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Viral InfectionsPFN: SOMCML1D
Hours: 3.0
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Terminal Learning Objective
Action: Communicate knowledge of “Viral Infections”
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam IAW course standards
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References
Current Diagnosis & Treatment (51st
edition; 2012; Mcphee; Papadakis)
The Merck Manual (19th edition; 2011; Porter; Kaplan)
Special Operations Forces Medical Handbook, 2008
Pathophysiology for the Health Professions (4th edition; 2011; Gould; Dyer)
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Reason
The regions that SOF personnel deploy to are among the most disease‐ridden places on the planet. Preventative measures combined with maintaining a high index of suspicion will result in more combat ready forces on the battlefield accomplishing the mission.
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Agenda
Communicate factors specific to viral infections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of influenza
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of dengue and dengue hemorrhagic fever
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Chikungunya disease
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of yellow fever
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of viral hemorrhagic fevers, to include: Lassa fever, Bolivian hemorrhagic fever, Crimean‐Congo hemorrhagic fever, Marburg, and Ebola viruses
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of hantavirus infections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of arboviral encephalitis
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of rabies
Communicate the etiology, signs and symptoms, diagnostic tests, and management of poliomyelitis (polio)
Communicate the etiology, signs and symptoms, diagnostic tests, and management of infectious mononucleosis
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of viral hepatitis
Communicate the etiology, signs and symptoms, diagnostic tests, and management of HIV/AIDS
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Factors Specific to Viral Infections
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Viral Infections
What are viruses?
Minute particles of genetic material ‐ outer protein coat
Obligate intracellular parasites
What diseases are caused by viruses?
How are viruses spread?
Zoonotic viruses
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Viral Infections
Retrovirus (HIV)
Prion diseases (slow viral diseases)
Diagnosis
High index of suspicion
Travel history and pertinent exposures
Clinical evaluation of signs and symptoms
Prophylaxis and treatment
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Determine a Viral Infection
SUBJECTIVE
History ‐ Exposures Recent travel
Animals/Insects
Unusual dietary habits
High risk sexual behavior
Contact with ill persons
Inhalation of aerosolized dust
Contaminated water/mud (swimming, wading)
OBJECTIVE
Physical
Laboratory (CBC count and differential)
Neutropenia
Lymphocytosis
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Differentiate:Is it Viral?
Viral diseases will not cause elevated WBC
Viral diseases will not cause eosinophilia
Viruses require specialized viral culture
Viruses are not visible under a light microscope; seen by electron microscope
Antibiotics will have no effect on viruses
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Influenza
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Influenza
Etiology
Type B – antigenic drift, seasonal epidemics
Type A – antigenic shift, sporadic pandemics
Epidemiology
Clinical findings: “flu‐like” symptoms
Transmission
Complications
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Influenza
Pandemics
1918 Spanish flu (50 to 100 million deaths)
2009 H1N1 (Swine flu)
1997 H5N1 (Avian Influenza)
Treatment
Prevention
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Influenza
Cold versus Flu
Both are respiratory illnesses with similar symptoms, caused by different viruses
The flu usually has symptoms that are more intense
The presence of fever, body aches, extreme tiredness and dry cough often means flu
Colds generally do not result in serious health problems or complications
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Influenza
Assessment
Treatment:
symptomatic: rest; fluids, acetaminophen…
antibiotics (only if at risk for secondary infection)
moderate to severe nasal congestion (Afrin)*; pseudoephedrine
non‐productive cough, dextromethorphan
antiviral medications – within 48h
Prevention: Hand washing, vaccination
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The Etiology, Signs and Symptoms, Diagnostic Tests and Management
of Dengue Fever (Dengue Hemorrhagic Fever / Dengue Shock Syndrome)
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Dengue Fever
Take‐home points
Mosquito‐borne illness
First infection can be a bad experience
Second infection can be deadly, if caused by a different serotype
No antiviral treatment
No vaccine (yet)
Dengue infection may range from asymptomatic to severe hemorrhagic fever
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Dengue Fever
A.K.A. “Breakbone fever”
A mosquito‐borne flaviviral infection
Etiology – infection with one of four types of dengue virus
Transmission
• Vector: Aedesmosquito
• No person‐to‐person transmission
Geographic association: tropics and subtropics
Risk factors
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Dengue Fever
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Dengue Fever
Signs and symptoms
Sudden onset of fever, headache and myalgias, sore throat, nausea, and abdominal pain
Chills
Malaise
Prostration (similar to severe flu)
Retro‐orbital pain*
Rash appears with a second fever spike
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Dengue Fever
Focused History
What symptom bothers you the most? (severe headache, muscle pain and retro‐orbital pain are typical)
When did you first feel sick? (Typically patient can recall exact time of onset)
Have you traveled overseas within the past 2 weeks? (Look for travel to endemic area)
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Dengue Fever
Objective: Signs
Cyclical fevers up to 104oF (40oC) over 3‐7 days (“saddle‐back fever”)
Flushing with conjunctival injection; prominent maculopapular, blanching rash over trunk and extremities, sparing palms and soles
General lymphadenopathy, hepatosplenomegaly
Dengue fever is a self‐limiting disease
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Dengue Hemorrhagic Fever andDengue Shock Syndrome
More severe form of the disease with hypotension and bleeding
Occurs primarily in children < 10 living in an endemic area (previous exposure)
Acute onset of fever with GI symptoms
Any hemorrhagic manifestation
Evidence of increased vascular permeability
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Dengue Hemorrhagic Fever
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Dengue Hemorrhagic Fever
Objective
Lab: marked leukopenia on WBC, serial Hct and platelet counts: ↑Hct; ↓Platelets ‐ DHF
Blood smears x 3 to rule out malaria
Monitor pulse pressure and ↓BP ‐ DSS
DHF: Perform a tourniquet test if DHF is suspected
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Tourniquet Test
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Assessment
Clinical Diagnosis
Differentials
Malaria
Chikungunya
Yellow fever
Leptospirosis
Other viral hemorrhagic fevers
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Dengue Fever
Plan
Treatment: There is no specific treatment
Treat symptoms including pain with acetaminophen and codeine ‐ (Avoid aspirin,NSAIDs)
Patient education:
• General: use body fluid precautions
• Prevention: use personal protection against insect bites
Evacuate all DHF/DSS cases early and urgently
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THE TAKE‐HOME MESSAGE:
Consider dengue in any patient with a febrile illness who has recently traveled to a tropical area, especially if symptoms include severe myalgias and arthralgias, retro‐orbital pain, and fatigue.
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The Etiology, Signs and Symptoms, Diagnostic Tests and Management
of Chikungunya Disease
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Chikungunya Fever
Etiology – Arboviral infection (Alphavirus)
Transmitted by Aedesmosquito
Epidemiology‐ tropical Africa ,Asia & India
Clinical findings (arthritis is pronounced)
Diagnostic testing
Treatment and prevention
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Yellow Fever
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Yellow Fever
Etiology
Arboviral illness that causes hemorrhagic fever
The incubation period is 3‐6 days, and 80‐90% of cases recover completely
10‐20% develop jaundice and hemorrhagic disease (potential for epidemics)
Geographic association
Risk factors: Travel to YF endemic areas; occupational exposure (Sylvatic form)
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Yellow Fever
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Focused History
Have you ever been vaccinated against yellow fever?
(Reduces chance of yellow fever infection < 1%)
When did you first feel sick?
(Typically patient recalls exact time of onset of fever)
Have you traveled overseas in the past 3 weeks?
If so, where? (look for travel to endemic areas)
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Clinical Findings
Spectrum of clinical illness
Abortive, nonspecific febrile illness w/o jaundice
Life‐threatening disease with fever, jaundice, renal failure and hemorrhage
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Clinical Findings
Infection Phase
Abrupt onset of fever, chills and headache
Muscle pains: neck, back, and legs
Severe prostration, restlessness, irritability
Vomiting
In mild cases, illness ends at this stage after 1‐3 days
Remission Phase 24‐48 hours
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Clinical Findings
Severe cases: fever returns “intoxication phase”
Jaundice, and disorientation
Some deteriorate with coffee‐ground hematemesis (“Black Vomit”)
Malignant cases: delirium, convulsions, and coma
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“Black Vomit”
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Laboratory Findings
Lab: Proteinuria on urinalysis (nephritis), CBC, Hct, and platelet count; type and cross match if bleeding
White blood cell count (WBC) drops
Neutropenia
Thrombocytopenia (decreasing platelet count)
↑Hct (rising to > 50%) hemo‐concentration
Blood smear to r/o malaria
Quick assay cards
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Diagnosis
Clinical diagnosis
Endemic area, and exposure to biting vector
No history of yellow fever immunization*
Classic triad
Jaundice
Hematemisis or other signs of bleeding
Albuminuria (protein in the urine)
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Plan
General: Use body fluid precautions
Activity: Bed rest
Diet: NPO if hemorrhagic, until stable
Medications: Codeine for pain. Avoid acetaminophen (liver) and aspirin (bleeding)
Prevention: Immunize with yellow fever vaccine. Booster q 10 years
Consult infectious disease specialist for all cases of hemorrhagic yellow fever, and for any cases in team members (Evacuate severe cases)
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management of Viral Hemorrhagic Fevers, to include: Lassa Fever, Bolivian
Hemorrhagic Fever, Crimean‐Congo Hemorrhagic Fever, Marburg, and
Ebola Viruses
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Definition
Viral hemorrhagic fever (VHF):
Acute, febrile, mutisystemic illness characterized by malaise, myalgia, prostration, and bleeding diathesis
Bleeding is the hallmark finding of the VHFs
Caused by lipid‐enveloped, single‐stranded, RNA viruses
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Viral Hemorrhagic Fever
Overview
VHFs in general
Epidemiology: epidemics occur sporadically
Clinical aspects
Diagnosis
Preventive measures
Treatment
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Viral Hemorrhagic Fever
Lassa fever
Bolivian hemorrhagic fever
Crimean‐Congo hemorrhagic fever
Marburg fever
Ebola fever
*SOF Handbook (CBR: Biological Warfare –pp. 6‐52)
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Transmission
Person to person
Nosocomial/lab transmission
Inhaling or ingesting excretions / secretions from rodent hosts (urine, feces)
Bite from an infected arthropod (tick, mosquito)
Bushmeat
Other reservoir species, such as bats
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Viral Hemorrhagic Fever
Spectrum of Clinical Presentations
Early phase – symptoms are similar
• Flu‐like illness
• Gastroenteritis
• Hepatitis
Late phase‐ more specific
• Organ failure
• Persistent leukopenia
• Hemorrhage
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Petechiae Purpura
Ecchymosis
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Lassa Virus
Sub‐Sahara
West Africa
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Bolivian Hemorrhagic Fever
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Crimean‐Congo Hemorrhagic Fever
Europe, Africa, Asia
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Marburg Virus
Uganda , Kenya, Zimbabwe
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Ebola Virus
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Viral Hemorrhagic Fever
Management
Supportive care while minimizing risk to others
Isolation of patient /quarantine
Barrier precautions
Contact Infectious Disease expert
Prevention includes proper handling of the dead
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Viral Hemorrhagic Fever
Geographically restricted
Linked to ecology, reservoir/vector – get a detailed travel history!
VHF should be suspected in any patient presenting with severe febrile illness and evidence of vascular involvement who has traveled to an area where VHF is known to occur
Differential diagnosis should include malaria
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The Etiology, Signs and Symptoms, Diagnostic Tests and Management
of Hantavirus Infections
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Hantavirus Infections
Hanta viruses infect rodents worldwide
Transmission to humans is through inhalation of infectious aerosols from rodent urine, droppings, and saliva (excreta)
Incubation is generally 1‐4 weeks
Divided into two groups
HFRS "old‐world"
HPS "new‐world
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Transmission
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Hantavirus Infections
Presentation of HFRS:
Constitutional: high fever, chills, myalgias, headache, fatigue and lethargy
Specific: abdominal pain, flushed face
• Petechiae
• Lowered blood pressure, low urine output
• Back pain
• Diuresis, renal concentrating defect (>2wks)
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Hantavirus Pulmonary Syndrome (HPS)
Presentation of HPS:
Constitutional: same as HFRS
Specific: dizziness, abdominal pain, diarrhea
• Dyspnea
• Non‐productive cough
• Shock
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Hantavirus Pulmonary Syndrome
Focused History
Have you recently seen evidence mice/rats near or in where you live or sleep? (typical exposure)
Have others in your family, village or unit had similar symptoms? (outbreaks occur in others similarly exposed)
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Hantavirus Infections
Plan
Supportive care
Avoid excess fluids
HFRS: ribavirin IV, consider blood transfusion, give O2, and Trendelenburg position for shock
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Hantavirus Pulmonary Syndrome
Plan
HPS: Infection has high mortality, most deaths occur with the first 48 hours
Prevention: minimize human‐rodent contact
Evacuate
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Arboviral Encephalitis
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Arboviral Encephalitides
Etiology – zoonotic diseases, flavivirus
Japanese encephalitis (JE)
West Nile (WN)
Transmission arthropod vector (mosquito)
Epidemiology – cause periodic epidemics
Sporadic fatal meningoencephalitis
Non‐specific flu‐like syndrome
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Japanese Encephalitis
Most common and one of the most dangerous
Over 50,000 cases reported annually
25% die and 50% are left with permanent neurologic sequelae
Typically many hundreds of asymptomatic infections occur for each clinical case of encephalitis
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Japanese Encephalitis
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Japanese Encephalitis
Mode of transmission
Occurrence
Risk for travelers
Clinical presentation
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Japanese Encephalitis
Diagnosis – Clinical
High index of suspicion
Recent travel to endemic area
Treatment
Intensive supportive therapy
Evacuate suspected cases of encephalitis
Prevention
Vaccination
Personal protective measures
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West Nile Virus
West Nile Virus is found throughout Asia, Africa, the Middle East and the U.S.
Spread to humans by infected mosquitoes
Clinical findings
Treatment is supportive
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Arboviral Encephalitis
Geographic association:
Seasonal variation: mosquito vector…
Risk factors: exposure to infectious viruses in vectors or animal hosts
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Focused History
Have you completed the full vaccination series for JE?
Was fever your first symptom? (Typically, there is sudden rise of fever after a period of apparent recovery from acute febrile illness, or without any prodromal symptoms)
Have you traveled outside the country or been bitten by mosquitoes?
Have there been recent outbreaks of animal diseases in the area?
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Assessment
Clinical diagnosis
DDX:
Malaria
Meningitis
Herpes simplex encephalitis
Rabies
Subdural hematoma, and other trauma
Drug use (esp. opioids)
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Plan
There is no drug treatment for JE or other arboviral encephalitidies
Closely monitor obtunded patients (seizures, aspiration, etc.) pending evacuation
Analgesics for fever or pain
Consult infectious disease expert
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Plan
Prevention: Vaccinate against JE, decrease exposure to vector
Evacuate suspected cases of arboviral encephalitis
Provide antibiotic therapy if unable to rule out bacterial meningitis
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Rabies
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Rabies
Rabies is a fatal, acute, viral encephalitis
Infection through bites, scratches, or licks from an infected animal
Worldwide ( 99% ‐ Asia, Africa, and South America)
Invariably fatal once CNS symptoms begin
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Rabies
Incubation period varies
Typified by fever with ascending paralysis and abnormalities of consciousness and behavior
Hydrophobia
Prevention‐ rabies vaccine pre‐exposure
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Rabies
Prodromal Stage (4‐10 days)
Tingling or pain at inoculation site
Fever, malaise, headache, nausea, vomiting
CNS Stage (Encephalitis)
Apprehension, agitation, hyperactivity
Bizarre behavior, hallucinations
Hydrophobia
Nuchal rigidity, paralysis
Coma, death (100% mortality)
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Rabies
Focused History
Have there been behavioral changes or increased aggressiveness in the patient?
How long has the patient been ill? (>5 days with progression)
Is there history of animal bite, exposure to bats, or travel to rabies endemic area within the past several months? (increase suspicion of rabies)
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Rabies
Assessment (Clinical)
Positive exposure history of animal bite
Pathognomonic: fluctuating consciousness and hydrophobia
Biting animals should be quarantined and observed for 10 days
Report of Animal Bite‐Rabies Exposure
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Rabies
Post exposure management
Immediately scrub with soap and water
Debride or irrigate with water or sterile saline
• Flush individual punctures with ~ 200 cc of solution
• Do not suture wounds
Give tetanus prophylaxis, antibiotic tx for animal bites
Use narcotics and benzodiazepines judiciously
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Rabies
Post exposure prophylaxis (PEP)
Infiltrate around wound with human rabies immune globulin (HRIG)
If patient is not immunized: start human diploid cell rabies vaccine (HDCV) x 5
Previously immunized, two doses HDCV, (HRIG not required)
HRIG and HDCV should never be given in the same syringe or at the same site
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Rabies
Post exposure
If possible, isolate suspected animal and observe 10 days for signs of rabies
Credible bite report (DD form 2341)
Prevention: pre‐exposure prophylactic rabies vaccination (HDCV) x 3
Evacuate personnel suspected of exposure
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The Etiology, Signs and Symptoms, Diagnostic Tests and Management
of Poliomyelitis (Polio)
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Poliomyelitis (Polio)
Description‐ Polio is a highly infectious disease that invades the nervous system
Transmission‐ Polio is spread by person to person contact through fecal or pharyngeal secretions
Complications: Polio is associated with outbreaks of paralytic poliomyelitis.
Paralysis leads to disability
Death
Incubation is 7‐14 days
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Poliomyelitis (Polio)
Typically asymptomatic; < 1% develop neurologic disease
Polio is primarily a disease associated with poor sanitation and is found in developing countries of Asia and Africa
Symptomatic polio manifests in 3 ways
Abortive poliomyelitis (minor illness)
Nonparalytic poliomyelitis
Paralytic poliomyelitis
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Poliomyelitis (Polio)
Patient presents with:
Malaise, headache, nausea, vomiting, and sore throat; uneventful recovery within several days (abortive poliomyelitis)
Some progress with severe muscle spasms, neck and back stiffness, and muscle tenderness lasting about 10 days (nonparalyticpoliomyelitis)
Few develop paralytic poliomyelitis:asymmetric weakness or paralysis
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Poliomyelitis (Polio)
Focused history
Have you completed the full polio vaccination series?
Did fever precede the limb weakness?
Have you traveled or been exposed to poliovirus?
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Complications of Polio
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Complications of Polio
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Poliomyelitis (Polio)
Assessment
Asymmetric flaccid limb paralysis or bulbar palsies without sensory loss during and acute febrile illness in a child or young adult
Possible respiratory complications
Laboratory – consistent with viral cause
•Normal WBC
• Lymphocytosis
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Poliomyelitis (Polio)
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Poliomyelitis (Polio)
Plan
Treatment‐ Supportive care is indicated:
• Analgesics for fever or pain
• No specific treatment exists for these viruses
Prevention:
• Do not expose others to infected body fluids
• Immunize with inactivated poliovirus vaccine (Salk)
• Live OPV (Sabin) limited to usage for outbreaks
Evacuate patients suspected of having polio
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Infectious Mononucleosis
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Infectious Mononucleosis
Caused by Epstein‐Barr virus (EBV)
“Mono” is common in young adults
Transmitted by infectious salivary secretions (“kissing disease”)
Incubation 4‐6 weeks
Risk factors: Transmission is facilitated by crowded conditions, close contact
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Infectious Mononucleosis
Focused history
Do you have a cough? (IM rarely has pulmonary symptoms)
What were your first symptoms? (Malaise for several days, then fever and sore throat)
Has anyone you live with been sick with similar illness in the past few months?
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Infectious Mononucleosis
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Infectious Mononucleosis
Patient presents with:
Fever, sore throat, malaise
swollen lymph nodes in neck
Chronic fatigue
Splenomegaly (in up to 50% of patients)
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Infectious Mononucleosis
Objective: Signs
Vitals: Fever to 100.4‐104F
Nontoxic appearance, swollen neck, faint measles‐like rash, pharyngitis with edema or exudative tonsillitis, palatal petechiae (red spots on back of throat)
Splenic enlargement, +/‐ hepatomegaly; swollen cervical lymph nodes
Laboratory: Mono‐spot
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Infectious Mononucleosis
Assessment
Clinical diagnosis – classic triad:
• Fever
• Pharyngitis
• Lymphadenopathy
Laboratory
•Mono spot test
• Heterophile antibody test
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Infectious Mononucleosis
Laboratory
Mono spot test
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Infectious Mononucleosis
Plan
Treatment is supportive: fever and sore throat (acetaminophen), warm saline gargles
Caution: no heavy lifting or contact sports (or parachuting) for 1 month to prevent splenic rupture
Rest during acute phase
Return immediately for sudden onset of severe abdominal pain, or fainting or lightheadedness after abdominal trauma
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Infectious Mononucleosis at a Glance
Here are key facts about infectious mononucleosis:
Epstein‐Barr virus (EBV) is a contagious infection that causes infectious mononucleosis.
The illness is spread by casual contact, usually via saliva. Mono has an incubation period of 4 to 6 weeks.
The vast majority of adults have antibodies against EBV, meaning they have been infected with the virus and are immune to mono.
Fatigue, severe sore throat, swollen lymph nodes, and fever are common symptoms of mono.
Specialized blood tests are used to confirm the diagnosis of mono.
Mono can be associated with an enlarged spleen and liver inflammation (hepatitis).
One should avoid contact sports during active mono illness and during recovery because of the possibility that the spleen can rupture.
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The Etiology, Signs and Symptoms, Diagnostic Tests and Management
of Viral Hepatitis
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Viral Hepatitis
Definition:
Inflammation of the liver
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Causes
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Viral Hepatitis
Diagnosis
History
Differential diagnosis
Laboratory
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Acute Viral Hepatitis
Inflammation of the liver caused by specific hepatotropic viruses:
Hepatitis A virus (HAV)
Hepatitis B virus (HBV)
Hepatitis C virus (HCV)
Hepatitis D virus (HDV)
Hepatitis E virus (HEV)
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Acute Viral Hepatitis
Symptoms and signs
Varies from mild flu‐like illness to fulminant, fatal liver failure
Prodromal phase: anorexia, nausea, vomiting, fever, clay colored stools, headache, RUQ pain, and arthralgias, itchy red hives
Icteric phase: urine darkens, jaundice
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Acute Viral Hepatitis
Symptoms and Signs (cont’d)
Recovery phase: variable jaundice, hepatomegaly
Laboratory: Striking aminotransferaseelevations, AST and ALT are typically 500 to 2000 IU/L
Hepatitis virus panel
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Chronic Hepatitis
Hepatitis C, B
Carriers of the virus
Cirrhosis of the Liver
Primary Liver Cancers
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Signs and Symptoms
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Diagnosis
Clinical signs and symptoms
Liver function tests (blood test)
Hepatitis Panel
Good history to identify possible cause
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Viral Hepatitis
Treatment
Supportive care in acute phase
Prognosis
Refrain from use of all alcohol products
Avoid medications that are cleared by liver
Prevention
No improvement/deterioration
Follow‐up actions
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Viral Hepatitis
Enterically transmitted hepatitis: A and E –primarily oral – fecal route
Parenterally transmitted hepatitis:
HBV, HDV primarily intimate personal contact
HCV primarily blood transfusion, IV drug use
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Hepatitis A“Infectious Hepatitis”
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Hepatitis A“Infectious Hepatitis”
Occurrence:
Cause/ transmission
Long‐term effects
Persons at risk
Prevention
Vaccine recommendations
Treatment and medical management
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Hepatitis E
Occurrence
Cause/ transmission
Long‐term effects
Persons at risk
Prevention
Medical management
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Parenterally Transmitted Hepatitis
B, C, and D
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Hepatitis B
Occurrence
Cause / transmission
Long‐term effects (without vaccination)
Persons at risk
Prevention
Vaccine recommendations
Treatment and medical management
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Chronic Hepatitis B
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Hepatitis C
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Hepatitis C
Occurrence
Cause/transmission
Long‐term effects
Recommendations for testing/risk groups
Prevention
Treatment and medical management
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Hepatocellular Carcinoma
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Hepatitis D
Occurrence
Cause/transmission
Long‐term effects
Persons at risks
Prevention
Medical management
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The Etiology, Signs and Symptoms, Diagnostic Tests and Management
of HIV/AIDS
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Human Immunodeficiency Virus(HIV)
HIV is a retrovirus
Transmitted through:
• Sexual contact, needlestick/sharps, perinatally, infected blood or body fluid contact with non‐intact skin or mucous membranes, breastfeeding and blood transfusions
Incubation period is weeks to months
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Acquired Immune Deficiency Syndrome (AIDS)
Acquired Immune Deficiency Syndrome (AIDS)
HIV positive
Opportunistic infections and malignancies
CD4 lymphocyte count below 200 cells/mcL
Untreated infections are eventually fatal!
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Human Immunodeficiency Virus(HIV)
Subjective: symptoms
Should be viewed as a continuum of initial exposure, asymptomatic infection, symptomatic disease, and end‐stage AIDS
Acute HIV Infection
• Pharyngitis
• Rash
Patient History (ask about risk factors)
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Human Immunodeficiency Virus(HIV)
Objective ‐ a thorough physical examination:
Respiratory (Pneumocystis jiroveci pneumonia)
Skin (Kaposi’s sarcoma)
Oral mucosa (candidiasis, herpes, oral hairy leukoplakia, and Kaposi’s sarcoma)
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Oral Hairy Leukoplakia
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Kaposi’s Sarcoma
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Human Immunodeficiency Virus(HIV)
Laboratory: In the “field,” Rapid Immunoassay – RIA (OraQuick)*
HIV Testing
Standard test is an enzyme‐linked immuno‐sorbent assay (ELISA) for antibodies to the virus
• Positive ELISA is repeated; if it is again positive, a confirmatory Western blot (immunoblot) test is performed
Skin testing for tuberculosis in HIV positive
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Human Immunodeficiency Virus(HIV)
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Human Immunodeficiency Virus(HIV)
Assessment:
Plan:
There is no cure
Evacuate newly diagnosed team members
• If evacuation is not available in foreseeable future, then test with PPD and treat with INH prophylaxis if >5mm
•Also treat active opportunistic infections
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Human Immunodeficiency Virus(HIV)
Treatment of the HIV/AIDS infection –HAART *
Prevention
Sexual practices
HIV testing
Screen blood products
Precautions regarding injection drug use
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Questions?
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Terminal Learning Objective
Action: Communicate knowledge of “Viral Infections”
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam IAW course standards
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Agenda
Communicate factors specific to viral infections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of influenza
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of dengue and dengue hemorrhagic fever
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Chikungunya disease
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of yellow fever
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of viral hemorrhagic fevers, to include: Lassa fever, Bolivian hemorrhagic fever, Crimean‐Congo hemorrhagic fever, Marburg, and Ebola viruses
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of hantavirus infections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of arboviral encephalitis
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of rabies
Communicate the etiology, signs and symptoms, diagnostic tests, and management of poliomyelitis (polio)
Communicate the etiology, signs and symptoms, diagnostic tests, and management of infectious mononucleosis
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of viral hepatitis
Communicate the etiology, signs and symptoms, diagnostic tests, and management of HIV/AIDS
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Reason
The regions that SOF personnel deploy to are among the most disease‐ridden places on the planet. Preventative measures combined with maintaining a high index of suspicion will result in more combat ready forces on the battlefield accomplishing the mission.
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Break
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Check on Learning
Which of the following does not aid in making a viral assessment in the field clinic setting?
A. High index of suspicion, based on history and presenting signs and symptoms
B. CBC with differential
C. Fever pattern
D. Antigen detection immunofluorescence
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Check on Learning
The SOF medic uses which “Classic Triad” to help make a clinical diagnosis of yellow fever?
A. Arthropod vector, fever, and rash
B. Jaundice, person‐to‐person contact, and myalgias
C. Travel to Asia, jaundice, and mosquito exposure
D. Jaundice, hematemisis, and protein in urine
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Check on Learning
In a young adult with fever, malaise, sore throat and swollen cervical lymph nodes you should suspect?
A. Abortive polio
B. Influenza
C. Dengue
D. Infectious mononucleosis
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Check on Learning
Your Afghan interpreter has just returned from a 30‐day visit home on leave. He tells you that while away he was bitten by a sick dog, but the wound has since healed. What is concerning?
A. Rabies is endemic to Afghanistan
B. Dogs are high risk for spreading rabies
C. Rabies incubation period in humans varies from 10 days to > one year and averages 1 ‐ 3 months
D. All of the above
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Check on Learning
What is the most likely form of transmission for hantavirus infections?
A. Arthropod vector
B. Person‐to‐person contact
C. Cough (airborne particles)
D. Inhalation, ingestion
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Check on Learning
Which of the following is true about viral hepatitis?
A. HAV is a leading cause for liver transplants
B. HBV has no chronic carrier state
C. Hepatitis D can only exist as a co‐infection with HBV
D. Hepatitis C is spread by contaminated food/water