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• #1.

  Chance favors the prepared mind Aichi Cancer Center Division of Infectious Diseases Naoya Itoh

• #2.

  【Case】 71y.o. female 【Chief Complaints】 Cough、Dyspnea

• #3.

  Case: 72yo, female　Chief Complaints：cough, dyspnea 【Medical History】 Currently being treated for dyslipidemia. 10y ago: pulmonology surgery dept suspected chest wall neoplasm of neurologic origin. 2mo ago: dry cough, dyspnea 38℃ fever for 3 days, resolving spontaneously. 1mo ago: dry cough, dyspnea continues Antitussive prescribed for 7 days. 2w ago: medication ineffective, re-examination indicated Chest X-ray: infiltrative shadow recognized. Examined in pulmonology surgery dept outpatient. Referred to infectious disease dept. for further examination. What additional information should be asked?

• #4.

  【Review of Systems】 Positive Findings: Left chest pain (during cough); headache: 2mo from admission Loss of appetite: since December 2022 Weight loss: 43kg→39kg in 2 months Negative Findings: Nausea, vomiting, chills, shivering, expectoration, pharyngitis Abdominal pain, diarrhea, polyuria, dysuria, urinary retention, arthralgia Sick-contact

• #5.

  【Current Medication】 　Pivatastatin (1mg) PO 1 tablet /day Supplement: 　 Collagen, blueberry, DHA, royal jelly 【Past Medical History】　 　24yo　Operated for appendicitis 　56yo　Breast augmentation surgery 　61yo　left chest wall tumor (neurologic origin) 　 69yo tumor regression; follow-up no longer indicated　 　68yo suspected NTM (lingular lobe, confirmed by follow-up CT)

• #6.

  【Social, Life History】 Household of 2; lives with husband Employee at a hotel Non-smoker; does not drink alcohol Sexual history: not questioned Animal contact: has 2 cats, fosters 10 stray cats no contact with birds Travel: Taiwan, Hong Kong, Hawaii (within the last 10y) Environmental contact: no contact with hot springs, closed-loop baths no contact with dirt, gardening

• #7.

  【Physical Findings】 Height：155cm　Weight：48kg　BMI：20.0 Alert, awake　BP：140/86mmHg　HR：78bpm　 RR：16/min.　SpO2：98%(room air)　BT：36.7℃ Sclera：no jaundice　Conjunctiva：no signs of anemia Oral cavity, pharynx：erythema, no edema Heart sound：S1→S2→S3(-)S4(-)　No murmurs Lung sound：no abnormalities Abdomen：Flat, soft; regular peristalsis; no tenderness; liver, spleen cannot be palpated Lymph nodes：superficial LN cannot be palpated.　 Limbs：no edema Skin：no rash, eruptions

• #8.

  Examination Findings WBC Neu. Eo. Mono. Ly. Baso. RBC Hb MCV Plt 5680 /μL 68.3 % 1.8 % 4.9 % 24.6 % 0.4 % 4.27x106 /μL 12.6 g/dl 93.0 fl 258x103 /μL AST ALT ALP LDH T-Bi Alb Na K Cl BUN Cr 21 IU/L 17 IU/L 290 IU/L 231 IU/L 0.5 mg/dl 4.1 g/dl 140 mEq/L 5.1 mEq/L 108 mEq/L 13.1 mg/dl 0.51 mg/dl CRP 1.69 mg/dl

• #9.

  Chest X-ray at admission

• #10.

  ［Admission］ ［3yrs ago］ Chest X-ray

• #11.

  Chest CT 1 2 3

• #12.

  Chest CT 2yrs ago 1 2 3

• #13.

  Problem List ＃ Dry cough ＃ Dyspnea ＃ Chest pain ＃ Loss of appetite ＃ Weight loss ＃ infiltrative shadow seen in left lung; bronchitis What will you do next? What is your diagnosis? ＃ Left chest wall tumor ＃ Dyslipidemia ＃ Left chest wall mass ＃ Contact with cats

• #14.

  Possible Differential Diagnoses 【Infectious】 　1) NTM infection 　2) Pulmonary tuberculosis 　 3) Community-acquired pneumonia 　 4) Nocardia/actinomyces pneumonia 　 5) Chronic pulmonary aspergillosis 　6) Pasteurella pneumonia 【Non-infectious】 　1) Malignant transformation of chest wall tumor 　2) Lung cancer 　3) Restrictive lung disease 　4) Cryptogenic organizing pneumonia

• #15.

  【Sputum Gram Stain】 G1 (poor quality) sputum sample presence of oral cavity flora, non-lactose fermenting microbes 【Acid Fast Bacteria】(3 sputum samples) stain, PCR (TB, M. avium, M. intra.) → negative Additional Examinations What will you do next?

• #16.

  ［Sputum Gram Stain］ ［BAL Gram Stain］ Bronchoscopy What is your final diagnosis?

• #17.

  Clinical Course Diagnosis: Pasteurella multocida pneumonia AMPC/CVA(Augmentin®+Amoxicillin®) was prescribed for 14 days. Follow-up examination planned in 2 weeks.

• #18.

  ［Admission］ ［After treatment］ Clinical Course

• #19.

  Clinical Course after starting treatment: cough / dyspnea improved in a few days and completely resolved soon after. follow-up planned for the lung shadow that was suggestive of NTM infection.

• #20.

  Final Diagnosis Pasteurella multocida Pneumonia

• #21.

  Pasteurella multocida Pasteurella spp. infection most commonly through dog bite (50%), cat scratch/bite(75%) N Engl J Med. 1999 Jan 14;340(2):85-92. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. J Infect. 2006 Dec;53(6):403-7.

• #22.

  P. multocida Infections 1) Skin, soft tissue infection: animal bite/scratch 2) Respiratory tract infection: pt with chronic lung disease are susceptible 3) Severe invasive infection: bite wounds may occasionally give rise to: Meningitis　 Intra-abdominal infection Infective endocarditis　 Ocular infection Medicine (Baltimore). 1984 May;63(3):133-54.

• #23.

  P. multocida Respiratory Infection P. multocida causes various infections in the upper and lower respiratory tract. Most patients with P. multocida infection have preexisting chronic lung diseases such as COPD, chronic bronchitis. Medicine (Baltimore). 2015 Sep;94(36):e1285. Medicine (Baltimore). 1984;63(3):133. Semin Respir Infect. 1997;12(1):54. Arch Intern Med. 2003;163(10):1239. Respir Care. 2004;49(12):1528. Ear Nose Throat J. 2010 Dec;89(12):E4.

• #24.

  P. multocida Respiratory Infection P. multocida infection most commonly presents as pneumonia. The majority of infections occur among elderly patients. 　 According to a review of 108 patients with P. multocida infection: Pneumonia: 49 patients Bronchitis: 37 patients Lung abscess: 3 patients → 93% of patients had a preexisting condition. Medicine (Baltimore). 1984;63(3):133. Respir Med Case Rep. 2015;15:54. Epub 2015 May 7. N C Med J. 1993 Jul;54(7):308-11.

• #25.

  P. multocida Pneumonia Pathogenesis / Etiology Int J Infect Dis. 2009 May;13(3):e81-3. 87yo patient with COPD Right upper lobe pneumonia due to P. multocida 2 weeks of Ceftriaxone IV No history of animal bite 　　 　　　　respiratory droplet transmission

• #26.

  P. multocida Pneumonia Treatment ・generally susceptible to various antibiotics. Infect Dis Clin North Am 1991; 5:663.

• #27.

  【1st Line Choice】 Amoxicillin • Clavulanic acid 375mg (1 tablet, 3 / day) 　　　+ 　 Amoxicillin 250mg (1 capsule, 3 / day) combination therapy for 5~7 days P. multocida Pneumonia Treatment Some P. multocida can produce β- lactamases Medicine (Baltimore). 2015 Sep;94(36):e1285. ※In case of penicillin allergy: DOXY, LVFX

• #28.

  Clinical Pearls Consider P. multocida infection when a patient with chronic lung disease presents with pneumonia. Asking about animal contact may help in determining the cause of pneumonia.

• #29.

  Louis Pasteur (1822-1895) French bacteriologist Identified Pasteurella multocida Pasteurella is highly selective for lungs with preexisting conditions Chance favors the prepared mind Itoh N, Kurai H. A case of Pasteurella multocida pneumonia needed to differentiate from non-tuberculous mycobacteriosis. IDCases. 2018 May 19;12:136-139. doi: 10.1016/j.idcr.2018.05.009. PMID: 29942772; PMCID: PMC6011017.