Clinical approach to the infectious disease patient Mobile Tropical Medicine, February 2014 Slide deck developed by LTC(

1. Clinical approach to the infectious disease patient Mobile Tropical Medicine, February 2014 Slide deck developed by LTC(P) Stephen Thomas, WRAIR VDB Richard Ruck, MD LTC, MC, USA Pediatric Infectious Diseases Viral Diseases Branch, WRAIR Richard.c.ruck.mil@mail.mil 301-319-9904

2. Outline • BLUF • Soliciting a detailed medical history • Infectious diseases of returning travelers • Geographic disease distribution • Infectious Disease Emergencies • Medical history and clinical syndromes making thediagnosis

3. BLUF: Caring for the ID Patient • A comprehensive, in-depth medical history is your best diagnostic tool • Geographic and ID threat situational awareness • Know your ID emergencies • Know what you don’t know, seek assistance when needed

4. Common Things are Common Not this… Usually this…

5. Soliciting a Detailed Medical History

6. Chief Complaint • Localizing • Focal lesion (cellulitis) • Bite (arthropod, animal, human) • Post-traumatic (altercation, vegetation) • Anatomical (CNS, GU, GI, etc.) • Generalized and systemic • Fever, chills, rigors • Muscle and / or joint pain • Fatigue

7. Cat bites causing skin /soft tissue infections

8. History of Present Illness • Key information • Detailed chronology of illness • Patient was well until…DATE…when…X…happened • Appearance / disappearance of signs / symptoms • Non-specific illnesses may declare themselves • Identify patterns if they exist • Example: patterns of fever (every 3 days) • Incorporate important medical background of patient • Age (impacts presentation, fever curves, etc.) • Immunodeficient (HIV, medications, malignancy)

9. History of Present Illness • Key information • Incorporate activities / exposures • Animals, arthropods, people, vegetation • Urban, rural environment exposure • Indoor or outdoor activities • Incorporate relevant active (recent) medications • Prophylaxis, immunomodulators, OTC medications • Incorporate relevant associated travel history

10. Review of Systems • Pertinent positives and negatives • Specifically mention if no fever • CNS: evidence of meningitis, encephalitis, any neuro • Respiratory: tracheobronchitis, pneumonia • Oropharynx: pharyngitis, bleeding gums, dentition • GI: diarrhea with blood, mucus, rice water appearance • GU: discharge, dysuria, abnormal menses • Skin: rash, location, itching, character • Extremities: localized pain, joint versus bone pain

11. Past Medical/Surgical History • Drill down on relevant pre-existing medical conditions • Immunosuppressive conditions • Drill down on chronic or re-occurring conditions • Examples: frequent respiratory infections, meningitis • Presence or absence of organs • Appendix, gallbladder, spleen, thymus • Previous surgical interventions • Heart surgery (valve) • Implant of any hardware or foreign material • Known lab / radiologic abnormalities • Examples: lung nodule/Ca++, heart block, etc.

12. Medications / Immunizations • Rx and OTC (previous antibiotics) • Immunosuppressives • Examples – prednisone • Anti-pyretics (ASA, NSAIDS, acetaminophen) • Manipulate fever curve • Prophylaxis (detailed account) • Test understanding (especially malaria prophylaxis) • Anything which could impact absorption or metabolism of chronic or prophylactic medications impacting their performance. • All routine and travel specific vaccinations!

13. Social History • Activities, hobbies, occupation (defines potential exposures) • Examples: hunter, gardener, fishing • Sexual practices • Examples: monogamous, MSM, high risk behaviors • Drugs and alcohol • Needle based drugs, potential for cirrhosis, etc. • Tobacco • American or foreign • Food • OCONUS (“on economy”),

14. Family History • First degree relatives • Immunosuppressive conditions • Recurrent infections • Individuals sharing household • Recent medical events (including vaccinations) • “Sick contacts” • Immunosuppressive conditions • Recent or current illness • If yes, explore diagnosis if known • Hospitalized?

15. Travel • Where (geographic specific infections) • When (rainy season = vectors) • Activities during travel (urban, rural) • Accommodations (hotel with A/C, outdoors) • Food (hot, cold, water, hotel, street, etc.) • Raw or uncooked meat, raw vegetables • Unpasteurized milk products • Precautions (any PPM?)

16. Differential diagnosisTravel history- activities • Sex - common during travel • Medical encounters • Medical/dental/tattoos • Recreational exposures • Fresh water • Soil contact • Insect exposures • Animal exposures • Bites • Direct contact with dogs, primates, etc.

17. College student not feeling well with fever, develops MS changes, hypotension, respiratory failure, the rash below

18. WF with RUQ pain, intermittent fever, expat. In Switzerland, owns dog, frequent walks in countryside, CT scan below. Diagnosis: Echinococcusmultilocularis

19. Service member wading in African stream, near Lake Victoria about four weeks ago. Now with right upper quadrant pain, fever, malaise, non-productive cough

20. Schistosomiasis: Geographic Distribution • Trematode • Widely distributed in tropical and subtropical regions • 207 million people infected worldwide • Over 800 million at risk of infection • 280,000 deaths annually • Amongst parasite infections, second only to malaria in its global impact

21. Infectious Diseases of Returning TravelersClues in Evaluation

22. Top 5 Illnesses in returning travelers

25. Differential DiagnosisIncubation Period

26. Differential diagnosisExposures and associated infections • Sex/body fluids • HAV, HBV, HCV, CMV • HIV • Syphilis • Freshwater • Leptospirosis • Schistosomiasis • Rodents • Hantaviruses • Lassa fever • Ingestions • Brucellosis • Animal exposure • Q fever • Rabies • Anthrax • Soil • Melioidosis • Dimorphic fungi

27. Differential diagnosisExposures and associated infections • Ticks/mites • Rickettsial • TBE • CCHF • Scrub typhus • Sandflies • Leishmaniasis • Lice • Relapsing fever • Epidemic typhus • Mosquitoes • Malaria • Yellow fever • Dengue • Chickungunya • Japanese encephalitis • Rift Valley fever • Fleas • Endemic typhus

28. Clinical syndromes

29. Differential DiagnosisClinical syndrome- undifferentiated fever • Malaria • Leptospirosis • Typhoid • Dengue • Chikungunya • Q fever • Acute schistosomiasis • Brucellosis • Amebic liver abscess • HIV

30. Differential diagnosisClinical syndrome- fever and hemorrhage Viral • Yellow fever • Dengue • Hantaviruses • Lassa fever • Ebola • Marburg • CCHR • Rift Valley fever Bacterial • Meningococcal • Leptospirosis • Rickettsial • Vibrio vulnificus

31. Differential diagnosisClinical syndrome- fever and CNS findings • Malaria • Meningococcal • Japanese encephalitis • Dengue • West Nile Virus • Rabies • African trypanosomiasis • T. b. rhodesiense • Q fever • Rickettsial • Brucellosis • Leptospirosis • Plague • Anthrax • Angiostrongyliasis

32. Differential diagnosisClinical syndrome- fever and respiratory symptoms • CAP • Influenza • SARS • Malaria • Hantaviruses • Plague • Anthrax • Tularemia • Q fever • Legionella • Cocci/Histo • Melioidosis • Tuberculosis • Acute schistosomiasis • Hookworm/ascariasis • Pulmonary embolism

33. Differential diagnosisClinical syndrome- fever and hepatitis • Hepatitis A • Hepatitis B • Hepatitis D • Hepatitis E • Yellow Fever • EBV • CMV • Q fever • Leptospirosis • Rickettsial • Brucellosis

34. Differential diagnosisClinical syndrome- fever and lymphadenopathy Localized • Tularemia • Leishmaniasis • Plague • Bartonella • HSV • LGV • Syphilis Generalized • Mononucleosis • Acute HIV • Rickettsial • Leptospirosis • Brucellosis • Relapsing fever • Trypanosomiasis • Toxoplasmosis

35. Geographic Disease DistributionCONUS / OCONUS

36. Typhoid fever • People often shed bacteria for months after infection • GI/abdominal symptoms, fever, headache, splenomegaly, elevated LFTs, furry tongue • -invades lymphatic tissues • -spread to any organ • Complications include intestinal hemorrhage or perforation, meningitis, myocarditis, cholecystitis, pneumonia, osteomyelitis • Rate of complications increased in individuals co-infected with Schistosomiasisand/or malaria.

37. Hepatitis A

38. Hepatitis E

39. HIV

40. Japanese Encephalitis

41. Malaria – E hemisphere

42. Malaria– W HemisphereMefloquineResistant

43. Melioidosis

44. Meningitis

45. Schistosomiasis

46. Tuberculosis

48. Rock Mountain Spotted Fever / Tularemia

49. Anaplasmosis / Babesiosis / Lyme Disease

50. Rock Mountain Spotted Fever