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PneumonicPlagueinaColoradoDogwithWidespreadPotential

HumanExposureJoshuaDaniels,DVM,PhD,DACVM

CSUVeterinaryDiagnosticLaboratories

• Pathology,Microbiology,Toxicology• Case#s 297,377totaltests /26,302(Bacteriology/Mycology)• Clientele

• Veterinarians• StateandFederalAgencies• Dairy/meat/eggindustries• Publicandprivateresearchentities

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DiagnosticBacteriologySection

• Aerobic&anaerobicbacteriology• Mycology• Antimicrobialsusceptibilitytesting• Bacterialserology• Molecularidentification

BacteriologyandMycology

• “Lifeislikeaboxofchocolates”• Nonselectivemicrobiologicalmedia• 99%routine/1%amazing

• Undescribedagents• Rareagents• Stuffwehaven’tseenbefore• BL3agents

Mmm..Bisgaard Taxon10

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Threecases

• Twodogs• Onellama

“Rupert”

•10Y+malellama•Hx chronicRmandibularswelling

•PresentedtoOhioStateUniversityVMC

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“Rupert”

• ExcisionalBx ofmandibularmass

• Osteomyelitis•Histopathology•Aerobicbacterialculture

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ColumbiaBloodAgar– 72hr

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AmysteriousjointinColorado

JoshDaniels

LivePolling

• Pleasetext:

JOSHDANIELS316to22333

orgoto

pollev.com/joshdaniels316

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Gunnar

Signalment

• 6mo (DOB4/11/18)• Male• GoldenRetriever

Problem#1

Vaguehistory

• 7/10/18SurrenderedtoKSUVHCforknownextrahepaticportosystemicshunt

• PassedtoManhattan,KShumanesociety• Managedonrestricteddietandlactulose

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Problem#2

• 7/20/18SepticarthritisRCFjoint• Cytologyfindings(@KSU)

• Neutrophilicinflammation• Bacteriologyfindings(@KSU)

• Culturette ofcentesis fluid• Noaerobic,anaerobicgrowth

• Rx amoxi/clav – durationunknown

• “Mildlywidenedrightproximalfemoralphysis mayrepresentphysitis,secondarytopreviouslysuspectedsepticarthritis,ornormalvariant.”(Radiographsfrom8/6/18)

Goodthings

• GoldenRetrieverRescueadoptedGunnar

• FosteredbytwoCSUDVMs• Splenocaval portosystemicshuntrepair8/6/18

• Uneventfulrecovery• Reducedlactulosedose• Renewedamoxi/clav Rx

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Problem#3

9/30/2018

• Rforelimblameness- Acute• Localizabletoelbow

• “Theopenphyses arenormalforthispatient'sage.Thereisan11.4mm,linear,proximodistallyorientated,lucency superimposedwiththemedialaspectofthelateralhumeralepicondyleadjacenttothesupratrochlearforamen.Themedialcoronoidprocessissmoothlymarginatedandwelldefined.Thereisnosofttissuethickening.Theremainderoftheosseousstructuresarenormal.”

Arthrocentesis

• Nocytologyperformed• FluidsubmittedinpediatricBacTec™bottlewithnoclinicalhistory(formsaid“jointfluid”)

• CSU-VDLbloodculturebottleprotocol:• Incubateventedin5%CO2

• Subculture@1d,2d,7d,14d• Monitorforturbiditydailyandsubcultureifdetected• SubculturesonCBAin5%CO2 à7dayincubation

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Gunnar’sbloodculturebottlemonitoring

• 1dsubcultureà nogrowth• 2dsubcultureà nogrowth• 7dsubcultureà growthdetectedafter2dayincubationofCBA

• Pinpoint,coalescingnon-hemolyticgrowthin1st quadrant

Identification

• MALDI-TOF(Biomerieux Vitek-MS)• Francisella tularensis @99.9%inRUOdatabase

• CDC-LRNrealtime PCRforF.tularensis• Positive

• SelectagentreleasereportedtoCDC• BiosafetybreachreportedtoCSU• Forfunziesà F.tularensis serologybymicroagglutination:1:8192@UWYO

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F.tularensis

• Gramnegative• Aerobic• Coccobacilli• Oxidasenegative• Weaklycatalasepositive• Ureasenegative• Transmittedviainhalation,insectbite,contactwithinfectedanimals

• Non-contagiousamongpeople• Selectagent

https://www.health.ny.gov/guidance/oph/wadsworth/francisella_tularensis.pdf

F.tularensis andsepticarthritis?

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Septicarthritisandhepaticshunt?

“Pearl”

• December2017

• 3yearoldMNmixedbreeddog

• PresentedtoDVMforlethargy

• Hadbeenjoggingwithowneronleashafewdaysprior– brieflysniffedadeadprairiedog

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“Pearl”• Rx:Amoxicillin/clavulanicacid• ReferredtoCSU-VTHnextdayduetobloodycough

• Management• Ampicillin/sulbactam IV• Enrofloxacin IV• O2• IVFluids

Rads Llateralon12/3/17

“Pearl”

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12/4/17

• CT,Lobectomy• Dx:Aspirationpneumonia• Surgicalremoval• Excisedlungdarkredandfirmwithfibrinonsurface

• Aerobic/Anaerobicculturessubmitted– plated12/5

heart

lunglung

sternum

Excisedlunglobe

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12/6/17• Decliningclinicalstatus• Verylight,pinpointbacterialgrowthobservedP.M.

• Aerobically• Anaerobically

• MALDI-TOFID• 91%Yersiniapseudotuberculosis• 99%Yersiniasp.

• SubmittedplateforLRNPCRfirstthing12/7

12/7/17

• Begancirculatingcontactlogsa.m.

• PCRpositive~12pm• Dogeuthanized

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Lung– severediffusepneumonia

Coloniesofbacteria!

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NecropsyperformedinBSL-3

• Necrotizingtonsillitis• Diffusenecrosuppurative/hemorrhagicpneumonia

• OnlyliverPCRpositive• Tonsil,lung,spleen,lymphnode,smallintestine,andkidneysampleswerenegative

Exposures

POTENTIALEXPOSURESDocumentedPotentialHumanExposures

VeterinaryTeachingHospitalEmployees

VeterinaryStudents

DiagnosticLabEmployees/Students

116

64(55%)

35(30%)

17(15%)DocumentedPotentialHospitalizedAnimalExposures

Canine

Feline

Lagomorph

46

37(80%)

8(17%)

1(2%)

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Post-exposureactions

• RiskassessmentbasedCDPHErecommendationsincluded:• antimicrobialprophylaxis(59%ofindividuals)• feverandsymptomwatch(33%ofindividuals)• ornoaction.

• Prophylacticantimicrobialswereprescribedforpotentiallyexposedhospitalizedveterinarypatients.

• Toourknowledge,therewerenoclinicalcasesofY.pestisinanyhumansoranimalspotentiallyexposedbythiscase.

Otherthingstothinkabout

• WouldPCRhavedetecteditinthelungorblood?• Loworganismburden– perhapsduetoantibiotictherapy- verylightgrowth/nointralesional organisms

• Upperrespiratorysignsarecommoninhumanbeings• LeadtooneRxchange:Doxyà SMZ/TMP+gentamicin

• Putting68peopleonantimicrobialprophy canhaveconsequences

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Casechallenges1. Atypicalpresentationinanatypicalspecies:

• Plagueisveryrareindogsandpneumonicplagueisexceedinglyrare.• Pneumonicplagueismorecommonincats.• Plaguecanbetransmittedfromhosts(suchasrats,prairiedogs)tohumansandotheranimalsbyfleas.

• Dogsandcatscanalsobeexposedbyhuntingandingestinginfectedrats,prairiedogs,etc.

Casechallenges2. Season:ThiscaseoccurredinDecember.

• ThemajorityofplaguecasesoccurbetweenApril-October.• NovemberandDecember2017wereverymildinColorado.• Theweatherwasonaverage8degreeshigherthannormalaccordingtodatafromNOAARegionalClimateCenters

• Unseasonablywarmweathermayhavecontributedtoplaguetransmission(byallowingfleasandprairiedogstobeactive)

GeneratedatHPRCCusingprovisionaldata,NOAARegionalClimateCenters.hprcc.unl.edu

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Casechallenges3. Atypicalimagingpattern:

• Solitarylunglobeconsolidationatpresentation(ratherthanbilateralinvolvement)resultedinclinicaldiagnosisofaspirationforeignbody.

• Plagueisusuallybilateralordiffusewhenitcausespneumonia

Casechallenges4. Histopathology:

• Nobacteriawereseenonhistologicexamination• Plaguecasesclassically havebacteriaevidenthistologically• BUTnotallplaguecasesaretreatedfor5dayswithantibioticsbeforetissuesampling…

• Antibioticadministrationmaychangetheclassicappearanceofplaguepneumonia***

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Casechallenges5. Failureofautomatedsystems:

• MALDI-TOFinitiallymisidentifiedthebacteriadespitehavingY.pestisinitslibrary.

• Machinesareuseful…buterrorshappen!

Emerg Infect Dis. 2019 Apr;25(4):800-803. doi: 10.3201

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Thankyou

• CSUVDLStaff• BarbPowers• KristyPabilonia• DeniseBolte• MikeRussell• TomPeppard• MarissaWilkey• ChristinaWeller

• ColoradoDept.ofPublicHealthandtheEnvironment

• JenniferHouse

• WyomingStateVeterinaryLab• KerrySondgeroth