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medical

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by

Fetoun AlZahrani

on 16 February 2014

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Transcript of medical

Microbiology

T
hank
Y
ou

Code of Ethics for Physicians - "Medical Ethics"
Code of Ethics for Nurses
Created and revised by the AMA - American Medical Association,
pertains specifically to doctors.
Emphasizes:
Autonomy - respect of person, confidentiality
Beneficence - benefiting others
Non-Maleficence - "do no harm." respecting others
Justice, Truth, Honesty
Created and revised by the ANA -
American Nursing Association
Used in nursing education, emphasizes patient-centered care
Code of Ethics for Pharmacists
Examples of 2013 Ethical Issues
in the Medical Field
Euthanasia
Abortion
Birth Control
Gene Testing
Vaccinations
Psychology Issues
Stem Cell Research
Created and revised by the APhA -
American Pharmacists Association
All ethical codes use principles from the Hippocratic Oath
Establishes the Pharmacist-Patient relationship
Ethics
Established by worldview, social norms, truth
Humans have been practicing medicine in one way or another for over a million years.
Case Presentation
Dr. Ahmed AlZahrani
Medical History

7 years old Saudi boy lives in

ASSIR

No previous

medical illnesses


Complained of abdominal pain, vomiting, decrease appetite and appearance of abdominal mass in the
last 2 months

No fever
, no hx of contact with animal or raw milk ingestion
Product of FT, no NICU admission
Vaccination
: up to date
Nutrition:
on home diet
Medication :

nil
Family history
:consangous parent with 2 children's , he is the eldest
No history of similar illness or any other medical problem
Allergy :

nil

Medical Course
After discharge
, he complained of abdominal pain, vomiting and stool coming from surgical site

In 26th of December
, re-exploration with abdominal drain on Lt side and colostomy was placed on Rt. side

Patient referred to

KFSHRC
Admitted to
Mahail Asir hospital
and diagnosed to have gastroenteritis & received supportive treatment

Father signed
(DAMA)

and took him to Abha private hospital, diagnosed to have
perforated appendicitis
,
peritonitis
and

abdominal mass
?

In
16th
of December 2013 exploratory laparotomy done to him(
Rt. hemicloctomy
)
Physical Examination
Afebrile
other vital signs stable,
BMI
:12.6
looked pale
, cachectic with muscle wasting and dry skin.

He

was conscious and alert
Chest
: good air entry no added sound
CVS
: S1+S2+ no murmur
Eye
: Negative
Ear/Nose/Mouth/Throat
: Negative
Genitourinary
: Negative
Developmental screen-7 year
: Within normal limits
Abdomen:

There was midline incision with minimal redness and yellowish discharge
Site of surgery showed non-healing wound; colostomy on the right side and abdominal drain in the left side
By palpation:
soft and lax abdomen, There was no tenderness and no any detected or appreciated organomegaly
Lower limb
showed no lower limb edema and no lower limb skin rash
No palpable
Lymph node
all over the body
Labs on Admission
WBC:
13.26
Neutrophil:
8%
lymphocyte:
3%
Eosinophil:

2%
HGb:10.1 Platlet:
819
PT:
14.4
PTT:
39
Renal function test:

K=5.3 other parameter within normal limit
LFT:
ALT=40.8 other parameter normal
Urine analysis:
normal

Differential Diagnosis

?
IBD
Granulomatous Diseases
Malignancy
C.T Scan Abdomen

CT scan abdomen was done in
Abha private hospital
and it showed appendicular mass around
5 x 3 x 2.5
cm

Microbiology

Peritoneal fluid
Gram stain show:
gram negative rods +2, gram positive cocci +1 and polymorphy nuclear cells +3
Culture show grow:
p.aeruginosa , E.coli and enterococcus fecalis
Fungal culture:
negative

Pathology Report

Right colon
, terminal ileum, cecum, appendix mesenteric mass and anastomosis site
Chronic

and

active inflammation

with eosinophilic abscesses with fungal hyphae consistent with basidiobolomycosis

The

inflammation

is destroying the bowel wall and reaching the serosa fat

H&E
H&E
GMS stain
PAS Stain
PAS Stain
Treatment
Itraconazole
was given for
2 weeks
then it was changed to voriconazole

Tazocin
was given for
2 weeks
then
stopped.

Basidiobolus
Classification
Basidiobolus ranarum
Basidiobolus: Epidemiology
Basidiobolus species
are filamentous
fungi

Family:
basidiobolaceae of the order entomophthorales

Greer and Friedman, 1966 Zahari et al, 1990 Gugnani, 1983
They are occasionally present as commensal in the
gastrointestinal tract
of
amphibians
,
reptiles
,
fish
and
mammals
such as toads, turtles, chameleons, horses, dogs and bats

Commonly found in
soil
and decaying
vegetable
matter

In the past clinical isolates of Basidiobolus were classified

B. ranarum
B. merisstosporus


B.haptosporus
Amr Jr Infect Dis: 9 (1): 1-6, 2013
B.ranarum
was first described by Eidam in
1886
as an isolate from frogs and it was later cultured from intestinal contents
(Sutherland-Campbell, 1929; Thaxter,1888)
and the excreta of frogs
It was first isolated in
1955
from
decaying plants
in the United States and subsequently has been found in
soil
and
vegetation's
throughout the world
B. ranarum
is a member of the order
Entomophthorales
of the class
Zygomycetes

Basidiobolomycosis
GI Basidiobolomycosis
GI Basidiobolomycosis
Epidemiology in in
Saudia Arabia

Basidiobolomycosis in general was recognized as the first human case of subcutaneous mycosis in Indonesia (Joe et al., 1956)

It is usually cause subcutaneous infection that affects mostly young males, and it is transmitted through traumatic inoculation


Most cases have been reported from tropical and subtropical regions

GI Basidiobolomycosis
has been scarcely reported in the literatures and the total reported cases since
1964
till end
2012
were
44 cases
worldwide.

Recently, its etiologic role in
gastrointestinal infections
has been increasingly recognized in
Saudi Arabia
(Jarie et al., 2003; El- Shabrawi et al., 2011; Hussein et al., 2007).

(Jarie et al., 2003; El- Shabrawi et al., 2011; Hussein et al., 2007)

Ingestion of soil
/

animal excreta

or

food
contaminated by either are the most believable route of infection in such cases

An emerging illness

as a result of various

environmental

and

demographic
factors


All cases were reported from the same region (
southern part of Saudi Arabia
) which is characterized by warm and humid climate

Southern parts
is a good environment for fungal growth and common presence of some species of reptiles



Wall lizards
reptiles are found to be one of the reptile species that have B. ranarum in their GI tract and assumed to be the cause in one of the reported cases


Mean
WBC
was
(20.68×10^3/uL)

Average
eosinophil’s
was
17.1%

Average
ESR

was
99.9
mm/hr in 16 patients

Histopathological Characteristics
Marked tissue
eosinophilia.
Granulomatous
inflammation
Microabscesses
Necrosis
and
giant
cells
Presence of thin
walled
,
broad,

septate
,
irregularly branching
hyphae rounded zygospores
eosinophilic material
(Splendore-Hoeppli phenomenon)
surrounding fungal elements

Treatment

Surgically removal
which help to debulk the mass
Itraconazole
Gastrointestinal Basidiobolomycosis
All 3 cases, patients presented with a clinical profile suggestive of malignancy

None of the patients gave any specific history that could point toward possible causes of fungal exposure

There was widespread abdominal disease with peritoneal involvement and colonic masses

Colonoscopy biopsy specimens showed nonspecific inflammation in 1 case; however, they showed only granulomatous inflammation in a second case and granulomas associated with fungal hyphae in a third

Can be detected on deeper mucosal biopsies, as the infection seems to involve the non mucosal layers of the gastrointestinal tract

Most patients are in apparent good health before acquiring infection

Basidiobolus ranarum organisms generally do not invade blood vessels and rarely disseminate

Definitive diagnosis
is based on isolation of fungus from tissue specimens

Macroscopic features:
Sabouraud agar is an
adequate medium
Visible growth is usually
present 2 to 3 days
after incubation at
25C to 30C
Colonies
appear white or pale grey and have radial folds
Kwon-Chung KJ,Bennett J Medical mycology
Microscopic features:

The fungal elements appear as broad, pleomorphic, sparsely septated hyphae, Zygospores with conjugation beaks
Kwon-Chung KJ,Bennett J Medical mycology
Serodiagnosis
can be used as an adjunctive diagnostic method
Test appears to be very specific for B. ranarum
Its sensitivity has not been determined
Full transcript