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גבר בן 69 עם חולשה קיצונית חלק ב' – אבחנה ודיון

גבר בן 69 עם חולשה קיצונית חלק ב' – אבחנה ודיון. ד"ר שי נתנזון – המחלקה לרפואת המשפחה של חיל הרפואה ומחלקה פנימית ב' מרכז רפואי שיבא – תל השומר. ד"ר נתנזון מתמחה בר. משפחה בחיל הרפואה ונמצא ברוטציה במחלקה פנימית ב' בתל השומר בהנהלת פרופ' י. שיינפלד. West Nile Virus WNV.

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גבר בן 69 עם חולשה קיצונית חלק ב' – אבחנה ודיון

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  1. גבר בן 69 עם חולשה קיצוניתחלק ב' – אבחנה ודיון ד"ר שי נתנזון – המחלקה לרפואת המשפחה של חיל הרפואה ומחלקה פנימית ב' מרכז רפואי שיבא – תל השומר ד"ר נתנזון מתמחה בר. משפחה בחיל הרפואה ונמצא ברוטציה במחלקה פנימית ב' בתל השומר בהנהלת פרופ' י. שיינפלד

  2. West Nile Virus WNV References : CDC , ACP Pier & AHFS Essentials, Ministry of Health, Journal of Infectious Diseases, Clinical Infectious Diseases

  3. VIRAL CLASSIFICATION • Arbovirus (arthropod-born) • Family - Flaviviridae • Species - WNV • Single strand RNA

  4. EPIDEMIOLOGY • 1937- first time isolated in Uganda, then spread through Africa, Asia, Middle East and Europe • Recent outbreaks - Romania (1996), Russia (1999), USA (1999) • Israel (year 2000 - 452 cases, of which 326 hospitalized, 29 fatalities) late summer. CDC Oct 2007

  5. TRANSMISSION

  6. OTHER WAYS OF TRANSMISSION • Blood transfusion • Organ transplant • Transplacental • Breast feeding • Occupational exposure (lab. workers)

  7. SUSCEPTIBILLITY • Asymptomatic infection 80% • Mild febrile syndrome - WNF 19% • Neuroinvasive disease - WNM or WNE 1% • People who are at higher risk of developing neuroinvasive disease : • Advanced age - most significant risk factor (<40 - 1% , >90 - 36%) • Immunocompromised - DM, HIV, TB, patients under chemotherapy, patients under immunosuppressive therapy • Genetic factor - CCR5 surf protein mutation (some protection against HIV but leads to more serious complications of CNS

  8. SYMPTOMS • Mild infection • Incubation period - 3-15 days (usually 6 days) • Fever (usually lasts 3 days – not more than 6 days) • Headache • Chills • Weakness • Myalgia • Lymphadenopathy • Drowsiness • Short lived truncal rash (maculopapular erythema) • GI complaints (nausea, vomiting, anorexia, diarrhea)

  9. Symptoms of Hospitalized Patients withWest Nile Virus, New York City, 1999 Fever 90% Weakness 56% Nausea 53% Vomiting 51% Headache 47% Change in mental status 46% Diarrhea 27% Rash 19% Lymphadenopathy 2%

  10. SYMPTOMS • Severe infection: • Symptoms above + • Mental status alterations (confusion, disorientation, personality changes, decreased consciousness) • Flaccid paralysis • Rarely associated: • Guillain - Barré syndrome • Multifocal chorioretinitis • Hepatitis • Nephritis • Pancreatitis • Splenomegaly

  11. CLINICAL DIAGNOSIS • Fever • Signs of meningitis (nuchal rigidity) • Signs of encephalitis (changes in mental status, coma) • Evidence of brainstem, cranial nerve or cerebellar dysfunction

  12. LABORATORY DIAGNOSIS • Take 2 samples of blood/CSF in a 7 days interval *Avidity is not a routine test

  13. DIAGNOSIS

  14. DD • Other viruses: HIV, Coxsackie virus, Echovirus , Enterovirus, • Bacterial infection: Lyme disease, Leptospira • Tick paralysis • Stroke • Brain abscess or paraspinal epidural abscess • Brain tumor

  15. TREATMENT • Supportive: • IV fluid and electrolyte management • Ventilator assistance for respiratory insufficiency • Management of cerebral edema • Control seizures • Consideration of other disease that present with ascending motor paralysis NO proven antiviral agent

  16. IV Human Immunoglobulin : The Israeli Experience ShimoniZ, Niven MJ, Pitlick S, Bulvik S – 2001- Patient with WNV and CLL Hamdan A, Green P, Mendelson E, Kramer MR, et al – 2002 – Patient after lung transplantation and WNV Haley M, Retter A, Fowler D, Gea-Banacloche, et al – in press- 6 patients

  17. ESSENTIALS OF PREVENTION

  18. USE GENEROUS AMOUNT OF MOSQUITO REPELLENT

  19. PREVENTION • Decrease exposure: • Wearing long sleeve shirts and pants for outdoor activities • Removal of standing water • Repair of window screens • Application of mosquito repellent • Spending less time outdoors after dusk or before dawn • Promote donor screening and donor deferral to prevent transmission through blood transfusion or organ transplantation from living donors • Promote prevention of maternal-fetal virus transmission through breastfeeding

  20. CONCLUSION • Spread via mosquito, infected blood products, vertical and breast feeding • Increase in rates in the latest years in western world • People at risk – elderly, immunocompromised, CCR5 • Flu like symptoms, complicate to meningitis and encephalitis • Diagnosis – presence of IgM or viral RNA in blood/CSF • No proven antiviral treatment • Prevention – STAY AWAY FROM MOSQUITOS!

  21. - THANK YOU -

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