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Tropical Microbiology
       Dr Paul Lane

   CICM Daydream Is 2012
Outline
Melioidosis
Leptospirosis



Questions…
Leptospirosis
Zoonotic disease, spirochaetes called
leptospires
Natural reservoir in Rodents
Enter thru skin cut, intact mucous
membranes with subsequent bloodstream
spread to all organs
Soldiers, Banana workers (1million/yr)
Outbreaks can occur in tropical areas
affected by disaster
Presentation
Weil’s/ Canecutters disease
Proinflammatory cytokines activate Toll
like receptors…detonation!
Unwell, fever, myalgia, liver, renal injury
with low platelets
Pulmonary Haemorrhage, ARDS…main
cause of DEATH
Vasodilation, inotropes
Spirochaetes found in CNS
Immune response
Patients often get worse!!
Cochrane support this!
Traditional recommendation is Penicillin
Onset of Jarisch Herxheimer reaction
Immune mechanisms play a key role in
pathogenesis of disease, particularly
pulmonary
Evolution of my practice…
Constantin etal J Rheum 1996
Antineutrophil cytoplasmic antibodies in
leptospirosis
Returned travellers treated with
immunosuppression and got better!!
Change to meropenum, IV steroids as
initial therapy….less pulmonary bleeding
What’s out there
Sri Lanka 2008 outbreak, started IV
methylprednisolone ( 500mg/3dys then
oral)…studied 230 patients
20% down to 10%
Once severe organ dysfunction
established steroids less helpful
Other studies
India Shenoy etal 2006 30 patients
Mumbai floods 2005
60% vs 18%
IF GIVEN EARLY….(first 12 hrs)

Other small case series…
Newer advancements
Cyclophosphamide (IV 60mg/kg stat)
Trivedi etal 2009 Severe Pulmonary
Involvement…failed steroids
90% to 40% mortality

Plasma Exchange ( same author)
236 severe pulm disease…protocol of 2
washes 25ml/kg removal and low dose
cyclophosphamide…again better survival
What do I do…
Early steroid (1mg/kg BD MP)
Meropenum by infusion
Get aggressive early if lung hit
Early CRRT
Plasma Exchange +/- CP
Extras
Prophylaxis probably doesn’t work
Doxycycline if allergic
Diagnosis….CLINICAL
Finding Leptospira (CSF, blood, urine)
Rising titre (MAT)
Positive IgM (EIA)
NAT
Questions??
Melioidosis
Whitmore Disease/ Flanders
Bacteria isolated from morphine addicts in
Ragoon 1912
B. mallei vs B. pseudomallei
“Vietnamese Time Bomb”…26yr
incubation
Inhalation, cut in skin exposed to
soil/water, ingestion
In NQ
15-25 cases/yr, 1/5 die
1/3 cases in ‘dry season’
Better with public education
Recent JCU work reveals run off water
during high rainfall contains more
organisms then soil
Presentation
Acute Fulminant Sepsis
Lethal CAP plus Sepsis (50%)
Genitourinary infection
Abscesses/Osteomyelitis/Septic Arthritis
Encephalitis, Paralysis
Reactivated disease, often asymptomatic
Chronic Disease (1/16)
Prostatic Melioidosis in 20%
Presentation
DM, excess ETOH, CRF, steroids and
Chronic Lung Disease
Can be ‘normal’
Normally easily Dx, tell lab-modified
culture
Serology occasionally-Neuro/reactivated
disease.
RETURNED TRAVELLER- no advice is
given….
Antibiotics
Resistant organism ( pen, ceph, gent, cipro)
Guidelines for CAP in endemic areas
1990’s IV Ceftazadime (14days)
oral trimethoprim/sulfamethoxazole (6mths)
Now Meropenum infusion (lower MIC)
No seizures, better killing profile and decrease
endotoxin release ( yet to show better survival)
Dramatic fall in mortality (Stephens, Currie)
G CSF??? ( Not in NEJM review)
Case
Febrile child.
Limb weakness following laceration
Camping in bush
Mild encephalopathy
Paul Lane on Tropical Microbiology
Paul Lane on Tropical Microbiology
Questions?

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Paul Lane on Tropical Microbiology

  • 1. Tropical Microbiology Dr Paul Lane CICM Daydream Is 2012
  • 3. Leptospirosis Zoonotic disease, spirochaetes called leptospires Natural reservoir in Rodents Enter thru skin cut, intact mucous membranes with subsequent bloodstream spread to all organs Soldiers, Banana workers (1million/yr) Outbreaks can occur in tropical areas affected by disaster
  • 4. Presentation Weil’s/ Canecutters disease Proinflammatory cytokines activate Toll like receptors…detonation! Unwell, fever, myalgia, liver, renal injury with low platelets Pulmonary Haemorrhage, ARDS…main cause of DEATH Vasodilation, inotropes Spirochaetes found in CNS
  • 5. Immune response Patients often get worse!! Cochrane support this! Traditional recommendation is Penicillin Onset of Jarisch Herxheimer reaction Immune mechanisms play a key role in pathogenesis of disease, particularly pulmonary
  • 6. Evolution of my practice… Constantin etal J Rheum 1996 Antineutrophil cytoplasmic antibodies in leptospirosis Returned travellers treated with immunosuppression and got better!! Change to meropenum, IV steroids as initial therapy….less pulmonary bleeding
  • 7. What’s out there Sri Lanka 2008 outbreak, started IV methylprednisolone ( 500mg/3dys then oral)…studied 230 patients 20% down to 10% Once severe organ dysfunction established steroids less helpful
  • 8. Other studies India Shenoy etal 2006 30 patients Mumbai floods 2005 60% vs 18% IF GIVEN EARLY….(first 12 hrs) Other small case series…
  • 9. Newer advancements Cyclophosphamide (IV 60mg/kg stat) Trivedi etal 2009 Severe Pulmonary Involvement…failed steroids 90% to 40% mortality Plasma Exchange ( same author) 236 severe pulm disease…protocol of 2 washes 25ml/kg removal and low dose cyclophosphamide…again better survival
  • 10. What do I do… Early steroid (1mg/kg BD MP) Meropenum by infusion Get aggressive early if lung hit Early CRRT Plasma Exchange +/- CP
  • 11. Extras Prophylaxis probably doesn’t work Doxycycline if allergic Diagnosis….CLINICAL Finding Leptospira (CSF, blood, urine) Rising titre (MAT) Positive IgM (EIA) NAT
  • 13. Melioidosis Whitmore Disease/ Flanders Bacteria isolated from morphine addicts in Ragoon 1912 B. mallei vs B. pseudomallei “Vietnamese Time Bomb”…26yr incubation Inhalation, cut in skin exposed to soil/water, ingestion
  • 14. In NQ 15-25 cases/yr, 1/5 die 1/3 cases in ‘dry season’ Better with public education Recent JCU work reveals run off water during high rainfall contains more organisms then soil
  • 15. Presentation Acute Fulminant Sepsis Lethal CAP plus Sepsis (50%) Genitourinary infection Abscesses/Osteomyelitis/Septic Arthritis Encephalitis, Paralysis Reactivated disease, often asymptomatic Chronic Disease (1/16) Prostatic Melioidosis in 20%
  • 16. Presentation DM, excess ETOH, CRF, steroids and Chronic Lung Disease Can be ‘normal’ Normally easily Dx, tell lab-modified culture Serology occasionally-Neuro/reactivated disease. RETURNED TRAVELLER- no advice is given….
  • 17. Antibiotics Resistant organism ( pen, ceph, gent, cipro) Guidelines for CAP in endemic areas 1990’s IV Ceftazadime (14days) oral trimethoprim/sulfamethoxazole (6mths) Now Meropenum infusion (lower MIC) No seizures, better killing profile and decrease endotoxin release ( yet to show better survival) Dramatic fall in mortality (Stephens, Currie) G CSF??? ( Not in NEJM review)
  • 18. Case Febrile child. Limb weakness following laceration Camping in bush Mild encephalopathy