Rhodococcus equi

Rhodococcus Equi Rhodococcus Equi

Trey RumphMercer University

Internal Medicine Rotation

…is it in you?

Patient CasePatient Case

PH is a 65 y/o WM admitted 2/5/2010

CC: N&V for 2 days, cough for weeks and left foot pain

PMH: ESRD, s/p related donor living renal transplant, T2DM, HTN, Polycystic Kidney disease, hx of Gout, hx of left upper lung pneumonia

SH: married, lives on farm in South Pittsburg, (-) tobacco, (-) EtOH, Owns and manages a demolition company, but has been a coal miner for approximately 12 years

Allergies: Demerol and Phenergan

Patient Case (HPI)Patient Case (HPI)

History of ESRD 2o polycystic kidney disease, s/p living related donor renal transplant from his daughter in 2005 (Baseline Cr ~1.4-1.6).

Presents to ER with CC of N&V with onset of 2 days ago

Cough worsened over the last several weeks ever since d/c from hospital with left upper lung pneumonia on 1/15/10

Left foot pain that has progressively worsened over the last several days (Gout)

BUN/Cr note to be 68/2.1 on presentation and volume

Home MedicationsHome Medications

Prograf 1mg PO BID Lasix 40mg BID Zyloprim 300mg Qdaily

CellCept 1gm PO BID Verapamil 120mg PO BID

Starlix 120mg QD

Prednisone 5mg PO BID Metoprolol 12.5mg PO BID

Lantus 20 units QHS

ASA 81mg BID Tessalon Perles prn

Immunosuppressants Heart Medications GoutDiabetes

Hospital medsHospital medsCellcept 500mg IV Q12

Morphine 4-8mg Q1/prn

Ambien 5mg QHS

Cytovene 500mg IV BID

Lopressor 12.5 BID Mycostatin 5mL QID

Solumedrol 10mg IV Q12

Calan 120mg BID Carafate 1gm Q6

Zithromax 500mg QDaily

Bumex 1mg IV Q12 Lantus 30units QHS

Vancocin 0.75g IV QDaily

Nitrol Ointment 1 inch Q6h

NovoLog SSI level 4

Roxicet UDL Q4/PRN

Phenergan 6.25-12.5mg Q6/prn

Procrit 10,000units on MWF @1600

Lortab 7.5mg Q4/prn

Zofran 4mg Q4/PRN

Apresoline 10-20mg Q6

ImmunosuppressantsAntibioticsPain Management

Pain ManagementHeart MedicationNausea Medication

Sleep AidAnti-FungalDiabetes

Patient Case (Hospital Course)Patient Case (Hospital Course)

Upon AdmissionAdmitted via ER with CC of nausea and

vomiting for 2 days and a cough for weeksCT scan shows left upper lobe mass of

6.5cm with lymph node involvement

Fig 1: There is an irregular large soft tissue mass in the left upper lung field which opposes the descending proximal thoracic aorta measuring some 5.5 x 6.5cm.

Course of ActionIV Solu-MedrolHold Prograf

◦Use of Rapamune?Zosyn 2.25mg Q8- obstructive pneumoniaBronchoscopy – left upper lobe mass

Prograf vs RapamunePrograf vs Rapamune

Tacrolimus Sirolimus

Post-transplant Diabetes (~20% first year)

At high doses:◦ Nephrotoxic◦ Neurotoxicity

Renal adjustmentsQT prolongation

Impaired wound healing

↑ K↓ MgHyperlipidemiaHypertriglyceridemiaLeukopenia

Results of BronchoscopyGeneralized erythema, mucosal bleeding

with no obstructing mass noted in the left upper lobe

Patient Case (Hospital Course)Patient Case (Hospital Course)

Patient is coughing up blood, productive with a green coloration

Course of ActionAdd Vancomycin IV 1g Q24o to treatment

(10.6mg/kg) and Zosyn 2.25mg Q8 (CrCl ~29.2)

Vancomycin Dosing and Trough Levels

Date Dose Date Trough level

2/9/10 1g

2/10/10 1g 2/12/10 17.6

2/20/10 30

2/21/10 27.6

2/24/10 27.3

2/25/10 0.75g 3/1/10 13.9

3/9/10 1g 3/9/10 23.6

Patient Case (Hospital Course)Patient Case (Hospital Course)

Blood in cough resolves, but kidney function begins to decline. Patients develops a hemothorax.

Planned Video-Assisted Thoracoscopic Surgery (VATS)◦Retained hemothorax via trapped lung

procedureID Consulted

◦Differential: CMV or atypical mycobacterium◦Ordered urine antigens and serology for Q-fever◦d/c Zosyn

Atypical PneumoniasAtypical PneumoniasLegionnaires disease (Legionella pneumophila)

Q fever (Coxiella burnetii )

Psittacosis (Chlamydia psittaci )

• Lung infection (pneumonia) CAP or HAP lasts 2-14 days

• Pontiac Fever symptoms usually last for 2 to 5 days and may also include fever, headaches, and muscle aches; however, there is no pneumonia.

• During birthing the organisms are shed in high numbers within the amniotic fluids and the placenta and aerolized

• Usually inhaled, extremely virulent

• Resistant to heat, drying, and many common disinfectants

AKA: Parrot Disease or Parrot Fever

•Found in bird droppings

Course of ActionLab Evaluation

◦Rare Gram(+) cocci to be identified…

◦?Malacoplakia or Rhodococcus Equi◦Vancomycin 1g Qdaily and Ancef 1g Q8o

◦Immunosuppressants started back Prednisone 20mg QD Cellcept 250mg Q12 Prograf 1g Daily

MalakoplakiaMalakoplakia

Inflammatory condition that leads to formation of papules, plaques and ulcerations (usually affecting the genitourinary tract)

Thought to result from the insufficient killing of bacteria by macrophages, that accumulate inside depositing iron and calcium forming the papules, etc.

Associated with patients who are immunosuppressed

Rhodococcus EquiRhodococcus Equi

Background Background R. EquiR. Equi

Characterized by rod-to-coccus morphologic variation during its growth cycle

Rhodococcus genus due to its ability to form a red (salmon-colored) pigment - “red-pigmented coccus”

Primarily causing zoonotic infections in grazing animals (ex: horses and foals)

A soil organism that require simple requirements to survive, which seem to be met perfectly by herbivore manure and summer temperature in temperate climates

BackgroundBackground

R Equi is an obligate aerobic, intracellular, nonmotile, non-spore-forming, gram-positive coccobacillus

Commonly transmitted via inhalation on farms

This latter histologic picture, termed malakoplakia, is extremely rare within the lung and, when present, is highly suggestive of a R. equi infection

PathogenesisPathogenesis

R. Equi is facultative intracellular pathogen, surviving inside macrophages to cause granulomatous inflammation and eventually destruction of macrophage.

In humans, has only be found in patients with compromised immune systems in the lungs

Patient PresentationPatient Presentation

#1 Pneumonia (~66%)

Other possible presentations◦Penetrating eye wound◦Inflammatory mass in the pelvis◦Bloody diarrhea and cachexia◦Pleural effusion◦Osteomyelitis◦Paraspinal abscess◦Inflammatory pseudotumor

Primarily CAP CulpritsPrimarily CAP Culprits

Typical Pathogens for CAP◦Streptococcus pneumoniae◦Moraxella catarrhalis◦Haemophilus influenzae

Pneumonia PresentationPneumonia Presentation

Physical Findings◦Rales heard upon Auscultation over the chest◦Pleural Effusion◦Purulent sputum ◦Blood-tinged sputum ◦Signs of consolidation

Typically seen with Legionella, Q fever, or psittacosis

Summary of Clinical Summary of Clinical PresentationPresentation

Surgical PathologySurgical Pathology

Left Upper Lobe Lung Mass – CT directed Core Biopsy◦Malakoplakia of the lung◦Gram (+) organisms present◦Cytomegalovirus Inclusions Present (in adjacent lung

tissue)

Comment:Pulmonary malakoplakia has been described in immunocompromised patients, including organ transplant patients. The most commonly isolated organism in this setting is Rhodococcus equi – initial cultures do show growth of a difficult to identify organism; the culture has been referred to a reference laboratory for typing.

PathologyPathology

Hematoxylin-and-Eosin Stain(Calcospherites)

Calcium Stain

PAS + material Gram Stain

Pathology

CMV inclusion

Pathology

PathologyPathology

From the pathology as well as the culture coming back with rare gram (+) cocci (Rhodococcus species), Infectious Disease concluded the presence of R Equi

Patient Case (Hospital Course)Patient Case (Hospital Course)

Changed Therapy to…◦∆ Vancomycin 1 g QDaily and Clindamycin◦Renal decides to hold Prograf due to declining

renal function◦∆ Clindamycin Zithromax◦Added Levaquin for cover for new cultures of

Klebsiella and Serratia found in the sputum

Vancocin 1g QDaily/ Levaquin 750mg QDaily/ Zithromax 250mg QDaily

Strategy to treatStrategy to treatR EquiR Equi

Must be covered by at least two or more agents

Combination antibiotics should include one agent with intracellular penetration (ex: Erythromycin or Rifampin)

Besides the use of anti-microbial drugs, the approach used in treatment of human infection involves drainage of the suppurative lesions, surgical resection of granulomatous tissue, and control of concurrent immunosuppressive drugs or control of underlying malignancies.

Duration of treatment 4-9 weeks

Antibiotics used to treatAntibiotics used to treatR. EquiR. Equi

ErythromycinAzithromycinClarithromycinClindamycinCiprofloxacinAminoglycosidesRifampinImipenemMeropenemVancomycinLinezolid

Macrolides

Lincosamides

Fluoroquinolones

Anti-tuberculosis Agent

Carbapenems

Oxazolidinones

Patient Case (Hospital Course)Patient Case (Hospital Course)

Patient still in Respiratory failurePatient suspected of CMV per Lung biopsyAdded Cytovene® (Ganciclovir) 200mg BIDPatient was scheduled for Tracheotomy

Surgery

Vancocin 1g QDaily/ Levaquin 750mg QDaily/ Zithromax 250mg QDaily/ Cytovene 200mg BID

Patient Case (Hospital Course)Patient Case (Hospital Course)After 14 days of treatment the Levaquin was

d/c’dPlaced DHT bedside via CORTRAK

Patient Case (Hospital Course)Patient Case (Hospital Course)

Still in Respiratory failureUnderwent the T-piece Trials on the ventPlaced catheter

Vancocin 1g QDaily/ Zithromax 250mg QDaily/ Cytovene 200mg BID

Patient Case (Hospital Course)Patient Case (Hospital Course)

Patient feels betterCase Management refer him to Siskin and

Kindred Kindred acceptsCytovene d/c, ID was never really clear if

CMV was a pathogen

Vancocin 1g Q48h/ Zithromax 250mg QDaily

Patient Case (Hospital Course)Patient Case (Hospital Course)Patient is transferred to Kindred Hospital

on…Cellcept 500mg BID Augmentin 875mg

QdailyZyloprim 300mg Qdaily

Prograf 2mg Qdaily ASA 325mg Qdaily Flomax 0.4mg after supper

Deltasone 5 mg BID Lopressor 25mg BID Mag-Ox 400mg BID

Lantus 20 units QHS Calan SR 240mg Qdaily

Colace 100mg BID

Lasix 60mg Qdaily

Immunosuppressants

Diabetes

Antibiotics

Heart Medications

Gout

Prostate Medication

ReferencesReferences

Munoz P, Palomo J, Guinea J, et al. Relapsing Rhodococcus equi infection in a heart transplant recipient successfully treated with long-term linezolid. Diagn Microbiol Infect Dis. Feb 2008;60(2):197-9

Prescott, John. Rhodococcus Equi: an Animal and Human Pathogen. Clinical Microbiology Review. Jan 1991; 20-30

Verville TD, Huycke MM, Greenfield RA, et al. Rhodococcus equi infections of humans. 12 cases and a review of the literature. Medicine (Baltimore). May 1994;73(3):119-32