Geriatric Secrets

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  • As of about three weeks ago, we have received reports of 59 cases of WNV illness that occurred in 2001. The first two reported cases were reported from Florida in mid-July and the last reported case occurred in Georgia in the first week of December. Cases occurred over a 22-week period with the peak occurring during the week ending September 1.
  • Geriatric Secrets

    1. 1. The West Nile Virus An Update for Physicians Ted Epperly, M.D. Chairman and Program Director Family Medicine Residency of Idaho Boise, Idaho Clinical Professor Department of Family and Community Medicine University of Washington School of Medicine Seattle, Washington
    2. 2. West Nile Virus (Viral Meningo-encephalitis) What is this all about?
    3. 4. Mosquitos Attack New York
    4. 5. West Nile Virus Late Update: 09/06/06 Patients Deaths States 1999 62 7 1 2000 21 2 3 2001 66 9 10 2002 4,156 284 40 2003 9,862 264 46 2004 2,539 100 41 2005 3,000 119 42 2006 1,267 31 33
    5. 6. West Nile Virus U.S.A. 2006 <ul><li>1,267 Cases with 31 Deaths (09/06/06) </li></ul><ul><li>33 States with Human Cases </li></ul><ul><li>The Top 5 States with Human Cases are: </li></ul>Cases Deaths Idaho 292 3 California 138 2 Texas 101 10 Nevada 85 0 North Dakota 77 1
    6. 7. West Nile Virus in Idaho <ul><li>568 Patients (09/05/06) </li></ul><ul><ul><ul><li>470 West Nile Fever </li></ul></ul></ul><ul><ul><ul><li>98 West Nile Disease </li></ul></ul></ul><ul><li>15,000 Seroconverters </li></ul>
    7. 8. = evidence of WNV in horses, birds or mosquitoes. = evidence of WNV in humans. = evidence of WNV in humans, and horses, birds or mosquitoes.
    8. 9. West Nile Virus Positive Surveillance Findings, Idaho, (9/05/06) Counties Humans ± Fever Humans ± Neuroinvasive Horses Birds Mosquito Pools Ada 129 25 39 25 POSITIVE Bannock 1 2 20 3 not tested Boise 1 0 6 0 not tested Bonneville 3 2 9 5 not tested Canyon 127 19 48 13 POSITIVE Elmore 38 6 4 6 not tested Gem 12 0 7 8 POSITIVE Owyhee 18 4 3 2 not tested Payette 15 1 2 0 not tested
    9. 10. West Nile Virus <ul><li>1937: First Identified from West Nile District of Uganda </li></ul><ul><li>Found Widely in Eastern Hemisphere </li></ul><ul><ul><li>Africa, Asia, Middle East, and Europe </li></ul></ul><ul><li>1957: Noted to Cause Severe Neurologic Illness During an Outbreak in Israeli Nursing Homes </li></ul><ul><li>1990-1999: Outbreaks Seen in Humans and Horses </li></ul><ul><ul><li>Romania, Morocco, Tunisia, Italy, Israel, Russia </li></ul></ul><ul><li>1999: First Identified in the Western Hemisphere, New York </li></ul>
    10. 11. West Nile Virus Outbreaks <ul><li>Israel – 1951-1954, 1957, 1997-2000 </li></ul><ul><li>France – 1962, 2000 </li></ul><ul><li>South Africa – 1974 </li></ul><ul><li>Romania – 1996 </li></ul><ul><li>Italy – 1997 </li></ul><ul><li>Russia – 1999 </li></ul><ul><li>United States – 1999 </li></ul>
    11. 14. West Nile Virus Virology <ul><li>Family Flaviviridae, genus Flavivirus </li></ul><ul><li>45-50 nm diameter </li></ul><ul><li>Enveloped, icosahedral nucleocapsid </li></ul><ul><li>Single-stranded RNA Virus </li></ul>
    12. 16. The Flaviviridae YF DEN1 DEN2 WNV JE BVDV, CSFV GBV-A GBV-C HCV
    13. 17. Epidemiology
    14. 18. West Nile Virus U.S.A. 1999
    15. 19. West Nile Virus U.S.A. 2000
    16. 20. West Nile Virus U.S.A. 2001
    17. 21. West Nile Virus U.S.A. 2002
    18. 22. West Nile Virus U.S.A. 2003
    19. 23. West Nile Virus U.S.A. 2004
    20. 24. West Nile Virus U.S.A. 2005
    21. 25. West Nile Virus U.S.A. 2006 August 29, 2006
    22. 26. Date of Symptom Onset 0 5 10 15 20 25 30 7/7 8/4 9/1 9/29 10/27 11/24 12/23 Week ending Number of cases 2001 2000 1999
    23. 27. West Nile Virus Epidemiology 99-03
    24. 28. West Nile Virus Wild Birds Hawaii Alaska P.R .
    25. 29. West Nile Virus Veterinary Hawaii Alaska P.R.
    26. 30. West Nile Virus Human Cases Hawaii Alaska P.R.
    27. 31. West Nile Virus Spread With Birds Mississippi Flyway Routes Atlantic Flyway
    28. 37. Culex nigripalpus
    29. 38. West Nile Virus <ul><li>The West Nile Virus has become a permanent fixture of the US Medical landscape. </li></ul>
    30. 39. West Nile Virus Clinical Course <ul><li>Incubation Period: 2 – 14 Days </li></ul><ul><li>Prodrome: 3 – 6 Days </li></ul><ul><li>Three Forms </li></ul><ul><ul><li>Asymptomatic – 80% </li></ul></ul><ul><ul><li>West Nile Fever – 20% </li></ul></ul><ul><ul><li>West Nile Disease – 0.6% </li></ul></ul>
    31. 40. West Nile Virus Infection <ul><li>80% Asymptomatic </li></ul><ul><li>20% Symptomatic but mild illness </li></ul><ul><li>0.6% Severe neurologic Illness </li></ul><ul><ul><li>Mortality: 5-14% </li></ul></ul><ul><li>Only 1 in 150 with meningitis or encephalitis </li></ul>
    32. 41. West Nile Fever <ul><li>Classical Description </li></ul><ul><ul><li>Mild-to-Moderate-to-Severe Influenza-Like Illness of Sudden Onset </li></ul></ul><ul><ul><li>Duration 3 - 10 Days </li></ul></ul><ul><ul><li>Fever, Headache, Malaise, Myalgias, Abdominal Pain, Nausea, Vomiting, Rash, Conjunctivitis, Eye Pain, Anorexia, Pharymites, Diarrhea </li></ul></ul>
    33. 42. West Nile Fever <ul><li>Fatigue (96%; 36 Days) </li></ul><ul><li>Fever (81%; 5 Days) </li></ul><ul><li>Headache (71%; 10 Days) </li></ul><ul><li>Muscle Weakness (61%; 28 Days) </li></ul><ul><li>Difficulty Concentrating (53%; 14 Days) </li></ul><ul><li>Rash (50%; < 7days) </li></ul>
    34. 44. West Nile Fever <ul><li>Hospitalization ~ 30% (~5 Days) </li></ul><ul><li>Missed Work/School ~ 80% (~10 Days) </li></ul><ul><li>At 30 Days – 63% Symptomatic </li></ul>
    35. 47. Meningitis and Encephalitis <ul><li>Meningitis </li></ul><ul><li>Inflammation of Meninges </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Nuchal Rigidity and Pain </li></ul></ul><ul><ul><li>CSF Pleocytosis </li></ul></ul><ul><li>Encephalitis </li></ul><ul><li>Inflammation of the Brain Parenchyma </li></ul><ul><ul><li>Meningeal Inflammation </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><li>Flacid Paralysis </li></ul><ul><ul><li>Asymetric </li></ul></ul><ul><ul><li>Anterior Horn Cell </li></ul></ul>
    36. 48. West Nile Virus Neurologic Disease <ul><li>Meningitis </li></ul><ul><li>Meningo-encephalitis </li></ul><ul><li>Encephalitis </li></ul><ul><li>Other </li></ul><ul><ul><li>Severe Weakness/ Flaccid Paralysis </li></ul></ul><ul><ul><li>Ataxia </li></ul></ul><ul><ul><li>Cranial Nerve Abnormalities </li></ul></ul><ul><ul><li>Polyradiculitis </li></ul></ul><ul><ul><li>Myelitis </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Optic Neuritis </li></ul></ul>
    37. 49. West Nile Virus Infection Neurologic Presentation <ul><li>Complaints of weakness out of proportion to evidence on physical exam. </li></ul><ul><li>Myoclonus nearly a universal finding. </li></ul><ul><li>Some patients have Parkinsonian-like signs: </li></ul><ul><ul><li>Tremor </li></ul></ul><ul><ul><li>Myoclonus </li></ul></ul><ul><ul><li>Rigidity </li></ul></ul><ul><ul><li>Bradykinesia </li></ul></ul><ul><li>Severe Neurologic Disease </li></ul><ul><ul><li>Recovery usually 1-2 weeks. </li></ul></ul><ul><ul><li>Death in first 2 weeks from neurological causes. </li></ul></ul><ul><ul><li>Death after 2 weeks from complications. </li></ul></ul>
    38. 50. West Nile Disease <ul><li>Fever (90%) </li></ul><ul><li>Weakness (50%) </li></ul><ul><li>Nausea / Vomiting (50%) </li></ul><ul><li>Headache (50%) </li></ul><ul><li>Rhabdomyolysis </li></ul><ul><li>Myocarditis </li></ul><ul><li>Hepatitis and Pancreatitis </li></ul><ul><li>Central Diabetes Insipidus </li></ul>
    39. 51. Culture-Negative Meningitis <ul><li>Approach To The Patient </li></ul><ul><ul><li>Empiric Antibiotics Pending Culture in Severe or Atypical Cases </li></ul></ul><ul><ul><li>Obtain Complete Epidemiologic History </li></ul></ul><ul><ul><ul><li>Exposure to Rodents, Ticks, and Mosquitos </li></ul></ul></ul><ul><ul><ul><li>Sexual Contacts </li></ul></ul></ul><ul><ul><ul><li>Exposure to Pre-school Age Children </li></ul></ul></ul><ul><ul><ul><li>New Medications Including Herbal and OTC </li></ul></ul></ul><ul><ul><li>Obtain Relevant Serologies </li></ul></ul><ul><ul><li>Consider Repeat LP at 24-48 Hours </li></ul></ul>
    40. 52. Seasonal Variation enterovirus tick-borne mosquito-borne mumps herpes Cases
    41. 53. West Nile Virus Epidemiology 99-03
    42. 54. Pathogenesis <ul><li>Viral Entry </li></ul><ul><li>Initial Multiplication in Local Lymphatics </li></ul><ul><li>Virema and Secondary Multiplication </li></ul><ul><li>Hematogenous Spread </li></ul><ul><li>CNS Invasion </li></ul><ul><ul><li>Direct Cerebral Capillary Invasion </li></ul></ul><ul><ul><li>Olfactory Nerve Entry </li></ul></ul><ul><ul><li>Choroid Plexus Entry </li></ul></ul><ul><li>Spread within CNS </li></ul><ul><li>Inflammation and Cytokine Release </li></ul>
    43. 55. Laboratory Findings <ul><li>Total Leukocyte Count Normal or Slightly Elevated </li></ul><ul><li>Hyponatremia Occasionally in Patients with Encephalitis </li></ul><ul><li>Csf </li></ul><ul><ul><li>Leukocytes: 0 - 1782 Cells/Mm3, Mostly Lymphocytes (Range 4-94%) </li></ul></ul><ul><ul><li>Protein Universally Elevated: 51 - 899 mg/dl </li></ul></ul><ul><ul><li>Glucose Normal </li></ul></ul><ul><li>CT Brain: No Evidence of Acute Disease </li></ul><ul><li>MRI in one-third Showed Enhancement of Leptomeninges, Periventricular Areas, or Both </li></ul>
    44. 56. State Labs <ul><li>Your state laboratory is currently able to assist with any undiagnosed aseptic encephalitis, meningitis, or meningoencephalitis cases by facilitating testing for IgM antibodies against WEE, SLE, and WN viruses. </li></ul><ul><li>Testing for these arboviral agents is usually free of charge. </li></ul>
    45. 57. Long-Term West Nile Virus IgM Activity in Human Serum N=29 7/12 (60%) of WN Encephalitis Virus Patients were IgM Positive at 500 Days Post-onset N = 29 0 5 10 15 20 25 30 0 50 100 150 200 250 300 350 400 Days Post-onset P/N
    46. 58. West Nile Virus Severe Disease <ul><li>Risk Factors </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><ul><li>Advanced age (>70) </li></ul></ul></ul><ul><ul><ul><ul><li>New York – hospitalized patients 9X mortality than <70 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Romania – Mortality rates 15 % over age 70 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Israel – Mortality rates 29 % over age 70 </li></ul></ul></ul></ul><ul><ul><ul><li>>50 – 20 X Mortality </li></ul></ul></ul><ul><ul><ul><li>>80 – 43 X Mortality </li></ul></ul></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>Immunosuppression </li></ul></ul><ul><ul><ul><li>Cancer </li></ul></ul></ul><ul><ul><ul><li>Steroids </li></ul></ul></ul><ul><ul><ul><li>Alcoholism </li></ul></ul></ul><ul><ul><ul><li>Starvation </li></ul></ul></ul><ul><ul><ul><li>Organ Transplant </li></ul></ul></ul>
    47. 59. Predictors of Death <ul><li>Change in Level of Consciousness </li></ul><ul><li>Encephalitis with Severe Muscle Weakness </li></ul><ul><li>Advanced Age </li></ul><ul><li>Possibly Diabetes Mellitus or Immunosuppression </li></ul><ul><li>Meningitis – 2% </li></ul><ul><li>Encephalitis – 12% </li></ul>
    48. 60. Outcome <ul><li>Outcome Of West Nile Virus Infection Among Hospitalized Patients </li></ul><ul><li>At Discharge (NY And NJ, 2000) </li></ul><ul><ul><li>More than half did not Return to Functional Level </li></ul></ul><ul><ul><li>Only One-Third Fully Ambulatory </li></ul></ul><ul><li>At One Year (NYC 1999 Patients) </li></ul><ul><ul><li>Fatigue 67%, Memory Loss 50%, Difficulty Walking 49%, Muscle Weakness 44%, Depression 38% </li></ul></ul>
    49. 61. Transmission of West Nile Virus <ul><li>Mosquito Bite </li></ul><ul><li>Blood Transfusion </li></ul><ul><li>Organ Donation </li></ul><ul><li>Breast Feeding </li></ul><ul><li>Transplacental </li></ul><ul><li>Lab Accidents </li></ul>
    50. 62. Treatment <ul><li>Supportive Treatment </li></ul><ul><ul><li>About 25% Require ICU Care; 10% Mechanical Ventilation </li></ul></ul><ul><li>Ribavirin and Interferon-a2b </li></ul><ul><ul><li>In-Vitro Activity in High Doses </li></ul></ul><ul><ul><li>Don’t Work Well in Patients </li></ul></ul><ul><li>IV Immunoglobulin G </li></ul>
    51. 63. Treatment <ul><li>No Controlled Studies of: </li></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Antiseizure Meds </li></ul></ul><ul><ul><li>Osmotic Agents </li></ul></ul>
    52. 64. Reported Neuroinvasive WNV Infection, Idaho Residents, 2006– by age group Source: Dr. C.Hahn, Idaho Division of Health (9/1/2006). N=84. Age not known on 16 additional cases.
    53. 65. Reported Neuroinvasive WNV infection, Idaho residents, 2006– by county of residence Source: Dr. C.Hahn, Idaho Division of Health (9/1/2006). N=100.
    54. 66. Reported WNV Neuroinvasive Disease, Idaho residents, 2006– by date onset Source: Dr. C. Hahn, Idaho Division of Health, 9/1/2006. N=97.
    55. 67. Idaho Deaths from West Nile Virus <ul><li>12 (+1 Out of State) </li></ul><ul><li>Average Age – 75 </li></ul><ul><li>Range of Ages 46 – 92 </li></ul><ul><li>Male 8 / Female 4 </li></ul>
    56. 68. Prevention <ul><li>Reducing the Number of Mosquitoes </li></ul><ul><ul><li>Spraying </li></ul></ul><ul><ul><li>Aerial Spraying </li></ul></ul><ul><ul><li>Drain Existing Water </li></ul></ul><ul><ul><li>Install or Repair Window or Door Screens </li></ul></ul><ul><li>Using Mosquito Repellants </li></ul><ul><ul><li>DEET – 10 – 50% </li></ul></ul><ul><li>Barrier Methods </li></ul><ul><li>Vaccines </li></ul><ul><li>Blood Donor Screening </li></ul>
    57. 69. Summary <ul><li>West Nile Virus infection is a mosquito-borne infection primarily of birds. </li></ul><ul><li>Majority of human infections are asymptomatic. </li></ul><ul><ul><li>West Nile Fever – 80% </li></ul></ul><ul><ul><li>West Nile Disease – 0.6% </li></ul></ul><ul><li>Presence of culture-negative meningitis encephalitis in late summer and fall with muscle weakness and geographic exposure are clinical clues. </li></ul><ul><li>ELISA testing of serum and CSF (IgM) can be performed at State Laboratories. </li></ul><ul><li>Treatment is supportive. </li></ul><ul><li>Personal protection measures – critical. </li></ul><ul><li>No human vaccine yet. </li></ul>
    58. 70. Thanks To… <ul><li>Resources </li></ul><ul><li>References </li></ul><ul><ul><li>Clinical Infectious Diseases </li></ul></ul><ul><ul><ul><li>2000;30:413-8 </li></ul></ul></ul><ul><ul><li>New England Journal of Medicine </li></ul></ul><ul><ul><ul><li>2001;344:1807-14 </li></ul></ul></ul><ul><ul><li>Emerging Infectious Diseases </li></ul></ul><ul><ul><ul><li>2001;7:611 </li></ul></ul></ul><ul><ul><li>Annals of Internal Medicine </li></ul></ul><ul><ul><ul><li>2002;137:173-179 </li></ul></ul></ul><ul><ul><li>Jama </li></ul></ul><ul><ul><ul><li>2002;288:13, 1573-4 </li></ul></ul></ul><ul><ul><li>Up-To-Date </li></ul></ul><ul><ul><ul><li>2006, 14.2 1-10 </li></ul></ul></ul> www.cdc.gov  http://www2.state.id.us/dhw/index.htm <ul><ul><li>Sky Blue, MD </li></ul></ul><ul><ul><li>Infectious Disease </li></ul></ul><ul><ul><li>Boise, Idaho </li></ul></ul><ul><ul><li>Christine Hahn, M.D. </li></ul></ul><ul><ul><li>State Epidemiologist </li></ul></ul><ul><ul><li>Boise, Idaho </li></ul></ul><ul><li>http://www.idahoahec.org/ </li></ul><ul><ul><li>Please e-mail [email_address] for copies of this presentation </li></ul></ul>

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