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ID Board Review

ID Board Review. March 24, 2009. Rickettsial Diseases. Rocky Mountain Spotted Fever. Peak incidence  spring & summer Mode of transmission  tick (esp. dog tick) Clinical Triad  Fever + Rash + Headache Nonspecific anorexia, myalgias , N/V, abdominal pain Rash

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ID Board Review

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  1. ID Board Review March 24, 2009

  2. Rickettsial Diseases

  3. Rocky Mountain Spotted Fever • Peak incidence  spring & summer • Mode of transmission  tick (esp. dog tick) • Clinical • Triad  Fever + Rash + Headache • Nonspecific anorexia, myalgias, N/V, abdominal pain • Rash • Maculopapular rash  petechial / purpuric • Begins on extremities (ankles, wrists, lower legs) • Includes palms and soles • Other rare findings: HSM, thrombosis, CNS • Fulminant (esp w/ G6PD) : coagulopathy, thrombosis, renal failure, liver failure, respiratory failure  death < 5 days

  4. Looks like RMSF but it’s not…. • Differential Diagnosis • Erlichiosis • Meningococcemia • Measles • Viral exanthems • Scarlet fever • TSS • ITP / TTP • HSP • Kawasaki disease

  5. Diagnosis & Treatment • Diagnosis • Clinical + epidemiological • Lab findings: thrombocytopenia, elevated AST/ALT, bilirubin • Late in dz: • Skin biopsy  staining for R. rickettsii (DO not get if > 48 hrs of tx) • Confirmation with serology • Indirect fluorescent Ab (IFA) + Ab 7-10 d after onset • Treatment • Doxycycline (even in those < 8 hrs) • Alternatives • Tetracycline • Chloramphenicol (pregnant women) • Treat at least 3 days after afebrile (5-7 d)

  6. Ehrlichiosis • Similar to RMSF • Human disease • Human monocyticehrlichiosis • Human granulocytic anaplasmosis • Vector • Wood tick or deer tick • Signs/Symptoms • Fever + Headache + Rash; N/V, myalgias, LAD, HSM • **Leukopenia / neutropenia, elevated AST/ALT • Treatment: Doxycycline

  7. Fungal Diseases

  8. Candida • Predisposing factors • Recent Antibiotic use • IC / Immunosuppressed (steroid use, BMT/organ transplant, malignancy), TPN, burns, DM, NICU/PICU setting, CVL • Disease Manifestations • Oropharyngeal, Cutaneous, Vulovaginitis/Balanitis • Invasive: UTI, PNA, Peri - / Endocarditis, Osteoarticular, Meningitis, Disseminated • Treatment • Antifungals : Fluconazole, topical (Nystatin), Itraconazole, Ketoconazole, Voriconazole, Ampho B, Micafungin

  9. Cryptococcosis • Encapsulated yeast • Inhalation of spores / direct from contaminated soil, bird droppings (pigeons) • Clinical Manifestations • **Opportunistic Infection • Immunocompetent : Pnuemonia • Immunosuppressed: Disseminated disease • Sepsis syndrome, Meningitis, Skin infection, • Arthritis, bone involvement, chrioretinitis, LAD

  10. Diagnosis & Treatment • Latex agglutination – Ag • India Ink • < sensitive than cx & Ag • Definitive: • fungus in tissue specimen • Treatment • Observation • Antifungals • Fluconazole • Ampho B +/- flucytosine

  11. Coccidioidomycosis • Dimorphic fungi • Found SW US (Arizona, CA, NM, west TX) • Acquired via inhalation of spores • Clinical manifestations • Flu like symptoms, PNA • Fever, night sweats, HA, cough, chest pain, myalgias/fatigue, rash • Sx can persist for months • Immunosuppressed Disseminated disease • Treatment • Observation • Antifungals: ketoconazole, fluconazole, ampho B

  12. Aspergillosis • Transmission soil, hay, decaying vegetation • Inhalation of spores • Signs/Symptoms • Allergic bronchopulmonaryaspergillosis • Hypersensitive reaction – asthma, CF • Fever, cough, wheezing, sputum production, hemoptysis • Progress to bronchietasis, fibrosis, resp. compromise • Aspergilloma (fungal ball in preexisting cavity) • Invasive disease – IC

  13. Histoplasmosis • Transmission via bird droppings (pigeons, bats, chickens) • Ohio, Missouri, Mississippi river valley • Signs/Symptoms • Up to 95% will be asymptomatic • Flu like symptoms (fever, HA, malaise, cough) • PNA, HSM, rash, arthritis, pericarditis, disseminated dz • Treatment • Self limited • Disseminated dz/IC: Ampho B, fluconazole, ketoconazole

  14. Sporotrichosis • Fungus Sporothrixschenckii • Found in soil, decaying vegetation • Acquired via trauma to skin or inhalation • Signs/Symptoms • Skin: Local pustule/ulcer , nodules developing along draining lymphatics • Systemic: • Pulmonary-- granulomatouspneumonitis • IC: Disseminated • Considered one of the AIDS related conditions • Treatment: KI, Antifungals (Ampho B, fluconazole)

  15. Parasites

  16. Giardiasis • Mode of transmission: fecal-oral, contaminated water • Risk factors: poor hygiene, poor handwashing • Common cause of diarrhea in daycares • Carrier rates up to 60% • Clinical presentation • Watery foul smelling diarrhea, NON-BLOODY • Other sx: low grade fever, bloating/flatus, abdominal cramps, nausea, generalized malaise, weight loss, anorexia • Subacute / Chronic – FTT • Duration 3-10 wks (untreated)

  17. Diagnosis & Treatment • Diagnosis • Stool x 3 for ova and parasites • Stool Ag detection (IFA, ELISA) • CBC  NO EOSINOPHILA • Treatment • Metronidazole (Flagyl) • Alternatives: Tinidazole,

  18. Toxoplasmosis • Mode of transmission: undercooked / raw meat, cat feces • Congenital • Early infection  less chance of fetal infection but more severe consequences • Late infection  more chance of fetal infection but less severe • Clinical • Asymptomatic • Microcephaly, hydrocephalus, chorioretinitis, diffuse cerebral calcifications (ring enhancing), jaundice, HSM • 50% rule • 50% of infected pregnant women pass to fetus • 50% will be asymptomatic at birth • Late findings • Hearing loss, vision impairment, seizures, MR, LD • Diagnosis • PCR of amniotic fluid • Infant IgG and IgM

  19. Toxoplasmosis • Acquired • Most will be asymptomatic • Fever, myalgias, HA, fatigue, LAD • Treatment • Pregnant mom : Spiramycin • Pyrimethamine or sulfadiazine + folinic acid

  20. Enterobiasis • Pinworm Enterobiusvermicularis • Common in children ages 5-10 yrs • Transmission: direct contact • Signs / Symptoms • Perianal itching (pruritusani) – esp. nocturnal • Restlessness, insomnia, abdominal pain, N/V • Vulvovaginitis, UTI, Eosinophileentrocolitis • Diagnosis • “Scotch tape” test x 3 (early AM) • Treatment • Mebendazole or albendazole x 1 dose • Repeat in 2 weeks • Other considerations • Treat household members, wash bedding and clothes • Can attend daycare

  21. Trichinosis • Nematode Trichinella • Ingestion of undercooked or raw meat (esp. pork) • Reportable disease • Signs/ Symptoms • Diarrhea, severe myalgias, fever, facial edema, HA, rash • Rhabdomyolysis like (elevated CPK, myoglobinuria) • Cardioneurologic Syndrome • Dx : Eosinophilia , ELISA after 2 wks, Western blot for confirmation; muscle biopsy • Treatment: Mebendazole + Steroids

  22. Ascaris • Intestinal roundworm Ascarislumricoides • Fecal – oral transmission, eating soil • Increased incidence poor sanitation, travelers, immigrants, refugees, adoption • Signs/ Symptoms • Early: fever, cough, dyspnea, wheezing • Late (GI) : passage of worms, N/V, abdominal pain • ***Intestinal obstruction, common bile duct obstruction, cholangitis • Eosinophilia, eggs in stool • Treatment • Albendazole, mebendazole • Alternatives: pyrantelpamoate

  23. Visceral Larva Migrans • Due to roundworm Toxocara species (dogs, cats) • Seen in preschool age children • History of eating dirt (ingest eggs) • Signs / Symptoms • Nonspecific fever, anorexia, pruritic /urticarial rash • GI: abdominal pain, HSM • Pulmonary: wheezing • More serious: Ocular involvement, seizures, Myocarditis, HSM, Encephalitis • Dx: Leukocytosis, eosinophilia, elevated isohemagglutinins A, B, ELISA • Treatment: supportive, +/- Mebendazole

  24. Amebiasis • Entamoebalhistolytica • Fecal – oral transmission • Signs/ Symptoms • Most cases asymptomatic • Gradual onset bloody diarrhea colicky abdominal pain, tenesmus, anorexia, weight loss, fever • Most common extraintestinal manifestation : Liver abscess • Other: brain abscess, toxic megacolon, pleuropulmonary • Labs: Stool + WBC & RBC, Stool culture + cyst & trophozoites, eosinophilia, mild elevation transminases • Treatment • Metronidazole

  25. Whew, that’s all for now!! Coming soon..… ID part deux Bacterial and Congenital Infections

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