[CIS PIDD] [cis-pidd] Sick infant with multiple septic arthritis and osteomyelitis

Fri Apr 13 16:04:59 EDT 2018

Thanks Karl!

I forwarded your email to my colleague.

I am currently in Qatar, so I also miss Chicago, sometimes even the cold weather!

Best,

Ramsay

On Apr 13, 2018, at 10:29 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>> wrote:

Hi, Dr. Fuleihan:

(I do miss Chicago – even north of the river)

Going by your chronology, this course does not sound unexpected if this premature infant indeed had a “missed” staphylococcal arthritis/osteomyelitis/occult bacteremia for several days prior to being diagnosed and antibiotic therapy started.  Even with the “correct” antibiotics, disseminated staphylococcal infection is hard to eradicate in premies.  Multiple operations and the need for “synergistic” coverage is not rare.

My three suggestions (ID hat on hand) would be (1) hunting for occult/drainable abscesses – renal / liver / spleen ultrasounds as a start, and (2) using either gentamicin or daptomycin as synergistic coverage on top of the MSSA/Serratia-active beta lactam.  I consider linezolid the inferior drug for disseminated MSSA disease – and it is actually antagonistic to all other anti-staph drugs.

Patience is needed.  It is not unusual for apparent lack of progress for a decent chunk of time before the kid would start turning a corner.  I’ve had 3 weeks’ running positive blood cultures in cases like this.  The delay in central venous catheter removal – not an atypical story for babies with poor access – prolonged the duration of bacteremia, I’m sure.

I’ve had hyper IgE seem to start to present this way in early infancy (bacteremias, GI disease/obstruction) – but, of course, the denominator for premature infants with difficult-to-control staphylococcal infection is much larger than numerator.

Good luck.

    - Karl

Karl O. A. Yu, M.D., Ph.D., F.A.A.P.
Scientist and Assistant Director, Center for Infectious Diseases and Immunology
RGH Research Institute | Rochester General Hospital | Rochester Regional Health
1425 Portland Ave., Room R-403, Rochester, NY   14621
Tel  585-922-3709  |  Fax  585-922-2415

From: cis-pidd at lyris.dundee.net<mailto:cis-pidd at lyris.dundee.net> [mailto:cis-pidd at lyris.dundee.net] On Behalf Of CIS-PIDD
Sent: Friday, April 13, 2018 2:15 PM
To: CIS-PIDD
Subject: [cis-pidd] Sick infant with multiple septic arthritis and osteomyelitis

Hi All!

I am posting a case for my colleagues in Chicago:

3 month old ex 25 week premature infant  who presented with multiple septic arthritis and osteomyelitis growing MSSA (including the skull, spine, hips, knees, and long bones). He is not responding to antibiotic therapy and is now growing pathogenic serratia from the lung.  Prior to 2 weeks ago, the child had been largely healthy aside from some possible joint swelling which was mild in the weeks prior.
Labs are as follows:
He has low platelets but is septic, and the platelets are large in size. He does not have eczema.
Flow cytometry was within normal limits, and a neutrophil oxidative burst was normal. TLR function was also normal except for IL-6 response was low for poly I:C stimulation but ok for other stimulants.
IgM is high at 216 and IgG high at 273, IgE elevated at 13.8
The Th17 cell number was normal. CRP has been elevated at times which is inconsistent with the report of IL-6 neutralizing antibodies.
At this point, we do not think it is CGD, MyD88/ IRAK4, or IL-17 pathway defects.
PID genotyping panel is pending
Any help in terms of suggestions for other diagnostic tests or empiric therapy would be much appreciated.

Thanks,

Ramsay

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