Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases

52 yo woman w/ DM and Charcot foot who presents with worsening swelling and redness around diabetic foot ulcer.
Patient reports that her foot ulcer had been present for several years, but that it changed about 1 week ago.
She denies any known history of trauma.
Her daughter was the one to notice that the ulcer on the bottom of her left foot was red and swollen, smelled horribly, and had a black area with white splotches.
The patient claims she feels no pain in the area but has had decreased sensation in that foot from neuropathy.

Patient was initially started on Zosyn, received 4 days of therapy then lost IV access and got levaquin/clinda x 1 dose until IV access could be secured.
ID was consulted for assistance with ABX

CVA '03 - short term memory deficits per daughter
HTN
DM TYPE 2
HYPERLIPIDEMIA
OBESITY
CHF

Soc Hx - Lives in Burlington, and she hasn't worked since her stroke in '03. Denies any etoh, tobacco, or illict drug use. No recent travel. No contact with dogs or birds. Has a cat – h/o bites to the hand but no bites or licks on the foot.
Fam Hx - Aunt with Breast CA, Cousin with
Breast CA, FH of DM, HTN, Hyperlipidemia.

NKDA
ASA 81MG ONCE DAILY
EFFEXOR XR 225 MG ONCE DAILY
ENALAPRIL MALEATE 20MG TWO TIMES A DAY
FUROSEMIDE 60MG ONCE DAILY
HYDROCHLOROTHIAZIDE 25MG ONCE DAILY
METFORMIN HCL 1000MG TWO TIMES A DAY
NORVASC 10 MG ONCE DAILY
PLAVIX 75MG ONCE DAILY
SIMVASTATIN 80 MG ONCE DAILY
TOPROL XL 150MG ONCE DAILY

She admits to polyuria/polyphasia. She denies any fevers or chills, but reports nausea and vomitting this am, where she vomitted water x3 this morning and couldn't keep her medications down. Patient denies any increased swelling in her legs.

BP 147/86
HR 90
RR 20
T 37.0
97% RA
NAD, alert/oriented x3, appropriate
EOMI, PERRLA
MMM, OP clear no palpable cervical nodes no carotid bruits
RRR, no m/r/g
CTAB, nonlabored soft, nontender, + bowel sounds, obese
FROM
CN 2-12 Grossly Intact moves all 4 extre's well
LE exam – next slide

2x2 cm wound over plantar surface of Left foot; moderate purulent drainage; moderate erythema
& swelling. Area of fluctuance present over ulcer
2-3+ pitting edema of lower extremities and feet.
Well circumscribed area of erythema and heat on left lower leg and left foot. no clubbing, cyanosis.

130
4.4
95
27
42
1.9
255
10.3
13.5
29.1
N-12.4
L-0.2
M-0.5
E-0.1
B-0.0
304
CRP >45
ESR 140
Ferritin 462
Hgb A1C 7.0

X-ray of foot on admission demonstrated presence of cortical bone effacement, concerning for osteomyelitis.

Subtle enhancement seen within the distal cuboid overlying the large skin ulcer as above may represent osteitis. Early osteomyelitis cannot be fully excluded and follow-up plain radiographs in 7 to 10 days is advised to assess for interval progression.
Diffuse cellulitis and/or edema of left foot and ankle.
Small joint effusion. A septic joint cannot be fully excluded; however, no signal abnormalities in the adjacent bones are seen to suggest this diagnosis.
Abnormal enhancement at the base of the metatarsals are most likely secondary to advanced neuropathic arthropathy.

Discussion

3/3 blood cultures positive for
Pasteurella multocida 3+
Oxacillin Susceptible Staphylococcus aureus 3+
2007-07-24PENICILLINR
2007-07-24OXACILLINS
2007-07-24GENTAMICINS
2007-07-24VANCOMYCIN MIC2S
2007-07-24ERYTHROMYCINR
2007-07-24CLINDAMYCINS
2007-07-24TRIMETH/SULFAMETS
2007-07-24DOXYCYCLINES
Streptococcus species 3+

Zoonotic (related to animal sources)
Short, encapsulated gram negative coccobacilli
Aerobic, facultatively anaerobic
Small, gray, shining colonies on blood agar
Grow well on sheep blood, chocolate, MHA
Growth uncommon on MacConkey
Resistance associated with degree of encapsulation

Found worldwide
Commensals in the upper respiratory tract of fowl and mammals
Carrier rate 55% in dogs and 60-90% of cats
Causes a variety of disease in animals
Fowl cholera mastitis

cont
0.6-1.8 cases of P. multocida infection per 100,000 per year
Most commonly transmitted to humans through bites
(cat, dog, other felines, horses, pigs, rats, rabbits, wolves)
Isolated from 50% of dog and 75% of cat bites
Infections not related to bites probably stem from contact with animal secretions

Soft tissue, bone, and joint infection (usuallly following animal bites/scratches)
Oral and respiratory infections
Serious invasive infection

Rapid development of intense inflammatory response, often within hours of bite
Purulent drainage in 40%, lymphangitis in 20%, regional adenopathy in 10%
Necrotizing fascitis can occur

See UpToDate
Available online at UNC Health Sciences Library
[on campus only]

Septic arthritis most commonly involves a single joint, usually the knee. Predilection for joints already damaged (RA, DJD, prostheses). Bite usually distal to involved joint without direct penetration.
NOT preceded by a bite or scratch in 1/3 of cases
(hematogenous spread)
More than 50% of patients with septic arthritis are immunosuppressed.

Local extension of soft-tissue infection or direct innoculation
Cat bites > dog bites because of the sharp little teeth that go down to bone
Treatment requires at least 4 weeks of IV antibiotics followed by oral antibiotics
50% of patients experience slow healing, nonunion, joint fusion, limitations of motion, or residual deformity
Poor functional outcome in hand infections

Usually have underlying COPD (37%), bronchiectasis (21%), malignancy (15%), cirrhosis (8%)
Pneumonia, pharyngitis, sinusitis, lung abscesses

Endocarditis: 15 case reports
Meningitis: 50% of cases infants < 1 year, 30% adults >
60 years
Peritonitis: usually associated with peritoneal dialysis
(cat had punctured dialysis tubing in 65%)
Endophthalmitis

Bacteremia
Most are immunocompromised (cirrhosis, malignancy/chemotherapy)
Mortality approximately 30%
Commonly accompanies a localized infection
Often seen with liver dysfunction

Very rare
In the past 5 years, we’ve had 4 positive pasteurella multocida isolates from blood at
UNC
Fun fact –pasteurella bacteremia at UNC is associated with Shaughnessy exposure (no causation. all patients had positive blood cultures prior to exposure. I promise I wash my hands!)

Cirrhosis of any etiology, hepatitis, infiltrating tumors
Impairment of reticuloendothelial system makes patient prone to infection with encapsulated organisms

Penicillin is drug of choice
If PCN allergic, quinolone, doxycycline, 1 st generation cephalosporin, septra
In cases of septic arthritis, IV abx and serial joint aspirations

Pip/tazo chosen for good coverage of pasteurella, OSSA, and anaerobes/pseudomonas (given diabetic foot ulcer)
Intensive debriedments and IV abx x 2 months showed only mild clinical improvement, no change in ESR
Repeat wound culture confirmed OSSA, no further positive cultures for pasteurella. All repeat blood cultures negative to date.
Currently getting hyperbaric oxygen therapy via our vascular surgery colleagues
Continuing IV Abx – trying to save the foot

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s
Principles of Internal Medicine, 15 th edition.
Book available online via the UNC-CH Libraries
Tseng, Su, Liu, & Lee. Pasteurella multocida bacteremia due to non-bite animal exposure in cirrhotic patients: report of two
cases. Journal of Microbiology, Immunology, and Infection.
2001; 34: 293-296.
Morris MJ, Mcallister CK. Bacteremia Due to Pasteurella
multocida.
Talan, Citron, Abrahamian, Moran, Goldstein. Bacteriologic
Analysis of Infected Dog and Cat Bites. The New England
Journal of Medicine. Vol 340, number 2. 1999.

Levinson, Jawetz. Medical Microbiology and Board Review.
McGraw-Hill, 1998. Pgs 133-134.
UpToDate [ available online at UNC HSL – on campus only ]
Mandell’s Principles and Practices of Infectious Disease, 6 th Ed.
Book available online via the UNC-CH Libraries
Weber, DJ, Wolfson, JS, Swartz, MN, Hooper, DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984; 63:133.
Weber, DJ, Hansen, AR. Infections resulting from animal bites.
Infect Dis Clin North Am 1991; 5:663.
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