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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for fungal balanitis and severe folliculitis

Answered by
Dr.
Dr. Panagiotis Zografakis

Internal Medicine Specialist

Practicing since :1999

Answered : 3675 Questions

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Posted on Tue, 30 Aug 2016 in Medicines and Side Effects
Question: Hello. I have had an 8 week+ health crisis. Began with LRTi very productive aggressive croup or pertussis like cough, purulent sputum which was treated with 6 courses of Abx - levoflox, biaxin, Zithromax X 2, then Septra DS follow a positive culture for Klebsiella (garden variety, not EBL / KPC). Two ER admits. One peri-septic. Elevated lactate / neut WBC. Developed severe folliculitis, also KP, while on Zithromax. After 7 days of Septra developed severe ? Fungal balanitis completely Azole resistant. WIC doc changed to lamasil, borderline improvement after 5 days. Now developing significant phimosis. Foreskin culture shows gram + cocci. Micro did not grow, stated normal flora. Foreskin is producing thick apple green exudate. Considered mupirocin. Have been using clinical grade probiotics thru out. Hep neg. syph/ HIV pending. Recent both neg, no serious concerns pos now. Thoughts?
doctor
Answered by Dr. Panagiotis Zografakis 1 hour later
Brief Answer:
HIV, diabetes, pseudomonas, urologic consultation

Detailed Answer:
Hello,

it's an unusual case, no doubt about it! First of all a LRTI is not supposed to last that long and in most cases it is supposed to respond rapidly to proper antibiotic treatment. Healthy individuals who don't come into contact with hospitals and hospitalized patients, do not usually carry resistant pathogens.

Please let me make clear that I can't obviously provide anything more than some thoughts about your case, which may be useful or not. If you'd like to provide more data (like test reports) it may help me to get a better idea of your condition.

Balanitis is common in diabetes. I guess that your doctors would have detected abnormal blood sugar during treatment.

Is KP keratosis pilaris? If it is, then it's irrelevant to the rest of your symptoms. Folliculitis may sometimes be caused by pseudomonas though. The green discharge from the foreskin raises some suspicions about this pathogen. Monotherapy with quinolones raises suspicions of resistant pseudomonas development. Just an assumption though... The cultures are more important than assumptions! Take into account that pseudomonas balanitis is not common although it may occur.

Persistent balanitis with phimosis may require circumcision (at least partial) so urological consultation is required.

The recently negative HIV eases the mind regarding AIDS. Immunosuppression requires a long time to develop and the tests should have become positive meanwhile. Syphilis and hepatitis are not relevant.

So in conclusion, your current problem seems to be the balanitis only. Phimosis (which is a complication or local infection) makes things worse and favors recurrences and treatment failures. In case of persistent infections, trying to culture the causative agent is important so that proper treatment would be given. Urologic intervention may provide another solution (a more permanent one perhaps), so you'd better seek an opinion soon.

I hope it helps!
Good luck!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Panagiotis Zografakis 7 hours later
Would help to know I have worked in healthcare for 15 years as an ER/ICU RN, RRT, Paramedic? Have had previous colonization with HA-MRSA. Mantou step 1 neg, awaiting 2nd test Aug 19th. Also concerned regarding immunosuppression. Any thoughts on chronic insomnia and immunosuppression? Developed PTSD 3 years ago, seems to primarily effect sleep patterns. Polysom shows chronic alpha wave intrusion. Rarely feel rested.
doctor
Answered by Dr. Panagiotis Zografakis 3 hours later
Brief Answer:
your sleep patterns do not affect the immune system significantly

Detailed Answer:
MRSA can be difficult or even impossible to treat in the outpatient setting. These staphylococci are resistant against commonly used antibiotics. Only a culture may prove their presence though, so you'd better try to get a good sample from your balanitis. The lab has to be informed that you take use antibiotics. It will help them to manage the sample accordingly.

I don't believe that tuberculosis is your problem. The negative first test is almost reassuring but the second test is required to be sure. Besides that it's unlikely that pneumonia caused by Mycobacterium tuberculosis would have resolved with common antibiotics, despite the fact that quinolones do have some activity against mycobacteria.

Finally chronic insomnia and the PTSD do not affect the immune system significantly. We don't expect patients with sleep problems to have more serious infections than the others.

Best regards!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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