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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
4/4/19
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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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8
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