Bioterrorism Present

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Bioterrorism Present

  1. 1. นพ.อินทนนท์ อิมสุวรรณ ่ โครงการจัดตังภาควิชาเวชศาสตร์ฉุกเฉิน ้ คณะแพทยศาสตร์ มหาวิทยาลัย ธรรมศาสตร์
  2. 2. Ä On October 2, 2001 0 a 63-year-old Caucasian photo editor working for a Florida newspaper o awoke early with nausea, vomiting, and confusion and was taken to a local emergency room for evaluation
  3. 3. P His illness, which started on September 27 during a trip to North Carolina characterized by malaise, fatigue, fever, chills, anorexia, and sweats , No history of headache, cough, chest pain, myalgias, dyspnea, abdominal pain, diarrhea, or skin lesions
  4. 4. Œ Patient was alert and interactive but spoke nonsensically l He was not oriented to person, place, or time t BT 39.2°C HR 109/min BP 110/80 RR 14/min 0 Initial pulmonary, heart, and abdominal examinations were normal e No nuchal rigidity
  5. 5. CBC: Hct 45.7 WBC 9400 N 76% L15% Plt 109,000 C Na 132 K 3.5 Cl 110 HCO3 24 1 UA :no RBC,WBC
  6. 6. l prominent superior mediastinum and small left pleural effusion
  7. 7. 0 WBC count 4,750/µL (81% neutrophils) µ RBC count 1,375/µL µ glucose 57 mg/dL (serum glucose 174 mg/dL) protein 666 mg/dL
  8. 8. Microscopy examination of the CSF showed many gram-positive bacilli
  9. 9. Shortly after admission m He had generalized seizures and was intubated for airway protection
  10. 10. The patient died on October 5 Autopsy findings hemorrhagic mediastinal lymphadenitis immunohistochemical staining showed disseminated B. anthracis in multiple organs
  11. 11. l a 59-year-old Caucasian man, contract employee at a U.S. State Department mail sorting facility that received mail from the District of Columbia postal facility became ill
  12. 12. He had drenching sweats 2 days of fever with chills,severe myalgias w cough with scant white sputum substernal chest pain nausea, vomiting, abdominal pain
  13. 13. BT 38.2°C HR 116/min BP 120/70 RR 16/min / oxygen saturation 94% (room air) n He appeared ill and had decreased breath sounds at the right base The rest of the examination was unremarkable
  14. 14. ì Hematocrit 48.1% ì WBC count 9,500/mm3 ( 81% N, 9% L 9% M) m Platelet count 196,000/ mm3 9 Normal electrolytes and creatinine
  15. 15. Widening mediastinum
  16. 16. Mediastinal adenopathy with evidence of hemorrhage Normal lung parenchyma Small bilateral pleural effusions Suspected small pericardial effusion
  17. 17. ° Intravenous penicillin c Rifampin c Ciprofloxacin c Vancomycin
  18. 18. Features that should alert possibility of bioterrorism-related outbreak r A rapidly increasing disease incidence (e.g., within hours or days) in a normally healthy population o An epidemic curve that rises and falls during a short period of time t especially with fever, respiratory, or gastrointestinal complaints
  19. 19. Features that should alert possibility of bioterrorism-related outbreak An endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern Lower attack rates among people who had been indoors especially in areas with filtered air or closed ventilation systems compared with people who had been outdoors s Clusters of patients arriving from a single locale
  20. 20. Features that should alert possibility of bioterrorism-related outbreak Large numbers of rapidly fatal cases s Any patient presenting with uncommon disease and has bioterrorism potential Pulmonary anthrax Tularemia Plague
  21. 21. Ä The U.S. Public health system and primary healthcare providers must be prepared to address various biological agents b pathogens that are rarely seen in the united states r High-priority agents include organisms that pose a risk to national security
  22. 22. P Category A agents Can be easily disseminated or transmitted from person to person Result in high mortality rates and have the potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness
  23. 23. • Anthrax (bacillus anthracis) i Botulism (clostridium botulinum toxin) 1 Plague (yersinia pestis) H Smallpox (variola major) a Tularemia (francisella tularensis) r Viral hemorrhagic fever filoviruses [Ebola, marburg] arenaviruses [Lassa, machupo]
  24. 24. Biological weapon In year 2001, US Anthrax was deliberately spread through the postal system by sending letters with powder containing anthrax 22 cases of anthrax infection
  25. 25. P Bacillus anthracis i a gram-positive spore-forming bacterium s “woolsorters'disease” a a disease of sheep, cattle, and horses
  26. 26. The spores are extremely hardy and can survive for years s The disease is caused by exposure to the spores, not the bacilli in their vegetative state
  27. 27. The spores germinate into bacilli inside macrophages n Releasing toxins protective antigen edema factor lethal factor O cause edema and cell death
  28. 28. Skin : cutaneous anthrax x Lung : inhalation anthrax Breathing in anthrax spores from infected animal products like wool l GI tract : gastrointestinal anthrax Eating undercooked meat from infected animals
  29. 29. Incubation period d ranges from 1day to 8 weeks (average 5days) depending on the exposure route and dose  2-60 days following pulmonary exposure  1-7 days following cutaneous exposure  1-7 days following ingestion
  30. 30. 0 the most lethal form of the disease f caused by inhaling spores into the lungs n the spores germinate and are transported to the tracheobronchial lymph nodes
  31. 31. Initial phase ð flulike illness with malaise w nonproductive cough, chest discomfort u initial phase can be delayed for more than a month in some patients s 50% of patients develop hemorrhagic meningitis
  32. 32. Within 24 to 48 hours h abrupt deterioration Overwhelming sepsis Dyspnea, stridor Shock Hemorrhagic mediastinitis
  33. 33. ΠChest radiograph show a widened mediastinum and hilar adenopathy
  34. 34. Mediastinal widening and pleural effusion
  35. 35. CT chest is more sensitive Bloody pleural effusions consolidation of the lung fields
  36. 36. H Clinical diagnosis Flulike or septic illness c A reason to consider anthrax in the first place Current outbreak, warning from authorities , Sputum culture, gram stain, and blood cultures are not helpful until late in the course of the disease
  37. 37. Tests to confirm the diagnosis PCR for identification of anthrax markers in pleural fluid i serologic detection of immunoglobulin to protective antigen e Immunohistochemical testing of biopsy specimens
  38. 38. l Influenza
  39. 39. spores are introduced into the skin through open wounds or abrasions n After I.P. 1 to 5 days 5 Begins as a papule usually on an exposed area the head, neck, or an upper extremity o The papule may resemble an insect or spider bite and may itch
  40. 40. a papule progressing to form a large vesicle over the next several days e Severe edema occurs around the lesion with regional lymphadenitis m The lesions are not tender m patient may or may not be febrile
  41. 41. Day 2 Day 4
  42. 42. Day 4 : edema Day 4 : Eschar formation
  43. 43. After about 1 week ü the lesion ruptures, forming a black eschar r surrounding erythema and edema increase h The necrotic ulcer is usually painless
  44. 44. Ulcer and vesicle ringblack eschar
  45. 45. Forearm lesion on day 7 n vesiculation and ulceration of initial macular or papular anthrax skin lesion
  46. 46. h Eschar of the neck on day 15, typical of the last day of lesion
  47. 47. In the next 2 to 3 weeks ü the eschar sloughs off f the organism disseminates and the patient dies
  48. 48. The mortality rate  20% without treatment  1% with treatment t Antibiotics do not affect the course of local disease e but are used to prevent dissemination and death
  49. 49. H Clinical diagnosis. i Confirmation Culturing of the lesion, punch biopsy,or serologic testing
  50. 50. l Rare manifestations o The ingestion of insufficiently cooked, contaminated meat t the spores are transported to regional lymphatic tissue r I.P 2- 5 day r The mortality rate is 50%
  51. 51. 0 Present with sore throat and neck swelling from cervical and submandibular lymphadenitis m The tonsils are frequently involved i Fever and toxicity t Dysphagia t Respiratory distress
  52. 52. ΠBegins with nausea, vomiting, and fever e Hematemesis e Ascites e Bloody diarrhea e Mesenteric lymphadenitis a Present with an acute abdomen
  53. 53. Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th Ed
  54. 54. , Death usually results within 3 days s The mortality rate was thought to exceed 90%
  55. 55. Œ Inactivated, cell-free anthrax vaccine l There is a vaccine to prevent anthrax, but it is not yet available for the general public a Anyone who may be exposed to anthrax Certain members of the US Armed forces Laboratory workers Workers who may enter contaminated areas In the event of an attack using anthrax as a weapon, people exposed would get the vaccine
  56. 56. ˆ Human-to-human transmission has not been reported with inhalational anthrax t Airborne transmission does not occur, but direct contact with skin lesions may result in cutaneous infection
  57. 57. è Yersinia pestis à gram-negative bacterium c Zoonotic disease is transmitted to humans by the bites of infected rodent fleas
  58. 58. Male Xenopsylla cheopis (oriental rat flea) engorged with blood. This flea is the primary vector of plague in most large plague epidemics in Asia, Africa, and South America
  59. 59. è suggestive of exposure to rodents, rodent fleas, wild rabbits, sick or dead carnivores, or patients with pneumonic plague. a Incubation period is 1–6 days
  60. 60. , Specimens bubo aspirates, blood cultures, sputum culture if pneumonic o Microscopic identification t culture confirmation t Serologic tests fourfold change in antibody titer to f1 antigen between acute- and convalescent-phase sera
  61. 61. Physicians should report all suspected plague cases to state or local health departments and/or consult with CDC to obtain information and access diagnostic services.
  62. 62. ( Parenteral antibiotic therapy Streptomycin O Alternatively Gentamicin ¤ Oral therapy Doxycycline
  63. 63. ì No vaccine is currently available in the united states. i aimed at reducing contact with fleas and potentially infected rodents and other wildlife
  64. 64. Generated by the infected patient during coughing, sneezing, talking during respiratory-care procedures
  65. 65. Healthcare providers and others should wear a surgical-type mask when within 3 feet of the infected patient c Some healthcare facilities require a mask be worn to enter the room of a patient on droplet precautions
  66. 66. Maintained until patient has completed 72 hours of antimicrobial therapy
  67. 67. Maintaining spatial separation of at least 3 feet between infected patients and others when cohorting is not achievable. r Avoiding placement in the same room with an immunocompromised patient. m Special air handling is not necessary and doors may remain open
  68. 68. 0 Prophylactic antibiotic treatment in person who exposure to bites of wild rodent fleas during an outbreak tissues of a plague-infected animal person or animal with suspected plague pneumonia
  69. 69. Contact precautions Wear clean gloves upon entry into patient room. Wear gown for all patient contact and for all contact with the patient’s environment. Require a gown be worn to enter the room of a patient. Gown must be removed before leaving the patient’s room. Wash hands using an antimicrobial agent
  70. 70. Healthcare facilities without patient rooms appropriate for Airborne Precautions e should have a plan for transfer of suspected or confirmed smallpox patients to neighboring facilities with appropriate isolation rooms
  71. 71. Ð Fever, headache and stiff neck a sepsis and rash in meningococcemia
  72. 72. H N. meningitidis colonizes mucosal surfaces of nasopharynx p direct contact with large droplet respiratory secretions from the patients or asymptomatic carriers c Humans are the only host
  73. 73. H Patients with meningococcemia should be placed in respiratory isolation for at least 24 hours.
  74. 74. H Close contacts should receive antibiotic prophylaxis. h Household, nursery school, and daycare center contacts r Intimate contacts and health care workers with intimate exposure mouth-to-mouth resuscitation, intubation,suctioning
  75. 75. Rifampin, 10 mg/kg (up to 600 mg) orally every 12 hours for four doses h The dose for infants younger than 1 month is 5 mg/kg. . Rifampin discolors the urine r Contact lenses should be removed to avoid permanent staining.
  76. 76. Ceftriaxone IM is effective against group A strains. 125 mg for children younger than 12 years 250 mg for those older than 12 years alternative for pregnant women and for people in whom compliance cannot be ensured. o Ciprofloxacin (500 mg orally)
  77. 77. È Meningococcal vaccine should be considered adjunct to prophylaxis in epidemics close contacts in sporadic cases n The currently available vaccine is a quadrivalent vaccine containing purified capsular polysaccharides for groups A, C, Y, W
  78. 78. No vaccine exists for group B the most prevalent serogroup in the United States.
  79. 79. The quadrivalent vaccine is not recommended for routine use r but should be administered to children 2 years of age older in high-risk groups functional or anatomic asplenia terminal complement deficiency
  80. 80. The vaccine is currently administered to U.S. military recruits. c Consideration in people traveling to endemic areas of the world such as sub- Saharan Africa.

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