SAFMLS Case Study

History
• 43 year-old active duty male evaluated in the
WRAMC ER on 01 May 2010
• Lives in the Chesapeake Bay area
• Recent return from Dallas, Texas
– Fevers and chills x 1 day
– Myalgia
– Nausea with vomiting x 4 days
– 20 to 30 episodes of watery diarrhea per day
 History
• PMHX: • FHX:
– Gastro Reflux Disease – Unknown
• PSHX: • SHX:
– Inguinal hernia repair – No additional travel
• MEDICATIONS: – No sick contacts
– Nexium – Symptom onset after
– Allegra eating a seafood burrito

• ALLERGIES:
– No Known Drug allergies
 Lab
• Hematology/Chemistry
– Normal
• Microbiology
– Stool culture plate set + TCBS
• Green colonies on TCBS
• Other biochemicals
– Oxidase positive
– Lipase negative
– ONPG positive
– Gram stain: Curved & straight Gram-
negative bacilli
– Ideas on the ID?
 Vibrio spp.
• Wide variety of aquatic environments including fresh
water, brackish, saltwater
• 9 species isolated from clinical specimens
• Variety of human illness
– Gastrointestinal
• V. cholera (Pandemic diarrheal disease), V. parahaemolyticus, V.
fluvialis, V. mimicus , V. hollisae
– Soft Tissue
• V. vulnificus, V. alginolyticus, V. damsela, V. metschnikovii
– Facultative anaerobic Gram-negative rods with classic
curved morphology
– Most “halophilic” – require NaCl for growth
 Biochemical Characteristics
Test V. parahaemolyticus V. cholera Patient isolate
Growth in nutrient - + +
broth (0% NaCl)
Growth in nutrient + + +
broth (1% NaCl)
Motility + + +
Indole + + +
Oxidase + + +
Nitrate reduction + + +

Arginine - - -

ONPG - + +
Sucrose - + -
Lysine + + +
GI group: V. Cholera, V. parahaemolyticus, V. fluvialis, V. mimicus , V. hollisae
Soft Tissue group: V. vulnificus, V. alginolyticus, V. damsela, V. metschnikovii
 Vibrio mimicus
• Name – “mimics” V. cholera
– Natural Habitat
• Free living bacterium associated w/ phytoplankton &
crustaceans. Ecology similar to V. cholera
• Normal marine flora of Atlantic & Gulf coast
• Virulence Determinants
– Some harbor TCP & CTx
• Isolation & ID
– Grows well on TCBS Agar:
• Green (sucrose negative) colonies
– Lipase negative (API 20E)
– No NaCl requirement in nutrient broth
• First identified as a new species in 1981
• 21 clinical isolates submitted to the CDC
– 2 from the ears of patients with otitis
– 19 from stool specimens
• 17 patients with diarrhea (mean duration 6 days)
• 9 hospitalized
• 4 treated with antibiotics
• All survived
Van den Abeele, A.M., et al. Isolation of Vibrio mimicus from a patient with
gastroenteritis in Belgium. Eur. J. Clin. Microbiol. Infect. Dis. Vol 8; 1989: 86-87.
 ER Follow up of Mr.
Seafood Burrito
• One liter of IV fluids
• Levofloxacin
• Phenergan
• Loperamide
• Outpatient care
• 306 people attending an academic dinner
– 8 of 10 dishes prepared with seafood
• 91% - watery diarrhea
– 145 sought hospital care
– 110 treated with OTC medications
– Incubation period: 6 to 36 hours
• IV fluids and norfloxacin
• Cultures from 24 patients all positive for V. mimicus
• No deaths
• 1989: 40 different isolates
– Annual incidence estimated at 1.6/100,000
• 3 of these isolates were V. mimicus
– 28 y/o male (raw oysters)
– 71 y/o male (lobster)
– 30 y/o male (seafood)
• No mortality or serious morbidity
 Notes from the Field: Vibrio mimicus Infection
from Consuming Crayfish --- Spokane,
Washington, June 2010
• Four cases of V. mimicus
infection from consuming boiled
crayfish
• Served from cooler that
previously contained pre-cooked
crayfish but not cleaned
– Cross contamination from raw
seafood then consumed
• DNA coding for Cholera Toxin
identified in all V. mimicus
specimens

MMWR: October 29, 2010 / 59(42);1374

• Strains produce heat-
labile enterotoxin
• Two strains (61892 and
63626) from patients in
Bangladesh
– Cholera toxin-like
enterotoxin
– Biologically and
immunologically
identical
• Potential reservoir
John Snow & the Broad Street Pump
Clinical Cases in Microbiology
 Patient History
• 24 y.o. mixed Hispanic/Caucasian male
• Naval Academy midshipman
• Previously healthy
• Anemia, fatigue, 30 lbs weight loss, chills, night
sweats, low grade fevers, nausea
• Symptoms x 3 months
• Admitted for malignancy work up by heme/onc
 Patient History (Cont.)
• Only documented clinic temp. was 100.4 F
• Recently travelled to San Antonio (family), Norfolk, and
NC
• Non smoker, occasional drinker
• Currently sexually active with girlfriend. Three partners
in past 6 months
• No known drug allergies
• No other medications
• No sick contacts, no foreign travel, no IVDU, and no
animal contacts
• Consumed barbacoa and Mexican cheese candy in San
Antonio during his visit
• Family history includes Diabetes Mellitus, but no
malignancy or autoimmune dx.
 Clinical Synopsis
• Late July / Early August:
– Loss of appetite, fatigue, nausea, abdominal pain, chills
– Two weeks after returning from San Antonio
– PPI given for gastroenteritis
– WBC = 9.6, Hgb = 11.6

• Late August / Early September

– Symptoms continued
– H.pylori IgG positive, received treatment
– WBC 11.2 (11% lymphs, 79% PMN’s), Hgb = 9.5, normal AST/ALT
– Monospot positive (repeat 6 days later was negative)
– Dx: Infectious Mono.
– EBV IgG, HIV, EBV IgM, EBV PCR, RPR all negative

• Early to Mid October

– Night sweats, weight loss, myalgias
– Sore throat and submandibular LAN, left sided abdominal pain
– Given course of Medrol dose pack, reported improvement
– CMV IgG, IgM, PCR all negative
– WBC 12.4, Hgb. 8.7, CRP 8.7, ESR 120
– WBC ranged from 10-15 two days after steroids
– Viral syndrome vs. malignancy
 At time of admission
• T=100.5˚F, HR 90’s, BP=110’s/70’s, Respiratory
rate=16, and SPO2=98%
– Daily fevers (up to 102˚F) during admission
• Tired appearing
• No oral lesions or ulcers
• No lymphadenopathy
• No heart murmur documented
 Labs
• WBC 7.8 (normal diff.)
– Ranged 7.6 – 11.9 during admission
• H/H: 5.8/17.2, repeat 6.2/18.7
– MCV 81, RDW 15, Retic. 1.6%, Hemolysis w/u neg.
• CRP 12, ESR > 120
• Protein 6.6, Albumin 3.1 (c/w recent labs)
• Alk. phos. 117 (mild elevation in last 2 months)
• AST/ALT, Bilirubin, Cr. all normal
• Repeat EBV serologies, hepatitis serologies, HIV,
Parvovirus serologies, all negative, ANA 1:80
• Blood culture and bone marrow biopsy pending
 Culture Results

• Blood culture positive at 53 hours – Gram negative coccobacilli

• Bone marrow biopsy culture – Gram negative coccobacilli
 Culture results (Cont.)

Growth on chocolate
 Culture Workup
• Grew in 3 days on sheep blood, chocolate
• Coccoid to coccobacillary
• Catalase positive
• Reduces nitrate
• Oxidase positive
• Brucella spp.?
– Doxycycline and gentamicin started for possible Brucella
• Urea negative
What’s the organism ?
 Aggregatibacter
actinomycetemcomitans
• Coccobacilli, GNR, grows best in 5-10% CO2
• Oxidase positive
• Urea negative
– Other actinobacillus are urea positive
• Catalase positive (the other HACEK organisms are
negative)
• Periodontal disease, soft tissue infections,
endocarditis, brain abscess, septic arthritis
• In >50% of adults with refractory periodontitis
• Aggregate with other bacteria
 Aggregatibacter
actinomycetemcomitans
Summary of Biochemical Tests (Hacek Group)
Catalase Oxidase Urease
Haemophilus aphrophilus - - -
Aggregatibacter actinomycetemcomitans + + -
Cardiobacterium hominis - + -
Eikenella corrodens - + -
Kingella kingae - + -
 A.actinomycetemcomitans treatment
• IV Ceftriaxone is first line
– 4 wks, 6 wks in prosthetic valve
– Gent. combination not recommended
• Treatmnent for Penicillin allergic patients
– Aminoglycosides, TMP/SMX, tetracyclines,
azithromycin, choramphenicol, aztreonam
• Drug susceptibility is difficult to detect
• Patient started on ceftriaxone 2 gm IV daily
 Dx: = A. actinomycetemcomitans
endocarditis with perivalvular abscess
• Aortic root abscess in native valve is rare (2)
• About 100 case reports of endocarditis
• Insidious onset, time of diagnosis = 13 weeks
• Most common among HACEK organisms
• Frequent embolizations / large vegetations
• Case series (Kaplan et al. Rev. Infect Dis 1989 / Paturel et al. Clin Micro Infect 2004)
– 45% with periodontal disease or recent dental work
– 60% with valve disease, 25% prosthetic valves
– Surgery in 23%
– 1/2 with fevers and 1/3 with splenomegaly
– 18% mortality
 Hospital course
• Patient referred to CT surgery
• Scheduled for Valve replacement
• Brain MRI and eye exam unremarkable
• Repeat blood cultures negative
• Bone marrow biopsy revealed no malignancy
 Clinical Cases in Infectious
Diseases
COL Helen B. Viscount, PhD, D(ABMM), SM(ASCP)
Medical Director, Infectious Disease Laboratories
Walter Reed army Medical Center
Case Records of the Massachusetts General Hospital

A 77-YEAR-OLD MAN WITH DYSPNEA,

WEAKNESS, AND DIAPHORESIS
 PMH
• Hypothyroidism
• Hyperlipidemia
• Hypercholesterolemia
• Hypertension
• Transient ischemic attack, a stroke while receiving
therapeutic anticoagulation
• Diverticular bleed 2 months before admission
• Appendectomy 3 months before admission
 SH
 No known allergies
 Retired, had returned from a prolonged wintertime trip to
Florida 3 weeks before admission
 Lived with his wife in a wooded suburban community in the
Northeast
 No pets
 Patient and wife traveled extensively in US
 Stopped smoking 35 years earlier, did not drink alcohol or use
illicit drugs
 Children healthy
 No contact with sick persons
 PE
 On examination, patient diaphoretic
 Weight 160 lbs, temp 97.9°F, BP 90/54 mm Hg
 Oxygen saturation 95% while patient breathing 40%
oxygen by face mask
 Diarrhea
 Digoxin level therapeutic
 Thyrotropin level normal
 Remained fatigued and dyspneic after minimal activity
 Labs
• Serum levels of total and direct bilirubin,total protein,
albumin, cholesterol, low-density lipoprotein, amylase,
and lipase normal
• Urinalysis
 clear yellow urine
 5.5 pH
 1.015 specific gravity
 1+ ketones
 3+ blood
 2+ protein
 5-10 RBCs and 0-2 WBCs/hpf
 Transferred to CCU
• 16 hrs after admission
• Prolonged episode of ventricular tachycardia (190
beats/min) and became unresponsive
• Trachea intubated
• IV fluids and vasopressors administered
• TTE - no vegetations
• Administered vanc, cefipime and metronidazole
• Abdominal radiograph
 No evidence of bowel obstruction or perforation
• Culture of blood and sputum
• Temp 102.9°F
 Differential Diagnosis
 Patient's initial presentation with weakness and worsening
dyspnea consistent with exacerbation of congestive heart failure
 Diaphoresis, development of fever & hypotension raise likelihood
that overwhelming systemic infection cause of cardiac
decompensation
 Notable laboratory findings
 Left shift
 Absolute lymphopenia
 Azotemia
 Increased aminotransferase levels
 Normal levels of alkaline phosphatase and bilirubin
 Elevated lactate dehydrogenase levels
 Differential

There are many causes of septic shock that are

consistent with patient’s presentation
Immunosenescence, a decline in immune system
function with age, affects both innate & adaptive
immunity
 May predispose the elderly to more frequent and more
severe infections than the non-elderly
Infections in elderly with causes of septic shock &
patient's presentation
 What infectious processes could be involved?
 Five Infectious Diseases

• Tickborne illnesses
• Pneumonia
• Infective endocarditis
• Infectious diarrhea
• Bacteremia
 R/O tickborne illnesses

 Lived in a wooded area of the Northeast and presented in

midspring, so r/o human infections that result from tick
exposure
 Could be at risk for Lyme disease
 No history of early localized skin manifestations of Lyme disease
 Disseminated infection leading to myocarditis without
concomitant neurologic findings rare
 Diarrhea raises the possibility of typhoidal tularemia
 Does not have the cholestasis, jaundice, or pulmonary
involvement seen in severe cases
 RMSF can present with elevated aminotransferase levels,
thrombocytopenia, and infrequently azotemia
 90% rash
 Incidence low
 R/O Tickborne Infection
 The vector epidemiology and clinical presentation in
this case are most supportive of a diagnosis of
 Babesiosis
 Ehrlichiosis
 Anaplasmosis
 Differential
 Babesiosis
 Absence of hemolysis effectively rules out babesiosis

 Ehrlichiosis
 Since Ehrlichia is most commonly found in the south
central states of Missouri, Oklahoma, Tennessee, and
Arkansas, not likely to be cause of patient's illness
 Anaplasmosis (human granulocytic ehrlichiosis)
 Although Ehrlichia infection can occur in the Northeast,
Anaplasma is more common pathogen in Massachusetts
 Peripheral Blood Smear
 (Panel A, arrow)
 Decreased number of
platelets and two neutrophil
band forms, one of which
contains a round bluish-
purple inclusion adjacent to
the nucleus
 (Panel B, arrows)
 Two other neutrophil band
forms contain morula
(intracytoplasmic bluish-
purple inclusions)
Tsibris AM et al. N Engl J Med 2011;364:759-767
 Molecular Diagnostics

• A specimen of blood was sent to a reference

laboratory for PCR, which was positive for A.
phagocytophilum DNA and negative for Ehrlichia.
• This confirmed the diagnosis of anaplasmosis.
Do Anaplasma organisms have any resistance to
doxycycline?

• Doxycycline resistance has not been described

• Empirical doxycycline therapy will treat tickborne illnesses
such as Lyme disease, Ehrlichia, or Anaplasma but would be a
poor choice for treatment of babesiosis or tularemia
• Therefore, it is important to make a specific diagnosis.
 Summary

• Patient's clinical presentation, laboratory abnormalities,

and acute decompensation in the context of known
cardiac disease and limited cardiac reserve are all
consistent with a severe infection with Anaplasma.
• Diagnostic test was peripheral-blood smear with
morulae seen in neutrophils
• Confirmed by molecular testing
 Back to the patient

 Once diagnosis of anaplasmosis made,

administration of doxycycline begun.
 Since the patient was critically ill, empirical
antimicrobial therapy with vancomycin and
cefepime was continued until he was clinically
stable.
 He was treated with doxycycline for approx10 days
 He spent several days in the coronary care unit, and
had a difficult time weaning from ventilator.
 Back to the patient

 He eventually required a tracheostomy

 Approx 1 month after admission, he was discharged
from the hospital with a tracheostomy mask to
administer oxygen through the tracheostomy
 He was readmitted to the hospital several times for
dyspnea
 Five months after initial presentation, he died at a
rehabilitation facility
 No postmortem examination
Tommy Hing Cheung Tang, M.R.C.P.,
and Owen Tak Yin Tsang, M.R.C.P.
N Engl J Med 2011; 364:e3

Fungal Infection from

Sweeping in the Wrong Place
 A 43-year-old man presented with fever, malaise, a
nonproductive cough, and skin lesions near the left
eyelid and eyebrow (Panel A) and left antecubital fossa
(Panel B).
 Histopathological analysis of the
biopsy specimen

• The symptoms had developed

during the course of several weeks.
The patient underwent a biopsy of
the facial lesion.
• (Panel C, arrow; hematoxylin and
eosin) spherules containing
endospores
 Patient history
• Antibodies to coccidioides species present in his serum.
• Patient had no history of travel to an area where
coccidioidomycosis is endemic
• He worked as a driver unloading containers at a port.
• He occasionally swept out containers shipped from the
United States.
• Infective arthroconidia may have been inadvertently
transported along with goods shipped to Hong Kong and
then inhaled by our patient after being aerosolized by his
broom.
• After approximately 1 year of therapy with fluconazole, he
was completely asymptomatic.
Deer-Associated Parapoxvirus
Papulonodular Lesions

• Panel A .The photograph of the right

index finger of Patient 1 was taken
approximately 5 weeks after exposure

• Panel B. The photograph of the left

index finger of Patient 2 was taken
approximately 9 weeks after
exposure.
Roess AA et al. N Engl J Med 2010;363:2621-2627.
EMs of Biopsy Tissue

• Examination of thin
sections of biopsy tissue
revealed ovoid virions
suggestive of parapoxvirus,
measuring approximately
258 nm by 113 nm in
Patient 1 (Panel A) and 250
nm by 130 nm in Patient 2
(Panel B).
Comfortably Numb
 Comfortably Numb
• 21 year old man
– Treated by his family physician on and off for 3
months, referred to ID, admitted to the hospital
for weakness, fatigue, 50 lb weight loss
– Social hx – experimental IVDU and other assorted
drugs
 Comfortably Numb

psychedelic
mushrooms
 Comfortably Numb
– Complaints of fevers, abdominal pain, and
diarrhea for 2.5 months
– He would occasionally go see a doctor concerning
this problem
– He lost 30 pounds in the first 10 days
– Constant diarrhea will do that to you!
 Comfortably Numb
– Progressively worsened and unable to care for
himself, moved back in with his parents.
– Weakness, fatigue, and shortness of breath
basically requiring full-time care from his parents.
– He only got out of bed to go to the bathroom and
even then he had a bedside urinal to use.
 Comfortably Numb
– Arthritic symptoms, pain in his fingers and toes,
severe symmetrical pain in his feet, couldn’t bare
for anyone to touch the bottom of his feet
– Dark urine – severely dehydrated or hematuria
– No health insurance – delay in getting proper care
– Physical exam: pale, weak, slight fever, diminished
breathing sounds, systolic murmur
 Comfortably Numb
• What is your differential?

• Most probable causative agent?

 Comfortably Numb
– TEE – vegetations on bicuspid valve
– Dx – acute endocarditis
– The pt did have a previous heart condition (info
not provided) and some GI problems, that were
exacerbated by the mushrooms
 Comfortably Numb
• Blood culture came up positive for
Streptococcus mitis!
• Were you thinking of something else?
Probably…………..
 Endocarditis
• Transient bacteremia may occur following IV drug
use.
• These organisms adhere readily to thrombotic
lesions on the heart valve.
• The adherent bacteria begin to grow and platelet
and fibrin deposition continues, resulting in an
enlarging vegetation.
• As this vegetation grows, small pieces break off
which contain fibrin, platelets, and bacteria and
then seed other areas of the vascular bed. These
are called septic emboli.
 Endocarditis
• The key to the diagnosis is detection by
echocardiogram of a vegetation on the aortic
heart valve and presence of continuous
bacteremia with positive blood cultures.
These patients have an enlarged spleen and
presence of a heart murmur. They often have
skin hemorrrhages due to embolic events.
• The patient was noted to have Janeway
lesions on his feet
 Endocarditis
• Common signs
 Endocarditis
• Infection of the endocardial surface of the heart -
severe valvular insufficiency, which may lead to
intractable congestive heart failure and
myocardial abscesses
• Endocarditis can involve the heart muscle, heart
valves, or lining of the heart. People with
endocarditis have some abnormality of a heart
valve
• Nosocomial infective endocarditis (NIE),
intravenous drug abuse (IVDA) IE, and prosthetic
valve endocarditis (PVE)
 Endocarditis
• Pathology
– All cases of IE develop from a commonly shared
process
– Bacteremia
– Adherence
– Eventual invasion of valvular leaflets
 Endocarditis
• Causes and risks
– Injection drug use
– Permanent central venous access lines
– Prior valve surgery
– Recent dental surgery
– Weakened valves
 Endocarditis
• Symptoms
– Abnormal urine color
– Chills and fever (common)
– Excessive sweating (common)
– Fatigue
– Joint pain, muscle aches and pains
– Night sweats
– Paleness
– Shortness of breath with activity
– Swelling of feet, legs, abdomen
– Weakness
– Weight loss
 Endocarditis
• Signs
– History
• Congenital heart disease
• Intravenous drug use
• Recent dental work
• Rheumatic fever
– Heart murmur
– Splinter hemorrhages, Roth spots, Osler’s nodes,
Clubbing, Janeway lesions
 Endocarditis
• Causes
– S aureus is the most common bacteria found in
patients with IVDA
– CoNS are the most frequent cause of PVE (30%).
– NIE obviously are related to the type of underlying
bacteremia. The gram-positive cocci (ie, S aureus,
CoNS, enterococci, nonenterococcal streptococci) are
the most common pathogens.
– Culture negative (initially) may be caused by fastidious
organisms (HACEK group, Brucella, Bartonella, etc)
 Streptococcus mitis
MSA Bile
Organism Hemolysis Bacitracin SXT
growth Esculin
Streptococcus oralis alpha neg neg S S
Streptococcus bovis alpha neg pos R R
Streptococcus equi beta neg neg S S
Enterococcus R <20
alpha pos pos R
faecalis mm
Streptococcus mitis alpha neg neg R R
 Streptococcus mitis
• Streptococcus mitis generally colonizes hard
surfaces in the oral cavity such as dental hard
tissues as well as mucous membranes and are
part of the oral flora.
• It may commonly cause bacterial endocarditis.
• S. mitis is usually an etiologic agent in
odontogenic infection and endocarditis and only
in some cases have been acknowledged as
respiratory pathogens. The most common host is
humans.
 Streptococcus mitis
• The major interaction in the pathogenesis of
infective endocarditis is the direct binding of
bacteria to platelets.
• S. mitis is closely related to Streptococcus
pneumoniae. Homologous recombination has
been observed between the 2 organisms. The
transfer of genetic determinants from S. mitis to
S. pneumoniae contributes to penicillin resistance
in the pathogen
 Streptococcus mitis Endocarditis
Report of 17 Cases
• Kevin B. Rapeport, MBBCh(Rand); José A. Girón, MD; Fred Rosner, MD
• Arch Intern Med. 1986;146(12):2361-2363.
– Seventeen patients with Streptococcus mitis endocarditis
were treated at a municipal hospital over a three-year
period. Thirteen patients were intravenous drug addicts.
Streptococcus mitis has a predilection for right-sided
endocarditis in intravenous drug addicts and left-sided
endocarditis in non-drug addicts. Streptococcus mitis is
highly susceptible to therapy with penicillin G potassium
(minimal inhibitory concentration less than or equal to 0.1
mg/L of penicillin in all of these 17 cases), and four to six
weeks of therapy is safe and effective.
 JAMA. 2001;285(17):2195 .
• Endocarditis Due to Streptococcus mitis With
High-Level Resistance to Penicillin and
Ceftriaxone
• To the Editor: Antimicrobial resistance is an
increasing problem in the treatment of infections
due to Streptococcus pneumoniae.​ Such
resistance has also recently been reported in the
United States among the viridans group of
streptococci, especially Streptococcus mitis.
 What About the Mushrooms?
• Multiple websites on the internet
• “Psilocybin” – main active agent, several
varieties
• Ingested
• Illegal and Dangerous
– Interaction with other substances
– They can go bad and grow “moldy”
– Poisonous vs “magic” mushrooms
Questions?
 Comfortably Numb
Pink Floyd
• Hello?
Is there anybody in there?
Just nod if you can hear me.
Is there anyone at home?
Come on, now,
I hear you're feeling down.
Well I can ease your pain
Get you on your feet again.
Relax.
I'll need some information first.
Just the basic facts.
Can you show me where it hurts?
There is no pain you are receding
A distant ship, smoke on the horizon.
You are only coming through in waves.
Your lips move but I can't hear what you're
saying.
When I was a child I had a fever
My hands felt just like two balloons.
Now I've got that feeling once again
I can't explain you would not understand
This is not how I am.
I have become comfortably numb.
• O.K.
Just a little pinprick.
There'll be no more aaaaaaaaah!
But you may feel a little sick.
Can you stand up?
I do believe it's working, good.
That'll keep you going through the show
Come on it's time to go.
There is no pain you are receding
A distant ship, smoke on the horizon.
You are only coming through in waves.
Your lips move but I can't hear what you're
saying.
When I was a child
I caught a fleeting glimpse
Out of the corner of my eye.
I turned to look but it was gone
I cannot put my finger on it now
The child is grown,
The dream is gone.
I have become comfortably numb.
Dust in the Wind
Wild Stallyns in the making…….
 Dust in the Wind
• 78 y/o male veteran seen at VA
– 10 days prior fever, sweating extremities (legs)
– DVT in left leg, multiple pulmonary emboli in
chest scan
– Developed fever and chills on day 6 of
hospitalization
 Dust in the Wind
• Extensive medical history
– Surgery for perforated ulcer, spleen removed,
small bone tumor in pelvis (benign) GERD,
frequent alcohol user, BPH, depression, skin
cancer, seizures, hypoglycemic
• Rx – typical VA pharmacy
– (10+ drugs)
• Social – lives alone 25 yrs

“This is Dave Beeth Oven, Maxine of Arc, Herman

the Kid, Bob “Genghis” Khan. Socrates Johnson,
Dennis Frood. And, uh… Abraham Lincoln.”
 Dust in the Wind
• Pets – dog, most faithful companion
– He loves that dog more than anything
• Physical exam
– Multiple scratches on arms and shoulder from the dog,
recently bitten during play, thin, older with a scar on
abdomen, some edema
• Travel Hx – none except during military days in South
Pacific as submariner
 Dust in the Wind
• Differential diagnosis
– Tuberculosis
– Bacterial pneumonia
– Viral pneumonia
– Lung nodules
– Unexplained suppurative disease
– Cavitating pulmonary disease
 Dust in the Wind
• Blood and urine cultures taken
• BC (+) urine (-)
• GNR, resistant to imipenem and polymixin B
• Burkholderia pseudomallei
• Meloidosis – “Vietnamese time bomb”
– Endemic to South Pacific, SE Asia, potentially long
incubation period
 Literature

• Cutaneous Melioidosis in a Man Who Was Taken as a

Prisoner of War by the Japanese during World War II
– JCM 43:970-972
• 82 y/o male
– Hx - diabetes, hypertension, chronic renal insufficiency, benign prostate hypertrophy (BPH)
coronary artery disease
• Non-healing ulcer from dog bite
• GNR, bipolar staining
• Resistant to aminoglycosides
• POW – Java, Singapore, Malaysia, Burma, Thailand
• CBC, ESR, LFTs – normal
• Wound culture positive
• Rx – long term therapy with imipenem/ceftazidime
 What is Melioidosis?
• Bacterial disease affecting humans and several animal
species
– Aliases – Whitmore’s disease, pseudoglanders, nightcliff
gardener’s disease, paddy-field disease
• Infections can be subclinical, acute, chronic, or fatal
septicemia
• Can affect almost any organ – mimicking other diseases
– “the great imitator”
– Infectious - Syphilis, Lyme disease, Nocardiosis,
Tuberculosis
– Non-infectious - Lupus, Celiac disease, Sarcoidosis,
Multiple Sclerosis, Fibromyalgia
 Epidemiology
• Infection by Burkholderia pseudomallei
• Endemic to SE Asia, China, Indian
subcontinent, Australia
– Caribbean, Middle East, South America,
Singapore, Taiwan
• Very few cases found in the US
– Reportable disease (CDC) 1-5 /year
• Affects both humans (pseudoglanders) and
animals (glanders)
Endemic Areas
 Transmission
• B. pseudomallei is a saprophytic bacterium
widespread in soil and muddy water in endemic
areas, common in moist clay soils
• Infections occur by ingestion, inhalation, wounds
and abrasions
• Most people become infected directly from the
environment
– Skin wounds major route – (war wounds)
– Inhalation – pneumonic form (during periods of heavy
rainfall and strong winds)
– Ingestion of contaminated water
 Organism Characteristics

• Burkholderia pseudomallei is an organism that has been

considered as a potential agent for biological warfare and
biological terrorism.
– Category B agent
• Are moderately easy to disseminate;
• Result in moderate morbidity rates and low mortality rates; and
• Require specific enhancements of CDC's diagnostic capacity and enhanced disease
surveillance.

• B. pseudomallei is a facultative intracellular pathogen. It is

pathogenic because of its ability to invade, resist serum, and
survive intracellularly.
• It is easily contracted by inhaling dust containing the
bacteria or by having contact between contaminated soil
and cuts or scrapes of the skin
 Organism Characteristics
• B. pseudomallei survivability
– RT water 8 months
– Muddy water 7 months
– Antiseptic and detergent solutions
– pH 4.5
– Soil dessication, less than 10% water
– Can enter the cells of protozoa (Acanthamoeba)
– Environmental stresses
 Incubation Period
• Naturally acquired infections
– Variable depending on level of exposure
– Less than a day to months
– Several months to years
• 29 years, 62 years – “Vietnamese time bomb”
• Artificially acquired infections (BW agent)
– Aerosolized 10-14 days
 Infection Types
• Acute, localized infection: nodule and results from inoculation
through a break in the skin. The acute form of melioidosis can
produce fever and general muscle aches, and may progress
rapidly to infect the bloodstream.
• Acute bloodstream infection: Patients with underlying illness
such as HIV, renal failure, and diabetes are affected usually
resulting in septic shock. The symptoms of the bloodstream
infection vary depending on the site of original infection, but
they generally include respiratory distress, severe headache,
fever, diarrhea, development of pus-filled lesions on the skin,
muscle tenderness, and disorientation. This is typically an
infection of short duration, and abscesses will be found
throughout the body.
 Infection Types
• Pulmonary infection: varies from mild bronchitis to severe
pneumonia. Onset accompanied by a high fever, headache,
anorexia, and general muscle soreness. Chest pain is common,
but a nonproductive or productive cough with normal
sputum.
• Chronic suppurative infection: Chronic melioidosis is an
infection that involves the organs of the body. These typically
include the joints, viscera, lymph nodes, skin, brain, liver, lung,
bones, and spleen.
• Some infected patients remain asymptomatic for years and
develop disease when they become immunosuppressed from
another condition
 Clinical Manifestations

• Infection of the lungs,

forming a cavity of pus.
– Pneumonia is the most
common symptom of
melioidosis.
• Other symptoms include
skin ulcers or abscesses
(swollen area with pus),
• Rare neurological diseases
such as brainstem
encephalitis and acute
paraplegia, and abscesses
in the prostate, spleen,
kidney, and liver.
 Diagnostic Tests
• Melioidosis is diagnosed by isolating
Burkholderia pseudomallei from the blood,
urine, sputum, or skin lesions.
• Selective media – Ashdown’s
• Detecting and measuring antibodies to the
bacteria in the blood is another means of
diagnosis.
 Diagnostic Tests
• Bipolar staining
• Oxidase (+)
• Motile
• Growth on MAC (+)
• Resistant to polymixin B
• OF glucose, maltose, lactose, mannitol (acid)
• Wrinkled colonies
• Cream or tan pigment
 Treatment
• Most cases of melioidosis can be treated with appropriate
antibiotics: imipenem, penicillin, doxycycline, amoxicillin-
clavulanic acid, azlocillin, ceftazidime, ticarcillin-clavulanic
acid, ceftriaxone, and aztreonam.
• Treatment should be initiated early in the course of the
disease. Although bloodstream infection with melioidosis can
be fatal, the other types of the disease are nonfatal.
• The type of infection and the course of treatment can predict
any long-term sequelae.
• Pulmonary resection or abscess drainage helps
 Prevention
• There is no vaccine for melioidosis.
• Prevention of the infection in endemic-disease areas can be
difficult since contact with contaminated soil is so common.
Persons with diabetes and skin lesions should avoid contact
with soil and standing water in these areas. Wearing boots
during agricultural work can prevent infection through the
feet and lower legs.
• In health care settings standard precautions can prevent
transmission. (No plate sniffing!)
 Morbidity and Mortality
• More than 70% of all cases occur in people
who have other illnesses
– Diabetes, thallassemia, kidney disease, chronic
lung disease, cancer, alcoholism steroid therapy
• Mortality varies by health care availability
– Rapid diagnosis – better survival rates
– >90% untreated septicemia, septic shock 95%
– Thailand (30 – 47%), Australia (20%)
 Gee Whiz File
• B. pseudomallei and B. cepacia are both associated with
infection of the lung.
• Large number of patients infected by B. pseudomallei usually
end up with pneumonia and those infected by B. cepacia (CF
patients) usually die of chronic lung disease.
• There is a growing concern that the Burkholderia genus is
being used to develop fungicides and biodegration agents for
commercial use. If this continues, the spread of Burkholderia
may become epidemic and it will become even harder to
develop a vaccine.
 "I'm trying to think, don't confuse me with facts."
— Plato
http://www.youtube.com/watch?v=BvYRqsRZ7vE&feature=player_detailpage
 Dust in the Wind
Kansas

• I close my eyes, only for a moment, and the moment's gone

All my dreams, pass before my eyes, a curiosity
Dust in the wind, all they are is dust in the wind.
Same old song, just a drop of water in an endless sea
All we do, crumbles to the ground, though we refuse to see
Dust in the wind, all we are is dust in the wind
[Now] Don't hang on, nothing lasts forever but the earth and sky
It slips away, and all your money won't another minute buy.
Dust in the wind, all we are is dust in the wind
Dust in the wind, everything is dust in the wind.
Night Fever
 Night Fever
• 26-year-old Thai female
– Presents to the ER with high fever x 5 days and
epigastric pain and headache x 1 day
– Noticed bleeding gums and some noticeable
petechiae on her face, forearms, and lower legs.
– G1P0 31 weeks pregnant
• Very good prenatal care from week 12 to present
– Admitted to the hospital
 Night Fever
• Admitted to the hospital
– Temperature was 37°C, BP, pulse, respiratory rate -
normal
– Mild dehydration, normal breathing and heart
sounds
– Palpable liver
– Fetal heart rate was 144 beats/min.
– Petechiae sized 1–2 mm noted around her face,
forearms and shins
 Night Fever
• Laboratory results:
– Hemoglobin 11.9 g/dl
– Hematocrit 35%, Complete blood count (CBC) Adults
Male Female

– White blood cells Hemoglobin (g/dl)

13.5 -
16.5
12.0 - 15.0

count 7,440/mm3 with Hematocrit (%) 41 - 50 36 - 44

RBC's ( x 106 /ml) 4.5 - 5.5 4.0 - 4.9
50% neutrophil, 45% RDW (RBC
< 14.5
lymphocytes and 3% distribution width)
MCV 80 - 100
atypical lymphocytes; MCH 26 - 34

– Platelet count was

MCHC % 31 - 37
Platelet count 100,000 to 450,000

10,100 /mm3
 Night Fever
• First 24 hours
– IV fluid replacement
– She was put under close observation for vital signs
and bleeding precaution.
– Twenty-four hours later, the epigastric pain
disappeared and the vital signs were within
normal limits.
– The hematocrit was 30% and the platelet count
was 6,320
 Night Fever
• On the third day, she
gradually recovered and
had an itching convalescent
rash on both shins.
• The hematocrit was 31%
with platelet count 15,000
/mm3.
• She was discharged on the
fourth day.
 Differential
Symptom review Potential causes
• High fever • Meningitis (meningococcal)
• Epigastric pain • RMSF
• Headache
• Rickettsial origin
• Bleeding gums
• Petechiae (small) • Viral hepatitis
• Palpable liver • ????
• Low hemoglobin/hematocrit
(anemia)
• Low platelets (clotting issue)
 Night Fever
• Previous medical history - unremarkable
– But then again, she lives in Thailand………
• What is endemic to Thailand?
– Mosquito borne diseases
• Malaria, dengue fever, Japanese encephalitis
– Other diseases
• Cholera, TB, pertussis
– Food and water associated illness
• Cholera, hepatitis A, schistosomiasis, typhoid
– Personal contact
• Hepatitis B, HIV

1975 JC Penney catalog

 Night Fever
• The physical examination, complete blood
counts as well as serology confirmed dengue
fever.
 Night Fever
• On 1 week follow-up, she was
healthy and hematocrit was 32%
with platelet count 354,000 /mm3.
• Serologic study of paired serum
detecting IgG antibody titer by the
hemagglutination inhibition test
indicated secondary viral dengue
serotype 2 infection.
 Night Fever
• At the 39 weeks' gestation, she delivered a
healthy female baby weighing 2,630 grams by
vaginal route with APGAR scores 9 and 10 at 1
and 5 minutes, respectively.
• No abnormality in newborn was detected.
 Dengue Fever
• Dengue is an Aedes aegypti mosquito-borne infection,
caused by dengue virus serotypes 1,2,3 and 4.
– No cross protective immunity
• It is a major public health problem in tropical countries
• In a small proportion of cases, the virus causes increased
vascular permeability that leads to disseminated
intravascular coagulation (DIC) known as dengue
hemorrhagic fever (DHF).
• In 20-30% of DHF cases, the patient develops shock, known
as the dengue shock syndrome (DSS). In contrast to classic
dengue, DHF/DSS is predominantly a disease of children.
 Dengue Transmission Vectors
• Aedes aegypti and Aedes albopictus
Aedes albopictus Female Feeding
Aedes aegypti Eggs
 Dengue Fever
• Symptoms begin after a 5- to 10-day incubation period.
• DHF/DSS usually occurs during a second dengue infection
in persons with preexisting actively or passively
(maternally) acquired immunity to a heterologous dengue
virus serotype.
• Illness begins abruptly with a minor stage of 2-4 days’
duration followed by rapid deterioration.
• Increased vascular permeability, bleeding, and possible
DIC may be mediated by circulating dengue antigen-
antibody complexes, activation of complement, and release
of vasoactive amines.
 Dengue Fever
• Common symptoms
– Fever, abrupt onset, rising to 39.5-41.4°C
– Accompanied by frontal or retro-orbital headache
– Lasts 1-7 days, then defervesces for 1-2 days
– Biphasic, recurring with second rash but not as
high
– Bone pain aka “break bone fever”
 Dengue Fever
• High fever and at least two of the following:
– Severe headache
– Severe eye pain (behind eyes)
– Joint pain
– Muscle and/or bone pain
– Rash
– Mild bleeding manifestation (e.g., nose or gum
bleed, petechiae, or easy bruising)
– Low white cell count
 Dengue Fever
• Physical Exam
– Fever
– Signs of intravascular volume depletion
– Hypotension with narrowed pulse pressure
– Delayed capillary refill
– Hemorrhagic manifestations
– Positive tourniquet test
• assesses fragility of capillary walls and is used to identify thrombocytopenia
– Petechiae, purpura, epistaxis, gum bleeding, GI bleeding, menorrhagia
– Rash
– Hepatomegaly (inconsistent)
– Generalized lymphadenopathy
 Dengue Fever
• Lab testing
• Laboratory diagnosis includes isolation of the
virus, using serological tests, or molecular
methods.
• Classical testing algorithms of dengue:
– MAC Elisa
– IgG Elisa
– Plaque Reduction and Neutralization Test (PRNT)
 Dengue Fever
• Lab studies
– Isolation of virus in serum and detection of
immunoglobulins (IgM and IgG) by enzyme-linked
immunosorbent assay (ELISA) antibody capture,
monoclonal antibody, or hemagglutination
– Complete blood count
– Hemoconcentration (hematocrit increased 20%)
– Thrombocytopenia (platelet count <100 x 109/L)
– Leukopenia
 Dengue Fever
• Emergency Department Care:
– Supportive therapy
– IV access, O2, and monitoring are helpful.
– IV crystalloids may be necessary for hypotension; central
line may be needed. Correct electrolyte abnormalities and
acidemia.
– Implement therapy for DIC if indicated.
– Corticosteroids are not helpful.
– No antiviral therapy is available.
Dengue Fever Globally
 Dengue Hemorrhagic Fever
• Patients with DHF may have fever lasting 2 to 7 days and a
variety of nonspecific signs and symptoms. At about the time
the fever begins to subside, the patient may become restless
or lethargic, show signs of circulatory failure, and experience
hemorrhagic manifestations.
• The most common of these manifestations are skin
hemorrhages such as petechiae, purpura, or ecchymoses, but
may also include epistaxis, bleeding gums, hematemesis, and
melena.
• DHF patients develop thrombocytopenia and
hemoconcentration, the latter as a result of the leakage of
plasma from the vascular compartment.
 Dengue Shock Syndrome
• The condition of these patients may rapidly evolve into
dengue shock syndrome (DSS), which, if not immediately
corrected, can lead to profound shock and death.
• Advance warning signs of DSS include severe abdominal pain,
protracted vomiting, marked change in temperature, or
change in mental status.
• Early signs of DSS include restlessness, cold clammy skin, rapid
weak pulse, and narrowing of pulse pressure and/or
hypotension. Fatality rates among those with DSS may be as
high as 44%. DHF/DSS can occur in children and adults.
MMWR July 23, 2010 / 59(28);878
• Dengue Epidemic --- Puerto Rico, January--
July 2010
• Dengue has been endemic in Puerto Rico for 4 decades.
Approximately 6000 cases
Florida
• Department of Health officials learned last week of the four cases, which
are the first in a decade to be contracted locally. They announced
Thursday two confirmed and two unconfirmed cases of dengue fever last
month in the same neighborhood. All four have recovered.
• The Health Department urged people to protect themselves from
mosquitoes to avoid getting the disease and, for those with the disease, to
avoid spreading the disease.
• "People are communicable from the time they're bit to the time they get
sick," Berman said. "The danger is there are other people who are
walking around without being aware they're carrying the virus during the
incubation period early on."
• 29 March 5th case noted
• A Wisconsin doctor initially diagnosed illness in the Pearl City woman,
who developed a high fever while visiting in Wisconsin and was
hospitalized, state Epidemiologist Sarah Park had said.
• All four people complained of similar symptoms: fever, body ache, pain
in the back of the eye and rash, she said.
• Park and Berman said doctors in Hawaii might not initially suspect dengue
fever when a patient comes in with high fever without runny nose or
bronchitis. But now that the Health Department has alerted doctors here,
they will consider dengue.
• The Centers for Disease Control says the Aedes albopictus, which is the
main transmitter of the illness in Hawaii, is an Asian species of mosquito
that is well established in the state.
 Avoiding
• Wear protective clothing especially long-sleeved
clothing and socks.
• Use insect repellent and coils.
• Employ mosquito netting around sleep and lounging
areas.
• Avoid going out at night and just before dawn.
• Coolers, flower pots, cans, eats should be emptied or
covered all the time and cleaned on regular basis.
Dengue Fever Awareness
 Eradication
• Spraying pesticides, eliminating standing
water sources
 Night Fever
Bee Gees
• Listen to the ground: there is movement all around.
There is somethin’ goin' down, and I can feel it.
On the waves of the air, there is dancin' out there.
If it's somethin' we can share, we can steal it.
And that sweet city woman, she moves through the light,
Controlling my mind and my soul.
When you reach out for me, yeah, and the feelin' is right,
The night fever, night fever: we know how to do it.
Gimme the night fever, night fever: we know how to show it.
Here I am, prayin' for this moment to last,
Livin' on the music so fine, borne on the wind,
Makin' it mine.
The night fever, night fever: we know how to do it.
Gimme the night fever, night fever: we know how to show it.
In the heat of our love, don't need no help for us to make it.
• Gimme just enough takin’ us to the mornin'.
I got fire in my mind. I get higher in my walkin',
And I'm glowin' in the dark; I give you warnin'.
And that sweet city woman, she moves through the light,
Controlling my mind and my soul.
When you reach out for me, yeah, and the feelin' is right,
The night fever, night fever: we know how to do it.
Gimme the night fever, night fever: we know how to show it.
Here I am, prayin' for this moment to last,
Livin' on the music so fine, borne on the wind,
Makin' it mine.
Night fever, night fever: we know how to do it.
Gimme the night fever, night fever: we know how to show it.
Gimme the night fever, night fever: we know how to do it.
Gimme the night fever, night fever: we know how to show it.
Gimme the night fever, night fever: we know how to do it.
The Joker
 The Joker
• 50 year old female – very active physically,
mountain biker
– Got run off the road
– Extensive injuries to both legs
– Left leg tibia plateau fix
– Right leg de-gloving procedure
• Debride the leg wound of rocks and other debris
 What is a tibial plateau fracture?
• The tibial plateau is the upper
surface of the tibia or shin bone.
It is prone to becoming fractured
in high velocity accidents such
as those associated with skiing,
horse riding and certain water
sports.
• The bone may break into two or
more fragments requiring
surgery to re-fix the fragments in
place. t
 The Joker
• 3 months later, she observed
some red raised bumps on her
lower right leg, which resolved
themselves over a few days and
she thought nothing of it
• About 3 months after that, the
red raised bumps returned, only
this time they were also hot and
tender to the touch
 The Joker
• She mentioned the problems
to another HCP friend of hers
(gynecologist) who treated
her with ultrasound and the
bumps went away
• The next month, they came
back again and she used the
same treatment with the
same results
 The Joker
• A few weeks later she
developed what her physician
friend called a ganglional cyst
which they treated with a
cortical steroid injection
• The following month, she
presented to her friend again
with a 2 x 3 cm mass on her
patella, which they thought
looked like cellulitis, but it was
a cyst that was filled with fluid
 The Joker
• They aspirated off 1 ml of
serosanguinous fluid and
submitted it for culture. That
culture was negative for growth.
A couple of months later, she had
a 3 x 4 cm lesion on the same
knee, more lateral this time and
they again aspirated off about 4
ml of clear fluid which turned out
to be culture negative.
 The Joker
• One week later, in the middle
of a bike race, she developed
a very tender swollen knee.
• Her physician friend
prescribed levoquin for her.
1 week later she developed 2
lesions on her knee which
this time were curious in
nature.
 The Joker
• They called it a bursa
around the knee joint and
the two lesions were
connected, meaning that
you could push on one of
them and the fluid would
go to the other lesion.
This time they aspirated
off 13 ml of a pustular
fluid for culture.
 The Joker
• Gram stain
 The Joker
• Culture plate
 The Joker
• One week after the drainage, she developed
shortness of breath and chest pain and the
lesions appeared on both legs. These were
red nodular patches on her legs. 1 week after
that she developed what they called
erythema nodosum.
 The Joker
• The organism was partially acid-fast.
• Gram stain results and presumptive diagnosis.
• Final disposition:
–Nocardia farcinica
 Nocardia - Epidemiology

• Soil organism, ubiquitous in nature

• Plant debris/splinters
• Most common aerobic
Actinomycete
• Usually affects severely
immunocompromised patients
• Men more commonly affected
 Typical Diagnosis

• Clinical and microbiological

difficulties
– Fever, productive cough, and non-
resolving infiltrates
• Usually requires invasive diagnostic
biopsy procedures
• Difficult to isolate and treat
effectively
• Imperfect classification
 Nocardia
Clinical Manifestations

• Primary lesion at site of inoculation

• Erythematous papules/nodules
• Purulent lesions and sinus tracts
• Fever and regional lymphadenopathy
• Pulmonary, brain, and cutaneous
abscesses
 Nocardia
Immunocompetent Host
• Colonization of sputum, skin, upper
respiratory tract
• Cutaneous infection
– mycetoma
– lymphocutaneous
– abscess
– secondary cutaneous with dissemination
• Ocular
 Nocardia
Immunocompromised Host
• Invasive pulmonary infection
• Disseminated infection
• Nosocomial transmission
• AIDS
 Nocardia Identification
• Physiologic and biochemical methods
• Cell wall composition
• Mycolic acids
• Fatty acid content
• Typing and subtyping
• DNA sequencing
 Nocardia Identification
• The gram stain helps to quickly recognize the
nocardiosis appears as beaded, branching,
gram positive rods. A partial acid fast would
confirm this.
 Nocardia Identification
• Nocardia will grow on BCYE, L-J, Sabourad
• The most suitable specimens are the sputum
or, when clinically necessary, bronchoalveolar
lavage or biopsy.
 Nocardia Identification

Organism Mod AF Lysozyme Opacity 43C Casein Tyrosine Xanthine Hypoxanthine Urease Gelatin
N asteroides + + - V - - - - + -
N brasiliensis + + - - + + - + + +
N otitidiscaviarum + + - V - - + + + -
N transvalensis + + - - - - - + + -
N farcinica + + + + - - - - + -
N nova + + - - - - - - V -
N pseudobrasiliensis + + - - + + - + +
Nocardia Public Health Significance
• Amino acid results 3-4 weeks
• Difficult to isolate because it may resemble
contaminants
• No kits can complete all tests
Nocardia Public Health Significance

• Serology tests are

experimental
• Antimicrobial susceptibility
testing difficulties
• Emerging infections
• Long term therapy required
– Survives in macrophages by
inhibiting phagosome-
lysosome fusion
 The Joker
Steve Miller Band

• Some people call me the space cowboy, yeah • Cause I'm a picker
Some call me the gangster of love I'm a grinner
Some people call me Maurice I'm a lover
And I'm a sinner
Cause I speak of the pompitous of love I play my music in the sun
People keep talkin' about me, baby I'm a joker
Say I'm doin' you wrong, doin' you wrong I'm a smoker
Well, don't you worry baby I'm a midnight toker
Don't worry I sure don't want to hurt no one
Cause I'm right here, right here, right here, right here at
Wooo Wooooo
home
People talk about me, baby
Cause I'm a picker Say I'm doin' you wrong, doin' you wrong
I'm a grinner Well, don't you worry baby
I'm a lover Don't worry mama
And I'm a sinner Cause I'm right here at home
I play my music in the sun
You're the cutest thing
That I ever did see
I'm a joker I really love your peaches
I'm a smoker Want to shake your tree
I'm a midnight toker Lovey-dovey, lovey-dovey, lovey-dovey all the time
I get my lovin' on the run Come on baby ill show you a good time
Wooo Wooooo

You're the cutest thing

That I ever did see
I really love your peaches
Want to shake your tree
Lovey-dovey, lovey-dovey, lovey-dovey all the time
Ooo-eee baby, I'll sure show you a good time