2013 ID Board Review Part 3

Greg Fenati DOARMC EM

Just got back from Africa…

Flu like symptoms Bleeding ??????

Marburg and Ebola Viruses

What to look for… Recent travel (specifically Africa) Hemorrhagic fever 7-10 days after

exposure Head ache, fever, myalgias,

arthralgias, lethargy GI – N/V/D Bleeding from the nose, mouth,

rectum, eyes and ears

Marburg and Ebola Viruses

Labs – Thrombocytopenia, Hemorrhagic anemia (specifically GI med student finger positive)

ELISA and PCR for confirmation

Management Supportive (death is common)

Parents find a bat in an infants room when they wake up in the AM.What are you worried about?

Rabies

Roughly 3 cases per year in the US however 40,000 deaths / yr worldwide

Most common bites for Dogs and Bats

Rabies

HIGH RISK Raccoon Skunk (not spray) Fox Bats Coyote Bite from larger

carnivore in endemic area

LOW RISK Domestic animals Small rodents Lagomorphs Groundhogs /

Woodchucks based on if area is endemic

SMALL ANIMALS ARE KILLED WHEN BITTEN

Rabies

Rhabdovirus transmitted though saliva into wound or mucous membrane

Replicates in muscle cells near bite site and stays at site during incubation period for 30 TO 90 DAYS. Head or neck is shorter

Tracks through peripheral nerves to brain stem, replicates, then enters salivary glands

Rabies Symptoms

Prodrome ->URI / GI viral like symptoms

Rabies Fury (encephalitis)-> agitation, irritable, hallucinations, ataxia, weakness, sz

Aerophobia then Hydrophabia Coma after one week followed

quickly by death

Rabies Dx

History, History, History Bite or exposure to suspected animal Animal should be observed for 10 DAYS

with animal vaccination hx obtained Travel to endemic area South West

(SoCal spared), NorCal, Midwest, East Brain Biopsy

Rabies Management

Clinical Rabies? – Sorry! Otherwise, Post Exposure Prophylaxis!!!

PEP for bats with no history or signs if in room while sleeping or unattended child or someone with dementia

Rabies PEP

Scrubbing with soap within 3 hours nearly 100% effective (Benzalkonium chloride, povidone-iodide)

Passive immunity Human Rabies Immunoglobulin (HRIG) 20 IU/kg as much as possible in and arround wound, the rest at distant site IM (must be 2 sites)

Active immunity Human diploid cell vaccine (HDCV) If no previous vacc then 1ml IM deltoid on days

0,3,7,14,28 If previously vacc then days 0,3

???????????

Small Pox (Variola)

Eradicated in 1980, last natural 1977

Untreated mortality 30% Airborne pathogen which is

concerning for bioterrorism

Small Pox (Variola) Sympt

Prodrome fever, malaise, back pain, myalgias

Rash was often confused with varicella Macules / Papules that progress to

pustules over 1 to 2 days Uniform progression (unlike vericalla) Centerfugal distribution usually face

and oral mucosa first

Small Pox (Variola) Dx

If clinically suspected.. Viral swab of oral mucosa or open

pustule Then call CDC and authorities for

suspected terrorist attack

Small Pox (Variola) Management

Contact and droplet iso Iso family and close contacts Vaccination and immunoglobulin Supportive once rash appears

Pt returned from (insert 3rd world country) now low grade fever which has been spiking high, flu like symptoms and very dark urine with a positive VDRL????

Malaria

Plasmodium falciparum, ovale, vivax, malariae

Falciparum is the most leathal (foul)

Malaria Signs/Symptoms/Hx

Recent Travel Irregular Fevers (intermittent very

high imposed on a low level background) Q48hrs

Hepatosplenomegally Blackwater fever secondary to

severe hemolysis

Malaria Complications

Cerebral Mostly falciprum AMS, sz, coma

Anemia Immune related hemolysis from RBC surface

antigen Thrombocytopenia Think G6PD deficiency in primaquine tx

Pulmonary Mostly falciprum -- fever/cough May develop ARDS

Malaria Dx

Peripheral blood smears Hemolytic anemia commonly with

thrombocytopenia False positive VDRL

Malaria Management

Uncomplicated Chloroquine (Haiti, Dominican Rep, Central America parts of Middle East)

Chloroquine Resistance? Quinine + Doxy

P. Falciparum? IV quinine or quinidine (causes profound hypoglycemia and dysrythmias)

Primaquine? hepatic phases of P. ovale and vivax – after testing for G6PD

Gardener / Landscaper ?????

Sporotrichosis Etiology

Fungal infection by Sporothrix scheenckii Mold on plants– Roses Cats, Armidillos

Inoculation into skin Farmers, gardeners, forestry

workers

Sporotrichosis Hx/Symptoms

Acute: Painless red papule

or papules Lesions can be

delayed up to a month post exposure

Lymphocutaneous spread

Chronic: Skin leasions may

persist intermittently for years

Pulm involvement with cough, fever, and weight loss

Osteomylitis, tenosynovitis, osteomyelitis

CNS unlikely

Sporotrichosis Dx/Management

Organisms found in skin bx or body fluid (blood, sputum, joint fluid)

MANAGEMENT CUTANEOUS ONLY months of azole tx DISSIMINATED

Itraconazole if well appearing Amphotericin if sick

Fevers, myalgias, dark urine traveled to the northeast?

Babesiosis

THE MALARIA OF NORTH EAST USA Protazoan Maria-like parasite

Babesia Multiplies in RBC’s resulting in

hemolysis then microvasculature has sludging effect

Vector Ixodes (dammini, scapularis, pacificus) with primary reservoir white footed mouse

Babesiosis Symptoms/Signs/Dx

Fevers, myalgias, dark urine, headache, fatigue

Hepatospleenomegally, anemia, thrombocytopenia, increased LFT’s and LDH

Giemsa and Wright stains on peripheral smears reveal rings

Tetrad forms on smear is pathognomonic

Babesiosis Management

Most patients have spontaneous remission

Can be deadly s/p splenectomy

If ill appearing quinine with clyndamycin

I went hiking and got a tick bite. A few days later I got a fever. A few days after that it went away. A few days after that it came back and now I feel like crap. What do I have??

Colorado Tick Fever

Western US and Germany Dermacentor Andersoni (wood tick) Can get with concurrent Rocky

Mountain Spotted Fever Incubation of 3-6 days after tick bite

Colorado Tick Fever

Symptoms/Signs:1 Acute chills,

lethargy, H/A, photophobia, abd pain, severe myalgias

2 Fever breaks after 2-3 days

3 Recurs for another 3 days

Management:Supportive

????

Lyme Disease

Most common tick disease North central to Northeastern and

Mid Atlantic areas --- also global Spirochete – Borrelia Burgdorferi Tick – Ixodes dammini Primary reservoir is field mouse Transmission 2 days after tick

attachment

Lyme Disease

Early: Erythema Migrans Secondary spread to

palms and soles H/A (meningeal

irritation) Hepatitis / Pharyngitis

Acute Disseminated: Neuro findings (4 wks)

Meningeoencephalitis, cranial neuropathy (Bells) which can be bilateral, extremity radiculopathy with assymetric pain/weakness

Cardiac (3-5 wks)AV block is most common with gradual resolution

Arthritis (wks-months)mono or polyarticular asymmetric arthritis

Late: (>1 yr) 10% chronic arthritis Neuro fatigue

syndromes, chronic encephalopathy (memory impairment, hypersomnolence, mild psych)

Lyme Disease Dx

Only some pts report tick bite <50% EM is diagostic IgM peaks at 3-6 weeks then

nondiagnostic IgG dectable at 2mo, peaks at 12 mo ELISA, Western blot, PCR for confirmation Lumbar puncture if neuro Lyme

Lyme Disease Management

Vaccination and Doxy prophylax single dose (72 hours after finding an engorged tick) only in high risk areas

Early Lyme Dz Doxy 100 Bid X 3wks If Preg or Peds

amoxicillin Jarish-Herxhiemer

rxn fever, tachycardia, mylaise, h/a (ASA/Rest for tx)

Early Disseminated Doxy or amox X 1 month and no steroids for Bells Meningitis/Enceph –

IV Ceftriaxone or PCN Cardiac first degree –

doxy or amox for 21-30 days

Cardiac high degree- Admit to tele, IV Ceftriaxone or PCN

Lyme Disease Management

Late Dz: Arthritis Doxy or Amox for 30 days if

persistant 2nd course OR 2-4wks IV Ceftriaxone

Neuro Ceftriaxone 2 G daily for 2 -4 wks often with no complete resolution of symptoms

WUZ GATOR HUNTIN WITH MY CUZ/WIFE AND I SAW A TICK ON ME!! NOW I’M SICK!! WHAT IS IT DOC??? (in July)

Erlichiosis

Spotless RMSF Summer Dz Endemic South Central and South

Atlantic Tick Ixodes scapularis Gram neg coccbacilli -- Organisms

live in the leukocytes Onset 9 days after bite (most pts

90% report bite)

Erlichiosis Signs/ Sympt

Abrupt fever, h/a, myalgias, chills, occaisional AGE symptoms

Complications: Optic Neuritis, , ARDS, Meningitis, Pericarditis, Renal Failure, DIC

Erlichiosis Dx/Management

DX Leukopenia Thrombocytopenia Incresed LFTs Peripheral smear

showing morula clusters

MANAGEMENT Doxy or

Tetracycline for 1-2wks

Rifampin Most recover

without residual

Went hiking next day severe h/a, calf tenderness and a rash???

Rocky Mountain Spotted Fever

5% mortality Endemic in 48 contiguous states except

Maine– Most prevalent in Southeast Ricketia Rickettsii–

Obligate intracellular gram neg coccobacillus Orginisms multiply in vascular endothelium

and smooth muscle Cause tPA and VWF release

Ticks – Dermacentor anderosi and variabilis (wood tick and dog tick). All warm blooded animals are resevoir

RMSF signs/symptoms

Tick bite history in most Abrupt onset of symptoms:

h/a, myalgias, N/V, abd mm myositis, calf tenderness

Rumple-Leede phenom– petechiae after BP cuff

Centripital Rash – initial pink/red blanchable macules, may involve palms and soles

RMSF Complications

Gangreen Myocarditis Interstitial pneumonitis / ARDS Rickettsial encephalitis, meningitis,

focal neuro deficits, sz, coma ARF Hypovolemic Shock DIC

RMSF Dx/Management

Dx: Serology (start tx

prior to results) Thrombocytopenia,

hyponatremia, anemia, azotemia, hyperbilirubinemia

ECG conduction abnormalities

Management: If suspected tx Doxy 100 BID 1-2wks Chloramphenicol 50

mg/kg/day (max 1 G) Supportive care No steroids unless:

Extensive vasculitis Encephalitis Cerebral edema

Went hiking a week ago and now I can’t move my legs. What do I have and can you fix me?

TICK PARALYSIS

Most common in Southeast in spring and summer

Dermacentor Species – toxin secreted in salivary glands during blood meal blocks acetylcholine release

TICK PARALYSIS

Signs Symptoms: Restlessness and

irritability 4-7 days Then ascending

flacid paralysis +/- ataxia

Loss of DTRs, bulbar involvement then resp paralysis

Management Remove Tick Improvement in a

few hours and recovery within 48 hours

We skinned up these rabbits good!!

Now I have this and belly pain.. What’s up?

Tularemia

Most common in southwest Untreated mortality 5-30% Treated <1% Francisella tularenis Gram neg

pleomorphic bacillus Reservoirs RABITS, domestic cat, Tick

(Amblyomma Americanum and Dermacento Variabilis)

Mode of transmission dictates illness

Tularemia Manifestations

Ulceroglandular Most common Ulceration of papules 2

days after tick innoculation Glandular

2nd most common Lymphadenopathy without

ulceration Oculoglandular

Unilateral conjunctivitis with regional adenopathy

Typhoidal Systemic dz without

identified entry site f/c/abd pain/ night sweats

Pulmonary Direct inhalation Similar to bacterial

pneumonia Concern for bio warfare

Oropharyngeal Least Common Undercooked rabbit meat Nonspecific GI issues…

may progress to GI bleed

Tularemia Dx/ Management

Dx: Clinical history Bubos Seerologic testing Do not aspirate LN

due to risk of transmission to health care worker

MaInagement: Isolation not

required Streptomysin for

active dz PEP Doxy 100 BID

X 14 days

Infectious Control Standard Precautions

Yeah Gown, Glove, blah, blah… For the test it is always hand wash,

hand wash, hand wash

Infectious Control Airborne

Particles <5 microns Patients need to be in negative

pressure rooms Keep door shut N-95 Rubeola, Vericella (including

desseminated zoster), TB

Infectious Control Droplet

Particles > 5 microns Neg pressure not required Doors may be open Standard precautions with mask when

within 3FT of pt Meningitis, diptheria, pertussis, plague,

bacterial pneumonia, scarlet fever, adenovirus, mumps, parvovirus

Occupational Exposure

Hep B blood exposure Consider booster if >10 yrs if prior

immunization and > 10mIU/ml 3 months after 3rd dose

If Prior immunization but non responder HBIG and Vaccine concurrently or HBIG at injury and again 1 month later

Unkown titers then draw and treat depending on results if lab results > 48 hours then treat

No prior immunization same options as nonresponder

Occupational Exposure

Hep C blood exposure Transmission is approximately 2-7% Good Luck!! No treatment or

vaccination exists

Occupational Exposure

HIV blood exposure Risk of all percutaneous exposure 0.3% if

source is HIV positive Viral load of source makes a difference Mucous memb exposure with blood risk 0.1% PEP Recommend only for high risk exposure

including Pt with AIDS plus mucous memb or skin

compramise Patients with symptomatic HIV Acute seroconversion High Viral load >1500 copies/ml

Occupational Exposure

HIV blood exposure Regimen:

Zidovudine and Lamivudine X 1 month Administer as soon as possible May be ineffective if started > 24 hours

Good luck on your boards!!