and IRU) which both increase in frequency in direct proportion to the area of retina that is infected.

The vision loss from CMV is commonly permanent, that is why an early diagnosis is of great importance. To enable early diagnosis, all patients with CD4 < 100 cells/mm3 should be referred for indirect opthalmoscopy without delay and should be screened within the first week of presentation for care.

009
Cerebral and pulmonary nocardiosis
Abstract - 009
Poster 009

Cerebral and pulmonary nocardiosis
Samantha Manyanga1, Evangelos Vryonis2, Peter Munthali3,1

1Microbiology, University Hospitals Coventry and Warwickshire NHS Trust. 2Infectious Diseases, University Hospitals Coventry and Warwickshire NHS Trust. 3University of Warwick Medical School

Introduction: Case presentation of a 69 year old patient found to have both brain and lung lesions, following the development of arm and leg weakness. Primary differential diagnosis was recurrence of previous lymphoma but imaging, microbiology culture findings and clinical response to appropriate treatment confirmed a diagnosis of nocardiosis.

Methods: Sixty-nine year old male who developed new onset progressive weakness in both right arm and leg over a four week period whilst on holiday in Canaries in January 2018. He had imaging of his head performed in Spain and, during his admission in UK, both a CT scan of his thorax, abdomen and pelvis and an MRI of the head were performed. When the patient began having high fevers, blood cultures were sent to microbiology. No biopsy of the brain lesion was possible due to his severe thrombocytopenia. His significant past medical history included Non-Hodgkin’s lymphoma in May 2016 and cold auto-immune haemolytic anaemia since 2011, of which the latter was still ongoing during this admission.

Discussion: This shows a case of both cerebral and pulmonary nocardiosis, a relatively uncommon infection in a male patient whose immune status is debatable. Despite a past medical history of lymphoma and immunosuppressive treatment, patient had been in remission for a year before this presentation and was otherwise well. It is unclear whether his cold auto-immune haemolytic anaemia would result in him being considered immunocompromised. This being said, patient had recent rituximab during his NHL treatment and is this is associated with an increased risk of infections, although it is unclear how long, post completion of the drug, this poses a risk.

It highlights the importance of considering infection, even though the patient’s past medical history made lymphoma recurrence very likely and therefore high on the differential diagnosis. Appearance of colonies from blood culture was not typical for Nocardia spp. but identification was confirmed.

It demonstrated that where it is not possible to get a diagnostic sample; a brain biopsy in this instance, blood culture isolate combined with clinical picture and a response to appropriate antibiotics enabled an indication towards a probable diagnosis of nocardiosis.

010
The curse of the contact lens
Abstract - 010
Poster 010

The curse of the contact lens

Bhamini Puvaneswaran, Manjusha Narayanan, Isha Rizal, Francisco Figueiredo
The Newcastle upon Tyne Hospitals

Introduction: A ubiquitous parasite, Acanthamoeba infection is a rare but recognised cause of potentially blinding keratitis. Presenting with photophobia and severe pain disproportionate to the clinical findings, there is a potential for misdiagnosis, particularly herpetic keratitis. This results in delayed diagnosis and potential sight loss. Most commonly associated with contact lens use, the management of Acanthamoeba keratitis (AK) is a diagnostic and therapeutic challenge.

Methods: A retrospective analysis of Acanthamoeba positive growth samples (corneal scrapes and contact lenses), from Newcastle upon Tyne Hospitals Laboratory from May 2013 to January 2018. A case series was compiled using patient demographics, risk factors, treatment and clinical outcomes.

Results: Twenty-nine patients were identified with positive results. Seven were excluded due to follow up outside the region. Of the 22 cases which were analysed, 12 had Acanthamoeba keratitis suspected at presentation. The mean age was 37 years (18 – 76) with no significant difference in gender distribution. Twenty cases were associated with contact lens use and the remaining 2 were secondary to trauma.

Of the 22 cases followed up, 20 were treated medically. Two with Hexamidine and chlorhexidine whilst 18 received Polyhexamethylene biguanide (PHMB) and Brolene. Of the 20 medically treated cases, 14 improved, 1 had early recurrence which subsequently improved and 1 required surgery with left amniotic membrane graft. The remaining 4 either did not attend follow up or were followed up elsewhere.

Discussion: Within our hospital, the majority of patients with Acanthamoeba keratitis were contact lens users and treated with medical therapy alone with 75% displaying improvement in symptoms. Whilst the prognosis for AK is variable, if caught early and treated appropriately, satisfactory outcomes are often achieved. Clinical suspicion coupled with in vivo confocal microscopy and Laboratory identification of Acanthamoeba is important to expedite diagnosis and guide treatment.

011
Fatal septic shock in 50 year old with unusual organism isolated in blood culture
Abstract - 011
Poster 011

Fatal septic shock in 50 year old with unusual organism isolated in blood culture

Robert Gray, Madhuri Vidwans
West Hertfordshire Hospitals, Watford

Introduction: A man in his 50s was admitted to the intensive care unit with fever, shock and low level of consciousness after being found collapsed. Initial assessment revealed severe acute liver failure (ALT 6300 U/L ALP 168 U/L PT 14.4 seconds) and renal failure, with significant acidosis (pH 7.04, lactate 9.5). Clinical examination showed decreased conscious level and a blanching erythematous macular rash of the back, chest and shoulders and peripheral vascular shut down. The patient was commenced on organ support and broad spectrum antibiotic chemotherapy, with meropenem and gentamicin.

Methods: CT Chest-Abdomen-Pelvis was performed and revealed patchy bibasal consolidation of the lungs and unremarkable appearances of the abdominal viscera. Past history was notable only for unconfirmed intravenous drug use and alcohol dependence. Blood cultures were drawn on the second day of ICU admission and incubated using standard protocol (biomerieux). Urine and sputum cultures were also performed.

Despite broad spectrum antimicrobials, haemofiltration and inotropic support, the patient failed to stabilise, and support was withdrawn on the fourth day of admission due to the extent of organ damage and high inotropic requirements, with low likelihood of recovery.

After 4 days incubation, growth was detected in the aerobic blood culture bottle and initial gram stain revealed the appearance of yeasts. After overnight culture on blood agar media, colonies were transferred to MALDI-TOF (Bruker) for analysis, which identified the microbe with high degree of certainty. What was the organism?

Discussion: Rhodotorula is a ubiquitous fungus in the environment, but is rarely reported in fungaemia. Indeed a literature review published in 2012 identified only 67 cases of Rhodotorula fungaemia reported between 2000 and 2011. Risk factors for fungaemia are presence of central venous catheters (CVC), haematological malignancy, cytotoxic agent use as well as steroid administration. Its widespread presence in the environment, including in foods and on human palms, make it a potential opportunistic agent, as well as a possible contaminant of blood cultures. Our case is unusual, as at the time that the blood culture was drawn, the patient lacked the described risk factors, and had a newly inserted CVC.

The gram stain morphology of Rhodotorula is very similar to that of Candida but the distinguishing feature is the colony morphology, with Rhodoturula comprising of characteristically red colonies. When the organism has been isolated and identified from the blood, amphotericin B has been the most frequently used antifungal agent. Azole antifungals such as fluconazole are not usually effective against Rhodotorula, and echinocandins are never effective. Our isolate was tested by the Bristol Mycology Reference Laboratory which confirmed high level resistance to fluconazole with MIC >64. MIC for Amphotericin B was 0.25, which is susceptible.

This case highlights the risks of fungaemia in severely unwell intensive care patients, and alerts the clinician to the possibility that invasive fungal disease can occur with unusual yeasts, including in this case with an organism which does not respond to fluconazole, the most frequently prescribed prophylactic anti-fungal agent used in the ICU setting.

012
When is a chest infection not a chest infection?
Abstract - 012
Poster 012

When is a chest infection not a chest infection?

Patricia Crossey, Norman Main, Chris Keegan, Manish Gautam, Fiona McGill
Royal Liverpool Hospital

Introduction: A 62 year old female was admitted with dysuria, haematuria, fevers and loin pain following a recent cervical smear. She had a recent course of nitrofurantoin from her GP with no improvement in her symptoms. On admission she was tachycardic with bilateral renal angle tenderness. Left sided fine crepitations were also heard on auscultation of her chest and oxygen saturations were 95% on room air. Bloods showed a leucocytosis with a total leukocyte count of 17.6 x 109/L, CRP was 30mg/L. Urinalysis was positive for blood but negative for nitrates and leucocytes. However, in view of her symptoms and a recent mid-stream specimen of urine growing a multi-resistant E. coli, she was commenced on ciprofloxacin for presumed pyelonephritis.

Methods: Over the next two days she became increasingly short of breath and hypoxic, ultimately requiring 85% inspired oxygen to maintain saturations above 90%. She had type 1 respiratory failure. Initial treatment was broadened with the addition of benzylpenicillin, oseltamivir and furosemide, to cover community acquired pneumonia, influenza and pulmonary oedema – all with no effect. She was transferred to a level two bed for respiratory support on day two of her admission and was commenced on non-invasive ventilation.

The underlying cause of her respiratory failure was unclear. Sequential chest x-rays showed worsening bilateral air space shadowing. Transthoracic echocardiogram revealed no evidence of cardiac failure. Urinary antigen tests were negative for Streptococcus pneumoniae and Legionella pneumophila. Upper respiratory tract swabs were negative for Influenza A and B, RSV, Mycoplasma pneumoniae and Chlamydophila pneumoniae by PCR.

Gradually over the next few days, with supportive treatment and without any new intervention, she slowly improved. Her respiratory symptoms settled, oxygen requirements decreased and she was discharged, on day eight, to a respiratory ward. She underwent a high resolution CT scan which showed ground glass changes in the right upper lobe. This finding was discussed in the lung MDT where the diagnosis of pneumonitis was raised and ultimately led us to identify the true cause of her respiratory failure.

Discussion: This case highlights an unusual cause of pneumonitis. It re-iterates the need for a thorough history taking and to consider all differentials, especially where the initial symptoms do not marry up with the clinical findings. Sometimes, the least likely diagnosis may be the correct one.

References:

Jick SS, et al. Hospitalizations for Pulmonary Reactions Following Nitrofurantoin Use. Chest. 1989; 96(3):512-5.

Holmberg L, Boman G. Pulmonary Reactions to Nitrofurantoin. 447 cases reported to the Swedish Adverse Drug Reaction Committee 1966-1976. Eur J Resp Dis 1981; 62(3):180

Kabbara WK, Kordahi MC. Nitrofurantoin-induced Pulmonary Toxicity: A Case Report and Review of the Literature. Journal of Infection and Public Health. 2015; 8:309.

013
Snake in the grass. The challenges of diagnosing and treating tropical animal bites
Abstract - 013
Poster 013

Snake in the grass. The challenges of diagnosing and treating tropical animal bites

Mauricio Arias, Angela Houston
St George’s Hospital NHS Trust, London

Introduction: We present a challenging and complex case of severe, life-threatening leg cellulitis resulting in leg amputation. A 45-year old male presented with severe cellulitis of his right leg after returning from visiting family in rural north Sri Lanka. He had a suspected arachnid or snake bite while asleep outside on the ground five days prior to admission after heavy alcohol intoxication.

Methods: He had attended a local doctor with blistering, pain and swelling in the leg but his symptoms rapidly worsened. He flew to the UK where he presented with a severely swollen, oedematous and painful leg extending to his groin. Puncture wounds were clearly visible on the lower leg. He was started on broad spectrum antibiotics and strict elevation of the leg. Surgical consultation was sought (to rule out necrotising fasciitis), as well as advice from the Snake Bite Emergency Response System in Liverpool. The cellulitis rapidly worsened with rising inflammatory markers (CRP 400, WCC 42). He developed acute renal injury (creatinine 200). Initial wound swabs grew Gram positive rods. During the next 48 hours he was admitted to the intensive care unit due to further deterioration. He developed a large pericardial effusion and myocardial injury (Troponin above 200), and his oxygen requirements increased.

Discussion: This was a complex and challenging case with several false leads which will be discussed along with the lessons learnt.

014
An overlooked cause of confusion in a patient with myasthenia gravis
Abstract - 014
Poster 014

An overlooked cause of confusion in a patient with myasthenia gravis

Marco Lee, Kavita Sethi, Aruna Chakrabarty
Leeds Teaching Hospitals NHS Trust

Introduction: A 58 year old male presented to hospital in December, 2017 with a three-day history confusion, change in behaviour, and vomiting.

No other symptoms were found on systemic enquiry. He has had no recent surgeries, dentalwork, sinusitis, otogenic infections, nor contact with known tuberculosis cases.

His background consists of myasthenia gravis (on mycophenolate for past 3 years), type 2 diabetes mellitus (on metformin and insulin), and a brainstem stroke (on clopidogrel and atorvastatin).

Physical examination showed a normal GCS, normal neurological, cardiovascular, and respiratory systems, no rash, good dentition, and no peripheral stigmata of endocarditis. Blood tests show a raised WBC of 16.7 x109 cells/L (neutrophils 13.7 x 109 cells/L), CRP <5 mg/L, and normal renal and liver function.

Methods: MRI brain showed two frontal ring-enhancing lesions associated with significant oedema. Two brain biopsies were performed in January, 2018 which showed acute inflammation with necrotic slough, consistent with abscess. Bacterial, fungal, and mycobacterial direct stains and cultures were negative.

Discussion: Further elucidation of social history revealed that he has lived on a farm for the past 14 years.The farm has cattle, sheep, and chickens. He also owns three dogs and three cats.

References:

1Bernardo, D. and Chahin, N. (2015). Toxoplasmic encephalitis during mycophenolate mofetil immunotherapy of neuromuscular disease. Neurology – Neuroimmunology Neuroinflammation, 2(1), p.e63.

2Schlüter, D., Däubener, W., Schares, G., Groß, U., Pleyer, U. and Lüder, C. (2014). Animals are key to human toxoplasmosis. International Journal of Medical Microbiology, 304(7), pp.917-929.

3Robert-Gangneux, F. and Darde, M. (2012). Epidemiology of and Diagnostic Strategies for Toxoplasmosis. Clinical Microbiology Reviews, 25(3), pp.583-583.

4Toxoplasma Reference Unit, Swansea, Wales. http://www.wales.nhs.uk/sites3/page.cfm?orgId=457&pid=25359

015
Rare cause of pulmonary infection in a renal transplant recipient
Abstract - 015
Poster 015

Rare cause of pulmonary infection in a renal transplant recipient

Ang Li, Julie Samuel
Newcastle upon Tyne Hospitals NHS Foundation Trust

Introduction: Patients with organ transplants present unique diagnostic challenges. Here, we present a case of a gentleman with recent renal transplantation who was treated at Newcastle Upon Tyne Hospitals.

Methods: A 51 year old gentleman was admitted to our hospital with urine leak from his abdominal wound following cadaveric renal transplantation 2.5 months previously. The patient had been taking mycophenolate and tacrolimus following transplantation. Indication for transplant was end stage renal failure secondary to spina bifida related neurogenic bladder.

An anastamotic leak was found between his kidney and pre-existing ileal conduit. This was treated through replacement of his ureteric stent. This leak was the likely cause for episodes of Escherichia coli and Candida glabrata bacteraemia at his local hospital. Meropenem and caspofungin had been started, which were continued on admission to complete 14 days of caspofungin and 4 weeks of meropenem.

6 days after completing treatment, this gentleman began to experience daily episodes of fever with a corresponding rise in CRP. There were no clinical symptoms or signs suggestive of potential source. Urine and multiple blood cultures were performed, with isolation of a glycopeptide resistant enterococcus from urine only. Initial imaging including CT were unremarkable.

The patient was restarted on meropenem, linezolid and caspofungin. This was switched after 48 hours to daptomycin, fluconazole and intravenous fosfomycin given previous exposure to echinocandins and pancytopenia. There was an initial improvement in CRP from 285 mg/L to 94 mg/L over the course of 7 days, however, the fevers continued unabated.

On day 9 of this regimen, the patient developed pleuritic chest pain and CT demonstrated a cavitating lung abscess in the right upper lobe. Given these radiological changes, ongoing fever and rising CRP, daptomycin and fosfomycin was replaced by clindamycin. Whilst initially successful in improving inflammatory markers, this combination did not lead to defervesence.

Given the likely differential diagnoses of invasive aspergillosis or atypical infection, the antimicrobial regimen was changed to meropenem, tigecycline, voriconazole and intravenous fosfomycin. Bronchioalveolar lavage was undertaken prior to starting voriconazole, with no bacteria or fungi isolated on routine, anaerobic or extended fungal culture. Mycobacterial culture yielded Mycobacterium chimera only. Serum and lavage Aspergillus antigen were negative. Serum Beta-D-glucan was positive on 2 separate occasions.

Abscess sampling was avoided initially due to concerns regarding potential seeding. However, given further rises in CRP and interval imaging demonstrating abscess enlargement despite voriconazole and broad-spectrum antimicrobials, a decision was made to proceed to CT guided aspiration. Microbiological and histological features of sample materials obtained during abscess aspiration were diagnostic. Targeted treatment led to clinical improvement and resolution of fever.

Discussion: This gentleman’s case of mixed lung abscess demonstrates the difficulties that can be encountered in diagnosing an unusual infection in an immunosuppressed patient and the range of organisms that should be considered. Until the onset of pleuritic pain, there was a distinct lack of clinical symptoms and signs aside from fever, which added to the diagnostic uncertainty and complexity.

The positive beta-d-glucan serum tests remain an interesting part of the case, the causative fungi should not produce a positive test due to the lack of beta-d-glucan within the cell wall, and there is equipoise regarding the clinical significance in this gentleman’s case.

The importance of obtaining samples for culture is highlighted in this particular case, given the unusual organism involved and the intrinsic resistances associated with it. It is unlikely that the diagnosis would have been possible without direct sampling.

016
Lung cancer a red herring: re-examine the evidence
Abstract - 016
Poster 016

Lung cancer a red herring: re-examine the evidence

Sarah Salameh, Hamad Abdel Hadi, Mohd Lateef Wani, Ehab Massad, Samir Alhayassat, Faraj Howady
Hamad General Hospital, Doha, Qatar

Introduction: A 64-year-old male patient was admitted with a week history of fever, cough and hemoptysis. On further review the patient also reported a weight loss of about 8 kg over the preceding month. There was no history of recent travel, tuberculosis or contact with TB-infected individuals. He is a lifelong smoker with 200-pack-year history. His recent medical problems included the assessment for diabetes since he recently presented with elevated blood sugar as well as probable cranial nerve palsy attributed to mono-neuritis multiplex secondary to diabetes or cerebro-vascular disease. At his assessment this admission chest X-ray revealed a well-defined rounded opacity projecting over the right hilum reported as “hilum overlay sign” denoting an anterior or posterior mediastinal mass. CT imaging was arranged as an outpatient, but the patient defaulted follow up to re-present on second occasion with cachexia, fever and persistent hemoptysis. Unlike previously where glycated HB had shown prediabetic values, on this presentation the patient had uncontrolled diabetes mellitus despite not meeting criteria for diabetic ketoacidosis.

Methods: Physical examination revealed right apical bronchial breathing with reduced breath sounds over the same. Abdominal exam revealed mild hepatomegaly without stigmata of chronic liver disease. Chest X-ray revealed progression of pathology with inhomogeneous opacity in the right upper lobe. Work-up for chronic chest infections and malignancy followed and contrast CT scans of the thorax, abdomen and pelvis were obtained accordingly. These revealed a large area of consolidation with widespread cystic changes of the affected lobe in addition to mediastinal lymphadenopathy. Radiologic changes were consistent with findings suggestive of alveolar cell carcinoma. Serology for human immunodeficiency virus was negative but Hepatitis C antibodies and PCR were positive. Tuberculin skin test was also positive. The patient’s diabetes was promptly controlled with insulin basal-boluses. Blood cultures returned negative and sputum bacterial cultures, AFB smears, and TB PCR were all negative repeatedly.

Bronchoscopy revealed moderate amount of thick secretions over the carina and right bronchial tree. Exam however did not show any endobronchial lesions. Bronchoalveolar lavage (BAL) from the right upper lobe consisted of a 96% neutrophilic infiltrate with negative bacterial and TB cultures as well as cytology. Obtained histology did not reveal any granuloma or malignant cells. Although BAL fungal cultures grew Rhizopus species, these were initially discarded as likely contaminants in a patient with probable lung cancer. Because of the consolidation, the patient was initially treated as having pneumonia and received parenteral antibiotics; Ceftriaxone followed by oral Co-amoxiclav. Fever and hemoptysis eventually subsided, and he was discharged with early follow up to repeat imaging. Upon third admission, the patient had recurrence of hemoptysis associated with syncopal attack. He was resuscitated while repeat CT of the thorax revealed a newly formed cavity in the right upper lobe within the previously identified area of consolidation. CT findings were suggestive of progression into lung abscess with possibility of tuberculous lesion. Vascular invasion by pulmonary artery tributaries within the cavity was also noted without appreciable decrease in area of consolidation. CT-guided aspiration of the apical lesion followed with negative bacterial and TB cultures but was inadequate for fungal cultures. Recurrent hemoptysis necessitated emergency interventional embolization. Since no definitive diagnosis we made, and the possibility of infection or malignancy cannot be ruled out with significant risks of hemoptysis; decision was made for surgical resection for therapeutic as well as diagnostic management. After obtaining informed consent, a right upper lobectomy was performed.

Discussion: Findings during the procedure included a large cavity in the right upper lobe with severe fibrous adhesions between the lobe and chest wall. Following uneventful recovery, the patient was discharged on oral antibiotics awaiting histopathologic and microbiologic diagnosis.

017
A beast not from the east?
Abstract - 017
Poster 017

A beast not from the east?

Samira Mohd Afzal1, Qandeel Khan2, Sannaan Irshad2, Timothy Kemp2
1Queen Elizabeth Hospital, Birmingham. 2University Hospital North Midlands, Stoke-on-Trent

Introduction: A 51-year-old barber with no significant co-morbidities presented with a five-day history of progressively worsening left upper quadrant abdominal pain. He also reported a three-week history of low-grade fevers, occasional night sweats and 5kg weight loss which he attributed to anorexia. He was originally from Iran and moved to England five years ago. He denied any travel outside the UK since emigration, did not consume alcohol, had never smoked and was not sexually active. He lived alone and had never kept any pets.

Methods: On clinical examination, he was cachectic, pale and mildly clubbed. He was pyrexial at 38.4’C, with a respiratory rate of 19 breaths per minute, saturations 98% on 3L oxygen via nasal cannulae, blood pressure 98/72 mmHg and pulse 98 beats per minute. The cardiac apex was displaced medially and he had reduced air entry on auscultation of the left lung. The abdomen was tender (particularly at the left upper quadrant), but he did not exhibit any signs of peritonism. There was no cervical, axillary or inguinal lymphadenopathy. Blood tests were remarkable for normocytic anaemia (Hb 83, MCV 83), raised alkaline phosphatase (ALP 325) and raised inflammatory markers (WCC 13, CRP 267). Chest radiograph on admission showed a large left-sided pleural effusion which displaced his mediastinum significantly. Abdominal computed tomography (CT) imaging revealed a large complex cystic lesion in the left subphrenium, measuring 20x16x14cm, with septations and haemorrhagic foci. These were beginning to form an organised collection. The lesion was inseparable from the tail of pancreas, and also involved his spleen and gastric fundus, which were significantly displaced and compressed. Splenic vein thrombosis was noted. The remaining pancreas was oedematous, with a 16x5cm cystic outpouching between the liver and head of pancreas. Numerous enlarged para-oesophageal, upper abdominal and mesenteric nodes were seen. HIV screen was negative.

Discussion: Differential diagnoses were discussed amongst multiple departments including radiology, infectious diseases, respiratory, gastroenterology, surgery and School of Tropical Medicine. The patient was commenced on meropenem empirically, but became progressively breathless, necessitating intubation on Intensive Care Unit. Emergency surgical chest and abdominal drains were inserted, yielding 1.5 and 2 litres of pus respectively. Pus aspirates revealed an interesting diagnosis.

018
A film with an unexpected twist
Abstract - 018
Poster 018

A film with an unexpected twist

Thien Nguyen, Abbas See, Jane Democratis
Wexham Park Hospital, Slough

Introduction: A 49-year old man was referred to hospital by his general practitioner with a 1-week history of lower back pain, rigors and urinary symptoms. His past medical history included only prediabetes. He worked an office job, was a non-smoker and drank two units of alcohol per week. He lived with his wife and two daughters. There were no other unwell members in his family or immediate social circle. There was no travel history in the past 12 months.

On examination, he was pyrexial (38.1oc) and complained of bilateral flank pain. Other findings were unremarkable. His chest X-ray was clear, his blood tests showed normal electrolytes, haemoglobin and white cell count. However, he had a low platelet count (36) and a high CRP (123). Given this, an initial diagnosis of urosepsis was made and, upon discovery of deranged liver function tests, biliary sepsis was included in the list of differentials. He was commenced on co-amoxiclav to cover both diagnoses. To investigate his deranged liver function, an abdominal ultrasound was done, which showed two echogenic foci in his liver, but a normal biliary system. After three days of antibiotics, the patient showed no clinical improvement and his CRP trend was erratic, rising from 123 to 154 after one dose of antibiotics and going down to 111 on day 3. It was also noted that he persistently had a low grade temperature of less than 38oc with two temperature spikes above 38oc, one on admission and one on day three, approximately 48 hours after his first spike. Given this, his antibiotics were escalated to gentamicin and further investigations were requested including a myeloma screen and an auto-antibody screen. All investigations were negative and the patient’s CRP improved with gentamicin. Having noticed the patient’s initial low platelet count, a routine blood film was done by the laboratory technician, leading to the diagnosis.

Methods: Patient’s notes, blood results and imaging were obtained using electronic patient records systems (EDMS, ICE and PACS).

Discussion: This case anecdotally highlights three things.

Firstly, the importance of a good travel history. Although a travel history was taken, it only included the last 12 months. While this is the norm, persistent signs of infection warrant taking an extended travel history and a history of previous infections. In this case, we found out that the patient travelled to a rural high-prevalence area of Pakistan 12 months prior, where his wife suffered from the same condition.

Secondly, the need to constantly question and revise the initial working diagnosis. Most patients will get better on antibiotics, even if it is not treating the underlying condition. A strong indicator for revising the diagnosis is the mismatch between biochemical markers and antibiotic course. In this case, all the abnormal findings fell into place once the right diagnosis was made; low platelets due to splenomegaly and two temperature spikes 48 hours apart due to the replication cycle. It is also important to note that in this case, correct testing is vitally important. The patient’s GP had previously requested rapid tests upon his return from Pakistan, which returned with negative results. As blood films have limited sensitivity (85%), it is recommended to test at least three times.

Lastly, this case illustrates beautifully the vital role held by laboratory technicians. A blood film was not requested but a suspicious low platelet count prompted the lab technician take a look at the blood film, which ultimately led to the right diagnosis.

019
Progressive multifocal leukoencephalopathy (PML) in immunocompetent patient secondary to carbamazepine-induced hypogammaglobulinaemia
Abstract - 019
Poster 019

Progressive multifocal leukoencephalopathy (PML) in immunocompetent patient secondary to carbamazepine-induced hypogammaglobulinaemia

Ali Khan, Noha ElSakka
NHS Grampian, Aberdeen

Introduction: PML is a fatal demyelinating disease of the brain caused by reactivation of the JC virus, and is classically described in patients with profound cellular immunosuppression, such as AIDS and haematological malignancies. We present a 65 year old lady who presented with 2 month history of left arm clumsiness, ataxia and dysarthria following a brief non-specific viral infection. She had no significant past medical history, however had been on Carbamazepine for well-controlled long term epilepsy.

Methods: Examination revealed left-sided cerebellar signs. MRI showed left-sided inflammatory changes in her cerebellum, and lumbar puncture showed a slight rise in protein with no oligoclonal bands. Various blood tests including HIV, Syphilis, ANA, ANCA, B12, folate and borrelia IgG were all normal. A course of steroids was commenced for presumed post-infective cerebellitis, however her symptoms worsened.

A repeat MRI 4 weeks later revealed worsening cerebellar changes. PET CT showed no occult malignancy. She was treated for possible listeria, Carbamazepine was gradually withdrawn because of its associated with ataxia. Immunoglobulins showed reduced IgG and IgM.

Discussion: JC reactivation in our patient appears to be related to hypogammaglobulinaemia secondary to longstanding Carbamazepine use. This association was not described in the literature before. Our patient has shown clinical improvement of her neurological manifestations on withdrawal of Carbamazepine and continues to improve.

020
Feeling sheepish: a rapidly progressing rash in a veterinary worker
Abstract - 020
Poster 020

Feeling sheepish: a rapidly progressing rash in a veterinary worker

Sophie Garrad, Amy Robinson
Bradford Teaching Hospitals Foundation Trust

Introduction: We present a rare case of severe disseminated rash occurring as a complication of an infection which usually runs a benign course. The report raises the awareness of this potential diagnosis in patients with a similar rash.

Methods: A previously healthy 37 year old women presented to an urban district hospital with a rapid onset prolific blistering and blanching pruritic rash which began on her left arm and spread outward to arms, legs, torso and face over a 48 hour period. She had oedema of her hands restricting finger movements. There were no mucosal lesions and she was afebrile with normal heart rate and blood pressure. Bloods demonstrated elevated eosinophils (1.37 x 109/L), neutrophils (10.5 x 109/L) and C-reactive protein (163mg/L). She had consulted healthcare professionals on several occasions over the preceding days however a diagnosis had not been reached.

Three weeks earlier she had noted a white hard lump on the index finger of her left hand which had blistered, ruptured and released serous fluid. She worked for a veterinary practice and owned a herd of sheep. She was concerned that the rash was due to disseminated infection.

A swab and biopsy of the finger were taken for viral investigations she was treated with intravenous fluids, antihistamines, steroid emollients, flucloxacillin and aciclovir. Potassium permanganate soaks were administered to the arms.

The rash coalesced and exuded large amounts of serous fluid before slowly improving. In total she was hospitalised for seven days and on follow-up two months later, she reported ongoing intermittent lesions. Electron microscopy of the finger tissue later confirmed the diagnosis.

Discussion: This is a rare clinical presentation, with less than 50 published cases1. Our patient was distressed by doctors’ unfamiliarity with this condition when she initially sought healthcare advice and we therefore urge clinicians to consider this diagnosis in those who present with rash after contact with sheep.

This zoonotic infection usually presents as a small lesion on the hand which heals without intervention2. The rare secondary skin reaction develops two weeks after the initial lesion1. The underlying mechanism is unknown but likely due to immunomodulatory virulence factors produced by the virus1. Those who are immunosuppressed are more susceptible to such complications3 therefore an HIV test should be considered.

Published case reports describe features comparable to our case1. The upper limbs are the commonest site, with potential for spread across the body with mucosal sparing1. Management is primarily supportive and there is no evidence for the use of systemic steroids. There have been two case reports of rapid resolution with topical immiquimod4.

Within the UK specimens can undergo diagnostic electron microscopy at Colindale laboratories. PCR can also be used in the detection but is not the initial recommend guidance by Public Health England 5.

References:

  1. Joseph RH et al. Erythema multiforme after orf virus infection: a report of two cases and literature review. Epidemiol. Infect. (2015), 143, 385–390
  2. Barraviera, S.R.C.S. Diseases caused by poxvirus – orf and milker’s nodules – a review. J. Venom. Anim. Toxins incl. Trop. Dis.2005; V.11, n.2, p.102-108,
  3. Centers for Disease Control and Prevention. Orf Virus (Sore Mouth Infection). https://www.cdc.gov/poxvirus/orf-virus/people.html (accessed 18th August 2018)
  4. Erbağci Zet al. Rapid improvement of human orf (ecthyma contagiosum) with topical imiquimod cream: report of four complicated cases. J Dermatolog Treat. 2005;16(5-6):353-6

5. Public Health England. Specialist and Reference Microbiology: laboratory tests and services 2014. https://www.gov.uk/guidance/specialist-and-reference-microbiology-laboratory-tests-and-services (accessed 19th August 2018)

021
An unusual case of multi-organ failure in pregnancy
Abstract - 021
Poster 021

An unusual case of multi-organ failure in pregnancy

Neil Stevenson, Aline Wilson, Nikolas Rae
Ninewells Hospital, Dundee

Introduction: A 28 year old lady, 29 weeks pregnant presents to maternity triage with a 3 day history of diarrhoea and vomiting, her 8 year old son having suffered a similar illness 1 week earlier. Initial observations and examination were unremarkable other than tachycardia of 110 and borderline pyrexia of 37.9.

Despite broad spectrum antibiotics she continued to deteriorate developing worsening fever and respiratory failure, then acute hepatitis followed by acute confusion. She was transferred initially to obstetric HDU then ICU and the baby was delivered by emergency caesarian section.

Methods: Bloods initially showed a raised C-reactive protein of 119 and lymphopenia of 0.8 and this was therefore thought to be a viral illness. Stool cultures and viral throat swab both came back negative.

CTPA was organised which excluded any occlusive thrombus but showed dense multi-lobar consolidation and inflammatory change. Pleural USS showed no effusion while transthoracic echocardiogram showed no obvious vegetations. HIV test, bloods cultures and an atypical screen all came back negative. CT brain showed no cause for her acute confusion on day 9.

CRP continued to climb to 285 and ALT rose from 132 to 708 from day 4 to 8. Liver USS showed no abnormality and a hepatitis screen was also negative. On day 12 CT abdomen showed Budd-Chiari syndrome and she underwent TIPSS to overcome this.

13 sets of blood cultures showed no growth. High vaginal swab grew mixed anaerobes, while candida was grown in a catheter urine specimen, ET tube aspirate and wound swab from the C-section. Staph aureus grew from drain fluid, while E coli was then grown in 2 ET tube aspirates. The diagnostic result eventually came from neonatal blood, with a retrospective test on the mother’s sample confirming the diagnosis in her case.

Discussion: Initial treatment was with IV co-amoxiclav and metronidazole, with erythromycin added later as she continued to spike temperatures. On day 6 she was changed to tazocin and erythromycin with advice to add linezolid if worsening to cover toxin-mediated gram positive infection. Given the worsening LFTs, she later switched to amoxicillin, temocillin and clindamycin in case the hepatitis was drug-related.

The baby was delivered on day 9 as the patient was transferred to ICU. Initial progress was good but the neonate then developed fulminant hepatic failure and DIC leading to massive pulmonary haemorrhage and cardiovascular collapse.

022
Primary meningococcal pericarditis: an uncommon cause of tamponade
Abstract - 022
Poster 022

Primary meningococcal pericarditis: an uncommon cause of tamponade

Rebecca Ward1, Martin Taylor2, Sajjad Mirza2, Hussain Contractor2
1Manchester University NHS Foundaion Trust. 2Manchester University NHS Foundation Trust

Introduction: A 50-year-old white Caucasian male with a history of depression and alcohol misuse was admitted to the emergency department of a large teaching hospital with a five day history of central chest pain radiating to the back and neck, exacerbated by lying flat and deep inspiration. He denied any shortness of breath, cough or other systemic features including fevers, neck stiffness, headache or visual disturbance but did complain of significant constitutional symptoms with a 10kg weight loss over the past three weeks. Current medications consisted of the SSRI Fluoxetine 20mg OD which he had been taking intermittently at a stable dose for several years. He was currently drinking more than 30 units of alcohol per day and had been doing so for several months and also smoked one to two cigarettes per day. He denied any drug misuse or recent travel and had no significant family history of medical problems. His electrocardiogram showed widespread ST elevation in leads V3-V4, I, II and III and ST depression in AVR. Routine bloods demonstrated a raised white cell count (WCC) 19.6×109/L (4.0 – 11.0) with a predominant neutrophilia of 17.2×109/L (2.0 – 7.5) and a significantly raised c-reactive protein (CRP) 426 mg/L (<5).Troponin-I however was not significantly elevated at 13 ng/L (0 – 34). The patient rapidly deteriorated with hypotension and breathlessness and a bedside echocardiogram revealed a large circumferential (3cm) pericardial effusion with right ventricular diastolic collapse suggesting impending tamponade.

Methods: Emergency pericardiocentesis drained 450mL of turbid, purulent fluid. Intravenous broad spectrum antibiotics were commenced. A CT scan of the thorax, abdomen and pelvis revealed a pericardial empyema with residual pus but no evidence of any underlying extra-cardiac infective foci or other findings of note. Fluid microscopy was reported as “++ leucocytes” with a neutrophilia but a gram-stain did not demonstrate any organisms. Urine and blood cultures remained negative despite subsequent intermittent pyrexias. Biochemical analysis confirmed the effusion as an exudate. HIV serology and hepatitis screens were negative as was screening for acid-fast bacilli. Reference laboratory analysis of the pericardial fluid identified the causative organism as Neisseria meningitides serogroup C type 2a with MIC’s for penicillin, cefotaxime, rifampicin and ciprofloxacin all in the sensitive range. The patient was switched to IV ceftriaxone 2g 12 hourly with an intended duration of four weeks. Standard isolation procedures were initiated. Public-Health England was notified and household contacts were given prophylaxis.

Discussion: Acute pericarditis is an acute inflammation of the pericardium and classically manifests with sharp chest pain and a pericardial friction rub on examination. It has many aetiologies both infectious (viral, post-viral, bacterial, tuberculous) and non-infectious (malignancy, auto-immune, post-MI, metabolic). Patients with acute pericarditis with findings suggestive of either a clinically significant pericardial effusion or a suspected bacterial infection require urgent hospital admission and consideration of pericardiocentesis. Meningococci account for 5.9% of all purulent pericarditis presentations ranking fourth after staphylococci, pneumococci and streptococci with meningococcal pericarditis being typically classified into three categories; a local manifestation of disseminated meningococcal disease, an immunoreactive pericarditis and a primary meningococcal pericarditis (PMP). PMP is defined as a purulent pericarditis caused by Neisseria meningitides without any clinical evidence of meningococcemia, meningitis or any other foci of meningococcal infection. Presenting features are often non-specific and most commonly diagnosis is made from pericardial fluid examination with gram-stain and cultures. Meningococci causing PMP are usually of serotype C (88%) or less commonly serotypes B or W135. Much rarer are cases of type Y. Neisseria meningitides pericarditis is a rare but important cause of pericarditis that can lead to rapid decompensation without appropriate initial management, with patients often presenting with seemingly indolent and non-specific symptoms.

023
When infection and immunity collide
Abstract - 023
Poster 023

When infection and immunity collide

Stuart Taylor, James Price, Jennifer Fitzpatrick
Royal Sussex County Hospital, Brighton

Introduction: Infections and autoimmune conditions are challenging to differentiate clinically as they both cause inflammatory disorders of the immune system. Accurate diagnosis is fundamental for effective treatment and optimal outcome. We present a recent case of a young person who developed a severe infection and autoimmune disorder and highlight learning points on diagnosis, investigation and management.

Methods: A 20-year old female student of Australian, Indian and Chinese-Malaysian descent was admitted to hospital with a four day history of fevers, generalised headache, and vomiting. Symptoms had developed on the last day of a one week activity holiday to Slovenia, where her and her family had undertaken forest walks, mountain climbing and fresh-water swimming. On examination she was febrile, meningitic, had a non-blanching rash on her ankles and was confused. Biochemical tests reveal an inflammatory response (CRP 248mg/L, total white cell count 20.8×10*9/L, neutrophils 19.5×10*9/L) and pregnancy test was negative. Blood cultures were taken.

Discussion: Collateral history revealed that she had been under investigation for intermittent photosensitivity, facial rash and joint swellings over the preceding nine months. She had no relevant family history and did not take any regular medication. She was a non-smoker, social drinker and denied recreational drug use. She lived in France where she studied politics.

Urgent CT brain was unremarkable but CSF was abnormal; raised opening pressure (32cmH2O), raised total white cell count (WBC 8,500 x106/L, 98% polymorphs), raised protein (3.5g), and low glucose (CSF 1.6 mmol/L, serum 5.1 mmol/L), no organisms were observed on Gram stain. The patient was treated empirically for presumed bacterial meningoencephalitis with intravenous Ceftriaxone and Acyclovir and did not receive corticosteroids. Amoxicillin was initially included whilst further information was gathered on previous management of polyarthralgia (i.e. immunosuppressives) but subsequently stopped.

CSF bacterial culture was negative but Neisseria meningitidis type B was detected via molecular assessment. Treatment was rationalised to Ceftriaxone single agent. Serology was negative for HIV, HBV, HCV, EBV, CMV, toxoplasma, Q-fever, Rickettsia, Leptospira, Flaviviruses, Phleboviruses and Syphilis.

Following a week of treatment, her clinical progress became complicated by persisting fevers, proteinuria, left shoulder reactive synovitis and symptomatic large transudative pleural and pericardial effusions. Initial concerns focused on progression of infection and potential antibiotic related reactions. MRI brain showed no focal lesions, sampling of effusions did not yield bacterial growth and symptoms persisted despite an antibiotic class change to a quinolone. In light of past medical history there were fears regarding a secondary pathology. With concerns about nephrotic syndrome and a flare of an undiagnosed autoimmune condition, urgent discussions were initiated with Rheumatology and Nephrology specialists. Urine protein creatinine ratio was raised at 206.8 mg/mmol and an autoimmune screen was abnormal; complement levels were low, ANA, Anti-DNA IgG, anti-Ro52, Anti-Ro60 and anti-Scl 70 were positive. In light of the mixed autoantibody profile and the subsequent development of diastolic hypertension there was anxiety that empirical corticosteroid therapy may precipitate a scleroderma renal crisis. To obtain a definitive diagnosis she underwent a renal biopsy which showed mesangiocapillary pattern glomerulonephritis with diffuse mesangial deposition of immunoglobulins; pathognomonic of a specific autoimmune condition. There was no evidence of scleroderma and she was therefore commenced on mycophenolate mofetil after which her fevers and serositis resolved. The patient was recently discharged with follow up by Infectious Diseases, Rheumatology and Renal teams.

This clinical vignette highlights the need to reconsider additional pathologies when clinical response is atypical, and that with difficult cases a multi-specialty approach is essential for best patient care.

024
One hump or two? The case of a swollen knee in a returning traveller
Abstract - 024
Poster 024

One hump or two? The case of a swollen knee in a returning traveller

Shuchita Soni, Francesca Knapper
Southmead Hospital, North Bristol Trust

Introduction: A 56 year old Somali gentleman presented to his GP with a painful, swollen left knee. The knee was surrounded by a large, non-tender effusion, and a therapeutic aspiration was performed in the surgery. Serous straw-coloured fluid was aspirated and sent for microscopy and culture and crystal analysis.

The patient had been living in the UK for 10 years, however yearly he spends the month of Ramadan in the city of Mecca, Saudia Arabia. He had last returned from Mecca at the end of June. He stayed in a hotel during the day but would travel to the desert to break the fast where he would drink camel’s milk before eating the Iftar meal.

He had been well in himself on returning home and had continued to work as a delivery driver. The swelling came on gradually, increasing in size to the point where he found it difficult to weight bear. He also described night sweats, weight loss, lower back and hip pain but denied any cough.

Methods: There was no growth on direct culture, however on day 3 the aerobic enrichment culture flagged positive. Gram stain, the following day showed a gram negative coccobacilli. Up to this point the sample has been handled under the incorrect containment. Public health were notified and the samples were transferred to a category 3 facility. Nine staff members were provided with prophylaxis, and a further 10 were identified as low risk and are being observed.

The patient was admitted and treated with the intravenous Gentamicin and oral Doxycycline as per WHO guidelines. Blood cultures on admission also subsequently positive. Chest x-ray and an MRI of his sacro-iliac joins and lumber spine was normal. Interferon-Gamma Release Assay (IGRA) was positive. After two weeks the swelling around the knee was nominal and repeat blood cultures were negative.

Results: The initial blood cultures were positive, subsequent blood cultures after 10 days of treatment became negative. Imaging of the sacro-illiac joints and hip did not show any seeding of infection and chest radiograph did not show any abnormality. A positive IGRA was found.

Discussion: As the patient had been visiting an endemic area and had had exposure to unpasteurised camel’s milk, the clinical index of suspicion is high for atypical organisms. Identifying this in the history is essential especially when looking at the additional laboratory precautions required to process samples.

It is also important to check IGRA in these patients as many are from areas with high TB prevalence. Rifampicin can be used in some combination regimes; however it should be used with caution in patients at risk of TB.

The patient completed two weeks of intravenous treatment in hospital and was symptom free. He was discharged home to complete the six weeks of oral treatment and will be followed up in a future clinic to discuss the significance of the positive IGRA and potential treatment for latent TB.

025
A clinically challenging diagnosis in a returning traveller with pyrexia of unknown origin
Abstract - 025
Poster 025

A clinically challenging diagnosis in a returning traveller with pyrexia of unknown origin

Priya Khetarpal, Shilan Jmor, Gabriel Wallis, Naina McCann, Mike Brown
Hospital for Tropical Diseases, University College Hospital, London

Introduction: Pyrexia of unknown origin (PUO) is accepted to be one of the most difficult diagnostic challenges in medicine. PUO in a returning traveller poses particular challenges based on a greater breadth of potential causes as a consequence of travel related exposures.

Methods: A 52 year old Guyanan woman presented with a 2 week history of fever, headache and lethargy. Her symptoms began 2 days after returning from Guyana where she had been staying with her mother and sister in Georgetown. Whilst in Guyana she ate home cooked foods and drunk bottled water. She had no freshwater exposure and no new sexual partners. She denied any other symptoms.

On examination she was febrile, tachycardic and had palpable cervical lymphadenopathy.

Initial blood tests revealed elevated inflammatory markers, renal impairment and a transanimitis.

An electrocardiogram showed T-Wave inversion in the anterior leads. Cardiac enzymes (troponin & B-natiuretic peptide) were elevated as was creatinine kinase.

The patient was empirically treated with ceftriaxone and doxycycline for suspected enteric fever and suspected leptospirosis. There was no improvement following 7 days of antibiotics so they were stopped.

The patient was investigated further with a CT Positron emission tomography (PET-CT) which showed small volume FDG-avid nodal disease above and below the diaphragm and FDG-avid spleen suspicious for lymphoproliferative disorder. A biopsy of the lymph node showed a reactive process only.

4 weeks into her illness the patient had persistent fevers with biochemical evidence of myositis and myocarditis.

Discussion: Acute toxoplasmosis should be considered in patients presenting with PUO especially if there is evidence of lymphadenopathy, myositis or myocarditis.

Acute toxoplasmosis in the immunocompetent patient is normally a self-limiting febrile illness, however a minority of patients may develop severe or prolonged disease in whom treatment is indicated.

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