Paul Lane on Tropical Microbiology

Tropical MicrobiologyTropical Microbiology

Dr Paul LaneDr Paul Lane

CICM Daydream Is 2012CICM Daydream Is 2012

OutlineOutline

MelioidosisMelioidosis

LeptospirosisLeptospirosis

Questions…Questions…

LeptospirosisLeptospirosis

Zoonotic disease, spirochaetes called Zoonotic disease, spirochaetes called leptospiresleptospiresNatural reservoir in RodentsNatural reservoir in RodentsEnter thru skin cut, intact mucous Enter thru skin cut, intact mucous membranes with subsequent bloodstream membranes with subsequent bloodstream spread to all organsspread to all organsSoldiers, Banana workers (1million/yr)Soldiers, Banana workers (1million/yr)Outbreaks can occur in tropical areas Outbreaks can occur in tropical areas affected by disasteraffected by disaster

PresentationPresentation

Weil’s/ Canecutters diseaseWeil’s/ Canecutters diseaseProinflammatory cytokines activate Toll Proinflammatory cytokines activate Toll like receptors…detonation!like receptors…detonation!Unwell, fever, myalgia, liver, renal injury Unwell, fever, myalgia, liver, renal injury with low plateletswith low plateletsPulmonary Haemorrhage, ARDS…main Pulmonary Haemorrhage, ARDS…main cause of DEATHcause of DEATHVasodilation, inotropesVasodilation, inotropesSpirochaetes found in CNSSpirochaetes found in CNS

Immune responseImmune response

Patients often get worse!!Patients often get worse!!

Cochrane support this!Cochrane support this!

Traditional recommendation is PenicillinTraditional recommendation is Penicillin

Onset of Jarisch Herxheimer reactionOnset of Jarisch Herxheimer reaction

Immune mechanisms play a key role in Immune mechanisms play a key role in pathogenesis of disease, particularly pathogenesis of disease, particularly pulmonarypulmonary

Evolution of my practice…Evolution of my practice…

Constantin etal J Rheum 1996Constantin etal J Rheum 1996

Antineutrophil cytoplasmic antibodies in Antineutrophil cytoplasmic antibodies in leptospirosisleptospirosis

Returned travellers treated with Returned travellers treated with immunosuppression and got better!!immunosuppression and got better!!

Change to meropenum, IV steroids as Change to meropenum, IV steroids as initial therapy….less pulmonary bleedinginitial therapy….less pulmonary bleeding

What’s out thereWhat’s out there

Sri Lanka 2008 outbreak, started IV Sri Lanka 2008 outbreak, started IV methylprednisolone ( 500mg/3dys then methylprednisolone ( 500mg/3dys then oral)…studied 230 patientsoral)…studied 230 patients

20% down to 10%20% down to 10%

Once severe organ dysfunction Once severe organ dysfunction established steroids less helpfulestablished steroids less helpful

Other studiesOther studies

India Shenoy etal 2006 30 patientsIndia Shenoy etal 2006 30 patients

Mumbai floods 2005Mumbai floods 2005

60% vs 18%60% vs 18%

IF GIVEN EARLY….(first 12 hrs)IF GIVEN EARLY….(first 12 hrs)

Other small case series…Other small case series…

Newer advancementsNewer advancements

Cyclophosphamide (IV 60mg/kg stat)Cyclophosphamide (IV 60mg/kg stat)Trivedi etal 2009 Severe Pulmonary Trivedi etal 2009 Severe Pulmonary Involvement…failed steroidsInvolvement…failed steroids90% to 40% mortality90% to 40% mortality

Plasma Exchange ( same author)Plasma Exchange ( same author)236 severe pulm disease…protocol of 2 236 severe pulm disease…protocol of 2 washes 25ml/kg removal and low dose washes 25ml/kg removal and low dose cyclophosphamide…again better survivalcyclophosphamide…again better survival

What do I do…What do I do…

Early steroid (1mg/kg BD MP)Early steroid (1mg/kg BD MP)

Meropenum by infusionMeropenum by infusion

Get aggressive early if lung hitGet aggressive early if lung hit

Early CRRTEarly CRRT

Plasma Exchange +/- CPPlasma Exchange +/- CP

ExtrasExtras

Prophylaxis probably doesn’t workProphylaxis probably doesn’t work

Doxycycline if allergicDoxycycline if allergic

Diagnosis….CLINICALDiagnosis….CLINICAL

Finding Leptospira (CSF, blood, urine)Finding Leptospira (CSF, blood, urine)

Rising titre (MAT)Rising titre (MAT)

Positive IgM (EIA)Positive IgM (EIA)

NATNAT

Questions??Questions??

MelioidosisMelioidosis

Whitmore Disease/ FlandersWhitmore Disease/ Flanders

Bacteria isolated from morphine addicts in Bacteria isolated from morphine addicts in Ragoon 1912Ragoon 1912

B. mallei vs B. pseudomalleiB. mallei vs B. pseudomallei

““Vietnamese Time Bomb”…26yr Vietnamese Time Bomb”…26yr incubationincubation

Inhalation, cut in skin exposed to Inhalation, cut in skin exposed to soil/water, ingestionsoil/water, ingestion

In NQIn NQ

15-25 cases/yr, 1/5 die15-25 cases/yr, 1/5 die

1/3 cases in ‘dry season’1/3 cases in ‘dry season’

Better with public educationBetter with public education

Recent JCU work reveals run off water Recent JCU work reveals run off water during high rainfall contains more during high rainfall contains more organisms then soilorganisms then soil

PresentationPresentation

Acute Fulminant SepsisAcute Fulminant SepsisLethal CAP plus Sepsis (50%)Lethal CAP plus Sepsis (50%)Genitourinary infectionGenitourinary infectionAbscesses/Osteomyelitis/Septic ArthritisAbscesses/Osteomyelitis/Septic ArthritisEncephalitis, ParalysisEncephalitis, ParalysisReactivated disease, often asymptomaticReactivated disease, often asymptomaticChronic Disease (1/16)Chronic Disease (1/16)Prostatic Melioidosis in 20% Prostatic Melioidosis in 20%

PresentationPresentation

DM, excess ETOH, CRF, steroids and DM, excess ETOH, CRF, steroids and Chronic Lung DiseaseChronic Lung DiseaseCan be ‘normal’Can be ‘normal’Normally easily Dx, tell lab-modified Normally easily Dx, tell lab-modified culturecultureSerology occasionally-Neuro/reactivated Serology occasionally-Neuro/reactivated disease.disease.RETURNED TRAVELLER- no advice is RETURNED TRAVELLER- no advice is given….given….

AntibioticsAntibiotics

Resistant organism ( pen, ceph, gent, cipro)Resistant organism ( pen, ceph, gent, cipro)Guidelines for CAP in endemic areasGuidelines for CAP in endemic areas1990’s IV Ceftazadime (14days) 1990’s IV Ceftazadime (14days) oral trimethoprim/sulfamethoxazole (6mths)oral trimethoprim/sulfamethoxazole (6mths)Now Meropenum infusion (lower MIC)Now Meropenum infusion (lower MIC)No seizures, better killing profile and decrease No seizures, better killing profile and decrease endotoxin release ( yet to show better survival)endotoxin release ( yet to show better survival)Dramatic fall in mortality (Stephens, Currie)Dramatic fall in mortality (Stephens, Currie)G CSF??? ( Not in NEJM review)G CSF??? ( Not in NEJM review)

CaseCase

Febrile child.Febrile child.

Limb weakness following lacerationLimb weakness following laceration

Camping in bushCamping in bush

Mild encephalopathyMild encephalopathy

Questions?Questions?