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Tag Archives: pleural

November 1, 2016
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Steven Oscherwitz
General Infectious Disease, Diagnosis, Epidemics & Emerging Diseases
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Valley Fever (Coccidioides imitis) Infection

November 1, 2016 General Infectious Disease, Diagnosis, Epidemics & Emerging Diseases Leave a comment
Coccidioides Spherules

Coccidioides Spherules

 

 

 

Coccidioides imitis is a soil fungus that requires alkaline soil to grow.  It is found in arid regions from California to Texas and in areas of Central and South America. It causes “Valley Fever”, which can mimic the flu, but is not contagious from person to person.

 

 

 

 

Fungi recycle dead plant and animal tissues, returning their elements to the soil for reuse. Coccidioides is one such soil fungus. It lives in the desert Southwest of the United States.

Fungi recycle dead plant and animal tissues, returning their elements to the soil for reuse. Coccidioides is one such soil fungus. It lives in the desert Southwest of the United States.

 

Arthroconidia

Arthroconidia

Arthroconidia (also known as arthrospores) are the form of Coccidioides that grows in soil. They can be aerosolized by wind or construction activities

Coccidioides infection begins when animals or people inhale its arthroconidia.  These are the soil form of the organism, usually found in the top four inches of desert soil.
Tourists passing through the Southwestern US may inhale large numbers of infectious arthroconidia.

When they reach the lungs, they grow and form spherules, the next stage in the Coccidioides  life cycle.

 

 

 

Our immune response to the fungal infection can result in fatigue, fever, cough, chest pain, headaches, rash, nightsweats, muscle pain, joint aches, weight loss and poor appetite.  

These are the symptoms of Valley Fever.

 

 

Valley Fever spherules in our tissues soon become surrounded by layers of white blood cells.  Since the white blood cells can’t kill the fungus, they try to wall it off.

Coccidioides granuloma

Onion-like granuloma, with inner core of infectious organisms (Coccidioides spherules) and outer layers of white blood cells.

Each granuloma is like an onion, with multiple layers of immune response cells surrounding its core of Coccidioides spherules.

 

Pathologists can use a microscope to see these granulomata and spherules in a tissue biopsy, allowing them to diagnose the fungal infection.  Serology tests for Coccidioides are available, too, but may be unreliable in certain patients.

 

Doctors may have problems diagnosing Coccidioides infection, especially in areas where the fungus does not reside.

 

 

 

 

 

Coccidioides left cavitary pneumonia

Coccidioides fungus has digested lung tissue to form a hole (cavity) on the left side

Even with a relatively strong immune system, tissue destruction and lung cavity formation can occur from Coccidioides infection.

Theis patient has a left lung cavity (hole eaten in lung tissue) from the fungal infection.

 

 

 

 

Coccidioides left lung cavitary pneumonia (patient also has breast implants)

Coccidioides left lung cavitary pneumonia (patient also has breast implants)

Adjusted CT image - shows lung markings & extent of disease better

Adjusted CT image – shows lung markings / extent of disease better

 

 

Radiologists can turn up the contrast on CT scan images to better see the extent of Coccidioides lung disease.

(Compare upper to lower image)

The fungal lung infection can affect the adjacent pleural membranes, pericardium and even the heart itself.

 

 

Coccidioides cavity with secondary bacterial right lung abscess

Coccidioides cavity with secondary bacterial right lung abscess

Bacteria from the mouth can find their way into a Cocci cavity, forming an abscess.  This can cause high fevers, chest pain and malaise.  Coccidioides infection can cause lung scarring, shrinking the involved lung. This patient’s diaphragm is pulled up into a “tent” or peak from scarring near the cavity.

 

 

thoracostomy tube placement

Thoracostomy tube placement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pus that breaks out of a lung cavity into the adjacent pleural space forms an empyema.

Empyemas require a thoracostomy tube for drainage.

 

If the empyema fluid is too thick to be removed by tube, surgical drainage is required for resolution.

Video Assisted Thoracoscopy or open thoracic surgery are used to remove the pleural “peel” (the “peel” forms from severe inflammation and pus remaining in the pleural space for weeks or months).

 

 

 

Coccidioides cervical lymphadenitis (patient has disseminated infection)

Coccidioides cervical lymphadenitis (patient has disseminated infection)

Someone with a weak immune system may die from disseminated infection (when Coccidioides spreads out of the lungs to involve the brain, bones, skin or other sites).

Patients with emphysema, diabetes, cancer chemotherapy, ongoing pregnancy or other immunosuppressive problems are more prone to severe disease with Coccidioides fungus.

Persons of Filipino, Polynesian and African ancestry can also suffer severe problems with the infection. Their immune systems are less effective in controlling the fungus.

 

Disseminated Coccidioides Infection with severe pneumonia

Disseminated Coccidioides Infection with severe pneumonia

Patients with disseminated disease are unable to contain the fungus.   Involvement of brain, bones, abdominal viscera, muscles and soft tissues can be life-threatening.  Most cases of disseminated Coccidioides are fatal without treatment.

 

 

 

Erythema multiforme is a rash that can be seen with Valley Fever and other diseases

Erythema multiforme is a rash that can be seen with Valley Fever and other diseases

Coccidioides fungus can activate the immune system, causing rashes of all sorts.

Joint pain, fatigue, red eyes, ulcers in the mouth and swelling of the lips and tongue can all be present with the rash.

 

 

Erythema multiforme is a flat or somewhat raised rash of doughnut or ring-shaped lesions that have a red or purple color.  The rings may be clearly evident as in the photo above, or less obvious, as seen below.

Erythema multiforme occurs when the immune system is activated by an infection, drug or other stimulus

Erythema multiforme occurs when the immune system is activated by an infection, drug or other stimulus

The rash, joint aches, lip and tongue swelling, fatigue and red eyes usually resolve promptly on treatment for Coccidioides infection. These rashes and other symptoms occur from immune system activation by the fungus.

 

Erythema nodosum consists of painful swellings beneath the skin

Erythema nodosum consists of painful swellings beneath the skin

Erythema nodosum is a different sort of skin inflammation than erythema multiforme.  It consists of large tender nodules beneath the skin.  These usually occur on the front of the legs, but they can appear anywhere on the body in patients with Coccidoides infection.  No Coccidioides fungus is found in these lesions; they are due to immune system stimulation by the infection.

 

Anti-fungal agents affect various parts of the fungal cell wall or cell membrane

Anti-fungal agents affect various parts of the fungal cell wall or cell membrane

 

Coccidioides therapy may include the different classes of anti-fungal drugs shown above.
Azoles are commonly used in patients able to take oral therapy (fluconazole, itraconazole, voriconazole, posaconazole).

Echinocandins are less easy to use outside of a hospital, since they are given intravenously.
Amphotericin B formulations are also intravenous, and are usually given to more seriously ill patients.

 

 

For more information about Valley Fever, visit

http://www.vfce.a4d.arizona.edu/
Valley Fever Center for Excellence website.

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October 8, 2016
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Steven Oscherwitz
General Infectious Disease, Hospital Infections
ICU, Staph, Staphylococci, Strep, Streptococci, ability, abscess, air, antibiotic, arteries, assist, atmosphere, bacteria, beating, bone, breath, breathing, bypass, cavity, chest, clogged, collapse, complication, coronary, coughing, course, debridement, dehisced, dehiscence, die, form, fungi, halves, heal, healed, heart, hose, infected, infection, inflate, injuries, lung, lungs, miracle, modern, motion, mycobacteria, negative, open, osteomyelitis, pain, painful, patient, patients, perform, pleural, pressure, procedure, pull, pulled, quick, recoveries, recovery, recur, repair, respiratory, rip, ripping, seal, severe, skin, soft, softened, space, split, spring, sternal, sternal wound infection & dehiscience, sternum, suffer, surgery, telemedicine, tension, thoracostomy, trauma, tube, tumor, vacuum, wall, wire, wires, wound, wounds, years

STERNAL WOUND INFECTION

October 8, 2016 General Infectious Disease, Hospital Infections Leave a comment

STERNAL WOUND INFECTION AND DEHISCIENCE

 

One of the miracles of modern surgery is the ability to perform open chest procedures to bypass clogged coronary arteries, repair traumatic injuries, remove tumors and clear the pleural space of infection. Such procedures usually go well, but like any operation, can take a turn for the worse.

Patients who suffer sternal wound infection and dehiscience after chest surgery may have painful recoveries, suffer severe complications or even die.

Staphylococci

Staphylococci often cause sternal wound infection & dehiscience. They have the appearance of grapes
(Staphyle = bunch of grapes in Greek)

Usually, skin bacteria such as Staphylococci and Streptococci are involved in these infections, but other organisms such as fungi and mycobacteria can also cause problems.

If the bony edges of the split sternum become infected (osteomyelitis), they may come apart. Breathing and coughing put tension on the wires holding the sternal halves together, and they may pull out of the softened bone. This can allow the sternum to spring open, ripping the overlying skin and making a direct route into the patient’s chest cavity for bacteria and air.  Patients with this complication must reach a hospital with an ICU quickly.

The picture below shows what sternal wound infection & dehiscience looks like.

Sternal wound infection & dehiscience

Sternal wound infection & dehiscience is a serious complication of thoracic surgery

http://www.drdetective.com/blog/wp-content/uploads/2016/10/20160916_120938.mp4

This video shows sternal wound infection & dehiscience.  You can see the respiratory motion of the two halves of the sternum, with the beating heart behind them.  An abscess had formed in the chest wall, and the sternal bone was infected.  The wires holding the sternum together pulled out of the softened bone, and were removed when the surgeon drained the abscess and cleaned everything up.

(If above not working, try link here:  https://vimeo.com/186106835)

 

 

thoracostomy tube placement

Thoracostomy tube placement

 

The spaces surrounding each lung are under negative pressure relative to our atmosphere, helping our lungs inflate on each breath. When the chest is opened, that vacuum-assist disappears, and the lungs collapse. Patients who have had chest surgery usually have a thoracostomy tube or two in place after their procedure, attached to a vacuum hose to help re-inflate the lungs. Once their wounds have healed a bit, allowing the chest to again maintain its seal, the tubes can be removed.

 

 

 

 

 

After sternal bone debridement (clean-up), rewiring and wound closure, the patient usually needs thoracostomy tubes and a prolonged course of intravenous antibiotics to try and penetrate the infected bone. The antibiotic course may run for 6 weeks or more, and the infection can recur again, even years after apparently successful therapy.

 

IV Antibiotics active against Staphylococci

IV Antibiotics active against Staphylococci

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