Greg Fenati, DO- Infectious Disease Board Review 2014 - Armc Emergency Medicine
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Greg Fenati, DO- Infectious Disease Board Review 2014 - Armc Emergency Medicine Presentation Transcript

  • 1. 2013 ID Board Review Part 3 Greg Fenati DO ARMC EM
  • 2. Just got back from Africa…    Flu like symptoms Bleeding ??????
  • 3. 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
  • 4. Marburg and Ebola Viruses    Labs – Thrombocytopenia, Hemorrhagic anemia (specifically GI med student finger positive) ELISA and PCR for confirmation Management  Supportive (death is common)
  • 5. Parents find a bat in an infants room when they wake up in the AM. What are you worried about?
  • 6. Rabies   Roughly 3 cases per year in the US however 40,000 deaths / yr worldwide Most common bites for Dogs and Bats
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. ???????????
  • 14. Small Pox (Variola)    Eradicated in 1980, last natural 1977 Untreated mortality 30% Airborne pathogen which is concerning for bioterrorism
  • 15. 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
  • 16. Small Pox (Variola) Dx    If clinically suspected.. Viral swab of oral mucosa or open pustule Then call CDC and authorities for suspected terrorist attack
  • 17. Small Pox (Variola) Management     Contact and droplet iso Iso family and close contacts Vaccination and immunoglobulin Supportive once rash appears
  • 18. 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????
  • 19. Malaria   Plasmodium falciparum, ovale, vivax, malariae Falciparum is the most leathal (foul)
  • 20. 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
  • 21. Malaria Complications  Cerebral    Anemia     Mostly falciprum AMS, sz, coma Immune related hemolysis from RBC surface antigen Thrombocytopenia Think G6PD deficiency in primaquine tx Pulmonary   Mostly falciprum -- fever/cough May develop ARDS
  • 22. Malaria Dx    Peripheral blood smears Hemolytic anemia commonly with thrombocytopenia False positive VDRL
  • 23. 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
  • 24. Gardener / Landscaper ?????
  • 25. Sporotrichosis Etiology  Fungal infection by Sporothrix scheenckii  Mold on plants– Roses  Cats, Armidillos   Inoculation into skin Farmers, gardeners, forestry workers
  • 26. 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
  • 27. 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 
  • 28. Fevers, myalgias, dark urine traveled to the northeast?
  • 29. 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
  • 30. 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
  • 31. Babesiosis Management    Most patients have spontaneous remission Can be deadly s/p splenectomy If ill appearing quinine with clyndamycin
  • 32. 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??
  • 33. 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
  • 34. 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
  • 35. ????
  • 36. 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
  • 37. 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 (wksmonths)mono or polyarticular asymmetric arthritis Late: (>1 yr)   10% chronic arthritis Neuro fatigue syndromes, chronic encephalopathy (memory impairment, hypersomnolence, mild psych)
  • 38. 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
  • 39. 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 2130 days Cardiac high degreeAdmit to tele, IV Ceftriaxone or PCN
  • 40. 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
  • 41. WUZ GATOR HUNTIN WITH MY CUZ/WIFE AND I SAW A TICK ON ME!! NOW I’M SICK!! WHAT IS IT DOC??? (in July)
  • 42. 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)
  • 43. Erlichiosis Signs/ Sympt   Abrupt fever, h/a, myalgias, chills, occaisional AGE symptoms Complications: Optic Neuritis, , ARDS, Meningitis, Pericarditis, Renal Failure, DIC
  • 44. Erlichiosis Dx/Management  DX     Leukopenia Thrombocytopenia Incresed LFTs Peripheral smear showing morula clusters  MANAGEMENT    Doxy or Tetracycline for 12wks Rifampin Most recover without residual
  • 45. Went hiking next day severe h/a, calf tenderness and a rash???
  • 46. 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
  • 47. 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
  • 48. RMSF Complications        Gangreen Myocarditis Interstitial pneumonitis / ARDS Rickettsial encephalitis, meningitis, focal neuro deficits, sz, coma ARF Hypovolemic Shock DIC
  • 49. 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
  • 50. Went hiking a week ago and now I can’t move my legs. What do I have and can you fix me?
  • 51. TICK PARALYSIS   Most common in Southeast in spring and summer Dermacentor Species – toxin secreted in salivary glands during blood meal blocks acetylcholine release
  • 52. 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
  • 53. We skinned up these rabbits good!!
  • 54. Now I have this and belly pain.. What’s up?
  • 55. 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
  • 56. Tularemia Manifestations  Ulceroglandular      Most common Ulceration of papules 2 days after tick innoculation Glandular      2nd most common Lymphadenopathy without ulceration Unilateral conjunctivitis with regional adenopathy    Systemic dz without identified entry site f/c/abd pain/ night sweats Pulmonary  Oculoglandular  Typhoidal Direct inhalation Similar to bacterial pneumonia Concern for bio warfare Oropharyngeal    Least Common Undercooked rabbit meat Nonspecific GI issues… may progress to GI bleed
  • 57. 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
  • 58. Infectious Control Standard Precautions   Yeah Gown, Glove, blah, blah… For the test it is always hand wash, hand wash, hand wash
  • 59. 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
  • 60. 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
  • 61. 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
  • 62. Occupational Exposure  Hep C blood exposure   Transmission is approximately 2-7%  Good Luck!!  No treatment or vaccination exists
  • 63. 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
  • 64. Occupational Exposure  HIV blood exposure   Regimen: Zidovudine and Lamivudine X 1 month  Administer as soon as possible  May be ineffective if started > 24 hours 
  • 65. Good luck on your boards!!