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Injectional anthrax: a new twist on an old disease
Abstracts lymph node specimens were negative. However, acid-fast bacilli were subsequently cultured from both.
Discussion The differential diagnosis, after imaging, included Crohn’s, ITB, yersiniosis and malignancy. Colonoscopic findings indicated Crohn’s or TB to be most likely. Clinical clues for ITB included origin from a high prevalence area and onset of symptoms at a period of relative immunosuppression (peri/post-partum), although the absence of fever and a normal chest x-ray raised some doubt. Radiological clues included the presence of lymph nodes larger than 1cm and mesenteric strands, although these are not always predictive. Identification of the cervical lymph node allowed for a diagnostic test and definitive histology, and negated the need for biopsy of the mesenteric nodes.
Conclusions Always consider ITB in the differential diagnosis of unusual gastrointestinal presentations, especially in highly endemic areas. Thorough clinical examination, especially for peripheral lymphadenopathy, may provide a key substrate for histological diagnosis, negating the need for a more invasive test. Caseous necrosis and acid-fast bacilli are present in only a minority of gut biopsy specimens as most TB lesions reside in the submucosa. Biopsy of mesenteric/cervical nodes (if present) is more likely to reveal diagnostic caseous necrosis. Having a high index of clinical suspicion in a proper geographical context is the most important step for making the prompt diagnosis of ITB.
e119 We report a case of papillitis with vitreitis and panuveitis as the initial presentation of syphilis, which led to the detection of HIV infection.
Scientific findings A 47-year-old MSM presented with progressive blurred vision and floaters over 6 weeks. He was diagnosed with bilateral papillitis, panuveitis and vitreitis; visual acuity was 6/60. He was commenced on oral steroids but his visual acuity worsened to light perception. Syphilis serology (EIA, TPPA) was positive with an RPR titre of 1:256. There was a rash on his feet, but no other syphilitic signs. MRI of the brain was normal; CSF showed normal cellularity, raised protein and RPR titre of 1:2. An HIV test was positive. He was treated with 17days of intravenous benzylpenicillin; his visual acuity improved to 6/9
Discussion This case reports ocular secondary syphilis causing blindness as an unusual presenting feature of HIV infection. Coinfection of syphilis and HIV affects the presentation and accelerates progression of syphilis. In the UK, there is a higher incidence of syphilis amongst MSM who are HIV positive. Syphilis is curable and prompt treatment with an appropriate neurosyphilis regimen can result in complete resolution of symptoms. It is important to remember that HIV positive patients can have other ocular disease concurrently.
Conclusions
St Bartholomew’s Hospital, London, United Kingdom
Syphilis is difficult to diagnose clinically and this case highlights the need to include syphilis in the differential diagnosis of any atypically presenting disease. It is important to diagnose ocular syphilis as it can cause blindness. This case reinforces the need for testing all patients presenting with syphilis for HIV infection as these patients frequently represent missed opportunities for detecting early infection. All manifestations of early syphilis are potentially reversible as early treatment is curative, most often with no sequelae.
Introduction
INJECTIONAL ANTHRAX: A NEW TWIST ON AN OLD DISEASECATEGORY: CLINICAL LESSON
BLINDED BY LOVE: OCULAR SYPHILIS AS THE INITIAL MANIFESTATION OF HIVCATEGORY: CLINICAL LESSON Janet Dua, Achyuta Nori, Emilie Elliot, Beng Goh, Chloe Orkin
There has been an outbreak of early syphilis in the UK, US, Australia and Europe since the early 2000s particularly in men who have sex with men (MSM). Diagnosis of syphilis requires a high index of suspicion as its manifestations are protean and are often non-specific, hence the adage "he who knows syphilis knows medicine". Syphilis increase the rate of acquisition of HIV infection and HIV may cause progression to neuro-ophthalmic syphilis. However, ocular syphilis is an uncommon presentation of syphilis and it is often associated with delayed diagnosis and treatment which may result in irreversible blindness.
Aula Abbara, Eimear Brannigan, Hugo Donaldson, James Hatcher, Alison Holmes Imperial College Healthcare NHS Trust, London, United Kingdom
Introduction Anthrax is one of the oldest diseases of grazing animals and had been responsible for the deaths of hundreds and thousands of livestock prior to the 20th Century when
e120 effective veterinary and human public health programs brought it under control. Robert Koch first identified the bacteria that causes anthrax in 1875 and his experiments with this microbe helped elucidate the role of microbes in causing illness. Anthrax associated with injection of heroin use does not manifest like classic anthrax (cutaneous, inhalational or gastrointestinal) but presents with a new pattern. Since December 2009, there have been 47 reports in Scotland and 4 in England of this condition. The only other report of heroin associated anthrax is in a skin popper in Norway (2000) who died. The two cases in our trust had mainly soft tissue manifestations; they had either skin popped or injected into a vein. There is significant oedema with necrosis however, unlike necrotising fasciitis, there is little demarcation between the affected and unaffected tissue. Other presentations have included intracranial or subarachnoid haemorrhage; most patients had gastrointestinal manifestations. Coagulopathy with disseminated intravascular coagulation and renal failure have also been marked features in affected patients. Anthrax spores survive for long periods of time in the environment after release, hence appropriate disposal of contaminated tissue, equipment and clothes is vital as is the handling of biological samples. Person to person spread of anthrax has not been reported. We report one of the two cases of anthrax in heroin users in our trust.
Abstracts resulting in an optimal outcome in this case. Anthrax can have a biphasic course with apparent initial stabilisation followed by rapid decline which may result in refractory shock and death. The role of anthrax immunoglobulin in therapy remains unclear and its role in management is being evaluated. The last case in England was in August 2010 in Leicestershire, hence contaminated anthrax could still be circulating. Vigilance in heroin users is therefore of paramount importance to ensure the optimal outcome.
THE EFFECT OF ANTIFUNGAL TREATMENTS ON LABORATORY DIAGNOSTIC ASSAYS FOR INVASIVE FUNGAL INFECTIONSCATEGORY: SCIENTIFIC FREE PAPER Elaine McCulloch 1, Gordon Ramage 2, Ranjith Rajendran 2, David Lappin 2, Brian Jones 5, Peter Warn 3, William Kirkpatrick 4, Thomas Patterson 4, Craig Williams 1 1
Royal Hospital for Sick Children, Glasgow, United Kingdom 2 University of Glasgow, Glasgow, United Kingdom 3 University of Manchester, Machester, United Kingdom 4 The University of Texas Health Science Center, Texas, United States 5 Glasgow Royal Infirmary, Glasgow, United Kingdom
Scientific findings A 32 year old man presented with a 24hr history of necrosis and swelling over the left buttock and swollen genitalia. He had skin popped heroin to his left buttock one week prior; he also reported shivers, fever and malaise. Anthrax was suspected and he was given broad spectrum antibiotics and was taken immediately to theatre for extensive debridement. He required ventilatory and renal support following this and received anthrax IV IG. Anthrax was identified in blood cultures and on PCR of tissue. He completed 60 days of Clindamycin and Ciprofloxacin and made a good recovery.
Discussion This case illustrates a new presentation of an old disease. The most prominent feature of anthrax in these patients has been oedema with little demarcation between the affected and unaffected tissue; there is also evidence of tissue necrosis and coagulopathy. Anthrax produces a toxin comprising three components; protective antigen (PA), lethal factor (LF) and oedema factor (OF.) The PA combine with the OF that leads to the significant oedema. Early recognition is vital as it progresses rapidly and has a high mortality; mortality was up to 50% early in the outbreak but is now nearer 30%.
Introduction Invasive aspergillosis (IA) remains a major concern in the management of patients undergoing haematopoietic stem cell transplantation. Due to the acknowledged risk of IA a number of strategies have been developed for the use of antifungal agents ranging from prophylaxis, via pre-emptive therapy to empiric therapy, however diagnosis of IA remains problematic with clinical symptoms that are often non-specific and some radiological findings, such as the presence of a halo sign or cavitating nodules in the lungs may being strongly suggestive of aspergillosis also associated with other infections. Diagnostic tests such as Galactomannan (GM) enzyme immunoassay and qPCR have been widely employed, but it is not clear how the different antifungal treatment strategies influence these tests. This study utilises an animal model of IA infection to examine the effect of antifungal treatment using the three main classes of drugs; azoles (pozaconazole), echinocandins (caspofungin) and polyenes (amphotericin B), on diagnostic tests and how these tests are impacted upon by the use of different classes of antifungal agents in this in vivo model of IA.
Conclusions
Scientific findings
Prompt antibiotic administration and early debridement were effective at controlling the bacterial load and toxin,
No significant differences were observed in the fungal burden of the lungs of any of the groups. Examination of
Discussion The differential diagnosis, after imaging, included Crohn’s, ITB, yersiniosis and malignancy. Colonoscopic findings indicated Crohn’s or TB to be most likely. Clinical clues for ITB included origin from a high prevalence area and onset of symptoms at a period of relative immunosuppression (peri/post-partum), although the absence of fever and a normal chest x-ray raised some doubt. Radiological clues included the presence of lymph nodes larger than 1cm and mesenteric strands, although these are not always predictive. Identification of the cervical lymph node allowed for a diagnostic test and definitive histology, and negated the need for biopsy of the mesenteric nodes.
Conclusions Always consider ITB in the differential diagnosis of unusual gastrointestinal presentations, especially in highly endemic areas. Thorough clinical examination, especially for peripheral lymphadenopathy, may provide a key substrate for histological diagnosis, negating the need for a more invasive test. Caseous necrosis and acid-fast bacilli are present in only a minority of gut biopsy specimens as most TB lesions reside in the submucosa. Biopsy of mesenteric/cervical nodes (if present) is more likely to reveal diagnostic caseous necrosis. Having a high index of clinical suspicion in a proper geographical context is the most important step for making the prompt diagnosis of ITB.
e119 We report a case of papillitis with vitreitis and panuveitis as the initial presentation of syphilis, which led to the detection of HIV infection.
Scientific findings A 47-year-old MSM presented with progressive blurred vision and floaters over 6 weeks. He was diagnosed with bilateral papillitis, panuveitis and vitreitis; visual acuity was 6/60. He was commenced on oral steroids but his visual acuity worsened to light perception. Syphilis serology (EIA, TPPA) was positive with an RPR titre of 1:256. There was a rash on his feet, but no other syphilitic signs. MRI of the brain was normal; CSF showed normal cellularity, raised protein and RPR titre of 1:2. An HIV test was positive. He was treated with 17days of intravenous benzylpenicillin; his visual acuity improved to 6/9
Discussion This case reports ocular secondary syphilis causing blindness as an unusual presenting feature of HIV infection. Coinfection of syphilis and HIV affects the presentation and accelerates progression of syphilis. In the UK, there is a higher incidence of syphilis amongst MSM who are HIV positive. Syphilis is curable and prompt treatment with an appropriate neurosyphilis regimen can result in complete resolution of symptoms. It is important to remember that HIV positive patients can have other ocular disease concurrently.
Conclusions
St Bartholomew’s Hospital, London, United Kingdom
Syphilis is difficult to diagnose clinically and this case highlights the need to include syphilis in the differential diagnosis of any atypically presenting disease. It is important to diagnose ocular syphilis as it can cause blindness. This case reinforces the need for testing all patients presenting with syphilis for HIV infection as these patients frequently represent missed opportunities for detecting early infection. All manifestations of early syphilis are potentially reversible as early treatment is curative, most often with no sequelae.
Introduction
INJECTIONAL ANTHRAX: A NEW TWIST ON AN OLD DISEASECATEGORY: CLINICAL LESSON
BLINDED BY LOVE: OCULAR SYPHILIS AS THE INITIAL MANIFESTATION OF HIVCATEGORY: CLINICAL LESSON Janet Dua, Achyuta Nori, Emilie Elliot, Beng Goh, Chloe Orkin
There has been an outbreak of early syphilis in the UK, US, Australia and Europe since the early 2000s particularly in men who have sex with men (MSM). Diagnosis of syphilis requires a high index of suspicion as its manifestations are protean and are often non-specific, hence the adage "he who knows syphilis knows medicine". Syphilis increase the rate of acquisition of HIV infection and HIV may cause progression to neuro-ophthalmic syphilis. However, ocular syphilis is an uncommon presentation of syphilis and it is often associated with delayed diagnosis and treatment which may result in irreversible blindness.
Aula Abbara, Eimear Brannigan, Hugo Donaldson, James Hatcher, Alison Holmes Imperial College Healthcare NHS Trust, London, United Kingdom
Introduction Anthrax is one of the oldest diseases of grazing animals and had been responsible for the deaths of hundreds and thousands of livestock prior to the 20th Century when
e120 effective veterinary and human public health programs brought it under control. Robert Koch first identified the bacteria that causes anthrax in 1875 and his experiments with this microbe helped elucidate the role of microbes in causing illness. Anthrax associated with injection of heroin use does not manifest like classic anthrax (cutaneous, inhalational or gastrointestinal) but presents with a new pattern. Since December 2009, there have been 47 reports in Scotland and 4 in England of this condition. The only other report of heroin associated anthrax is in a skin popper in Norway (2000) who died. The two cases in our trust had mainly soft tissue manifestations; they had either skin popped or injected into a vein. There is significant oedema with necrosis however, unlike necrotising fasciitis, there is little demarcation between the affected and unaffected tissue. Other presentations have included intracranial or subarachnoid haemorrhage; most patients had gastrointestinal manifestations. Coagulopathy with disseminated intravascular coagulation and renal failure have also been marked features in affected patients. Anthrax spores survive for long periods of time in the environment after release, hence appropriate disposal of contaminated tissue, equipment and clothes is vital as is the handling of biological samples. Person to person spread of anthrax has not been reported. We report one of the two cases of anthrax in heroin users in our trust.
Abstracts resulting in an optimal outcome in this case. Anthrax can have a biphasic course with apparent initial stabilisation followed by rapid decline which may result in refractory shock and death. The role of anthrax immunoglobulin in therapy remains unclear and its role in management is being evaluated. The last case in England was in August 2010 in Leicestershire, hence contaminated anthrax could still be circulating. Vigilance in heroin users is therefore of paramount importance to ensure the optimal outcome.
THE EFFECT OF ANTIFUNGAL TREATMENTS ON LABORATORY DIAGNOSTIC ASSAYS FOR INVASIVE FUNGAL INFECTIONSCATEGORY: SCIENTIFIC FREE PAPER Elaine McCulloch 1, Gordon Ramage 2, Ranjith Rajendran 2, David Lappin 2, Brian Jones 5, Peter Warn 3, William Kirkpatrick 4, Thomas Patterson 4, Craig Williams 1 1
Royal Hospital for Sick Children, Glasgow, United Kingdom 2 University of Glasgow, Glasgow, United Kingdom 3 University of Manchester, Machester, United Kingdom 4 The University of Texas Health Science Center, Texas, United States 5 Glasgow Royal Infirmary, Glasgow, United Kingdom
Scientific findings A 32 year old man presented with a 24hr history of necrosis and swelling over the left buttock and swollen genitalia. He had skin popped heroin to his left buttock one week prior; he also reported shivers, fever and malaise. Anthrax was suspected and he was given broad spectrum antibiotics and was taken immediately to theatre for extensive debridement. He required ventilatory and renal support following this and received anthrax IV IG. Anthrax was identified in blood cultures and on PCR of tissue. He completed 60 days of Clindamycin and Ciprofloxacin and made a good recovery.
Discussion This case illustrates a new presentation of an old disease. The most prominent feature of anthrax in these patients has been oedema with little demarcation between the affected and unaffected tissue; there is also evidence of tissue necrosis and coagulopathy. Anthrax produces a toxin comprising three components; protective antigen (PA), lethal factor (LF) and oedema factor (OF.) The PA combine with the OF that leads to the significant oedema. Early recognition is vital as it progresses rapidly and has a high mortality; mortality was up to 50% early in the outbreak but is now nearer 30%.
Introduction Invasive aspergillosis (IA) remains a major concern in the management of patients undergoing haematopoietic stem cell transplantation. Due to the acknowledged risk of IA a number of strategies have been developed for the use of antifungal agents ranging from prophylaxis, via pre-emptive therapy to empiric therapy, however diagnosis of IA remains problematic with clinical symptoms that are often non-specific and some radiological findings, such as the presence of a halo sign or cavitating nodules in the lungs may being strongly suggestive of aspergillosis also associated with other infections. Diagnostic tests such as Galactomannan (GM) enzyme immunoassay and qPCR have been widely employed, but it is not clear how the different antifungal treatment strategies influence these tests. This study utilises an animal model of IA infection to examine the effect of antifungal treatment using the three main classes of drugs; azoles (pozaconazole), echinocandins (caspofungin) and polyenes (amphotericin B), on diagnostic tests and how these tests are impacted upon by the use of different classes of antifungal agents in this in vivo model of IA.
Conclusions
Scientific findings
Prompt antibiotic administration and early debridement were effective at controlling the bacterial load and toxin,
No significant differences were observed in the fungal burden of the lungs of any of the groups. Examination of