Infectious Disease

1. Infectious Disease • Debbie King FNP • Nursing 8800

2. Influenza • Epidemics occur yearly in the US • Typically 5000-250,000 cases yearly • With severe outbreaks up to 40,000 deaths have occurred. • More elderly die • Occurs in winter and spring

3. Influenza • Patho • Classic flu is caused by orthomyxovirus influenza type A and to lesser extent, influenza type B • Worse than a cold, can lead to further infection • May develop into viral pneumonia • May develop further into a bacterial super-infection, esp. with Staph Aureus • Is important to give/get flu shots yearly • New vaccine is developed each year due to mutations of the major surface proteins- hemagglutinin and neuraminidase-rendering protein

4. Influenza • Presentation • Abrupt, with fever, chills malaise, myalgia, headache, nasal stuffiness, sore throat, and maybe nausea. • Early on there is a nonproductive cough • Fever is high lasting 3-5 days

5. Influenza Diagnostic testing presumptive diagnosis requires appropriate symptoms at the right time of the year may confirm with virology - a nasal swab culture

6. Influenza • Differentials • Lyme disease • Atypical mycoplasma pneumonia • Mono • Allergic rhinitis • Cytomegalovirus

7. Influenza • Management • Symptomatic care • Prevention of secondary infection rest, older people may need hospitalization, antipyretics, and analgesics, careful use of cough suppressants with type A may use antivirals such as Tamiflu 75mg bid x 5 days if started early in the illness

8. Influenza • Education • The very young and the elderly or immune compromised should avoid crowds • Get the vaccine • To call or be seen with increased or severe symptoms • Stay home when you are ill • Except to see your NP

9. Influenza • Follow up • Depends on the complications that occur • To be seen again if any of the following occur • Sinusitis, OM, bronchitis, pneumonia • Or if fever persists more than 4 or 5 days • Order CBC on follow up if pneumonia is suspected

10. Lyme Disease • Multisystem inflammatory disease of infectious etiology • Caused by a spirochete called Borrelia Burgdorferi • Is named for a town Old Lyme in Connecticut where it was isolated in the 1970’s • Found in the eastern US in wooded areas • Is a tic borne disease

11. Lyme Disease • Epidemiology and Causes • Unknown actual number of cases • Exaggerated number of cases • Over diagnosed and reported • Affects all demographics • Multiple strains • B. burgdorferi in the US • B. afzelii and B. garinii in Europe and Asia • The different strains cause different symptoms • More arthritis and erythema migrans in the US

12. Lyme Disease • Patho • Infection connected to the length of time of tick exposure • Tick must feed for 24 to 48 hours to pass the spirochete • Usually from the Ixodes scapularis tick which feed on mice, birds, ECT • Is spread more in the summer when the ticks are in the nymphs stage • Half the ticks in the eastern and mid-western US may be infected

13. Lyme Disease • Patho • Causative organisms are capable of producing systemic tissue injury, with a low microbial load • At initiation it is believed that the spirochetes bind fibronectin and epithelial cell-derived proteoglycans in the extracellular matrix • This causes cutaneous erythema at sites of invasion and centrifugal spread from the original site

14. Lyme Disease • Subjective • Early- flu like illness with fever, chills, myalgia. May have a rash or red spot • Later-comes malaise, fatigue, headache, neck pain and stiffness, and generalized pains. • Untreated even later- progresses to multiple joint arthritis • Late disease- memory loss, cognitive disturbances, mood changes, peripheral neuropathy plus arthritis

15. Lyme Disease • Objective • Early-localized disease, days to 1 month after exposure • Erythema migrans rashes in 90% • Cervical stiffness • Lymphadenopathy • Fever

16. Lyme Disease • Differentials • Rocky Mountain spotted fever • Viral syndromes • Influenza • Chronic Fatigue Syndrome- CFS • Fibromyalgia Syndrome- FMS

17. Lyme Disease • Early-disseminated disease, occurs days to 10 months after bite • Systemic manifestations • Carditis • Neurologic manifestations • Lymphocytic meningitis • Cranial nerve palsies- VIII most common • Radiculoneuritis-inflammation of one or more roots of the spinal nerves • With all three of the above, the triad is called Bannwarth syndrome, but is more common in Europe

18. Lyme Disease • Late disease- months to years after bite • Intermittent arthritis- 50% • These patients respond to antibiotic TX • Arthralgias- 20%, 10% of which have monoarthritis of the knee • Tertiary neuroborreliosis • Encephalopathy, neurocognitive impairment, and peripheral neuropathy • Cutaneous manifestations • Solitary lymphocyte, usually just in Europe

19. Lyme Disease • Diagnostic Tests • Cultures of skin lesion- 50% accurate • Serologic studies- often negative with early localized disease • ELISA tests against Borrelia • Western blot- has lower sensitivity but more specificity • Measure these test results against CDC standards, not the labs standards • Best to send to a lab or medical center doing research on Lyme disease • Histologic and immunologic staining- low yield in diagnostic testing • IgM and IgG are usually positive by 6-8 weeks • Early antibiotic treatment may be lead to negative results, or may be positive after treatment and resolution of the disease

20. Lyme Disease • Diagnostic testing • Results of test may be impacted if the patient had the LYMErix vaccine (no longer given) • Borrelia-specific antibody levels- from synovial fluid or CSF • Do not diagnose based on labs alone • Do not use the test as screening tools, but instead only to confirm • False positives are very common • Diagnosis based on clear clinical findings • FYI- new experimental tests being studied

21. Lyme Disease • Management • Goal is to stop manifestations and prevent progression • 90% of early localized disease responds to antibiotic TX • Early disease treat for 10-14 days • For more advanced treat for 30 days • Antibiotics preferred • Doxycycline 100 mg bid for adults (sun issues) • Doxycycline 2mg/kg for children over 8 years • Amoxil, Ceftin , EES, (rashes) • Patients may develop symptoms of rigors, fever or hypotension in first 24 hours of antibiotic treatment

22. Lyme Disease • Management • For cases with neurologic sequelae may use Rocephin IV or Claforan IV for 4 weeks • May be done on outpatient basis • Monitor CBC weekly for leukopenia • Monitor hepatic levels also weekly with Rocephin • Some symptoms such as HA, fatigue and malaise may persist after treatment • New or increases symptoms warrant more workup

23. Lyme Disease • Education • Avoid foliage- esp. ankle level • Walk in center of paths • Long sleeves and pants • Socks and/or boots over the pants • Button up shirt collars • Tick repellant • Inspections of body daily • Advise on the course of the disease

24. Lyme Disease • Follow up and referral • Weekly visits may be needed to make the diagnosis • During treatment visits will vary, with IV treatment at least weekly phone calls to discuss lab results • Symptoms may occur for years and need follow up on an as needed basis

25. Human Immunodeficiency Virus Infection and AIDS • Will be covered on April 16th this semester by an NP working in this field • This is a required attendance lecture • The time will be 2-5pm ** • There are several questions on the boards specific to HIV and AIDS

26. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • CFS is poorly understood • There is lack of agreement as to its cause, to the correct lab markers, and its clinical course • CFS has an overlap with fibromyalgia- also poorly understood • 70& of patients with FMS meet criteria of CFS • The majority of patients with CFS meet criteria for FMS • 30% of FMS patients meet criteria for depression, dysthymia or anxiety disorders • Many criticize the history and PE exam- diagnostic criteria for both

27. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Epidemiology and Causes • CFS does not have an accepted working definition and is impossible to ascertain its epidemiology • Chronic fatigue complaints represent up to 25% of patient visits • About 10% of these meet diagnostic criteria • It is thought it affects women 2x more than men • Hypothesized to autoimmune and infections • Is a Diagnosis of exclusion

28. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • FMS has more info published • Prevalence is 0.5% of men and 3.4% of women • Prevalence for women ages 60-79 is more than 7 % • 11 million people in the US have FMS with 80 –90% being women • Up to 20% of all rheumatology practice visits are for FMS • Is now considered the most common cause of generalized musculoskeletal pain in women aged 20- 55 years old • Some studies show up to 50% of patients with FMS have a history of sexual or violent abuse

29. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Patho is still unclear • Hypothesized that both syndromes may be disorders of muscle energy metabolism, inflammatory or immunopathologic diseases of muscle • No studies have confirmed etiologies • There is debate whether CFS and FMS overlap with depression and anxiety or one leads to the other

30. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Patho- studies underway • Exploring potential infectious etiology • Epstein-Barr, retroviruses, human herpesvirus • Looking at differences in immune function • Reduced numbers of natural killer cells with depressed function, reduced levels of If molecules and immune complexes, and increased numbers of cell surface adhesion molecules, ECT… • Studies are looking at neuroendocrine differences between affected patients and controls • Others are studying adrenocorticotropin hormone (ACTH) and reduced serum cortisol levels

31. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Patho studies • May be related to chronic hypoxia of muscular tissue • Most current thoughts are FMS patients suffer a disproportionate perceptions to pain, exacerbated by muscle inactivity and deconditioning • First degree relatives of patients with FMS have been found to have lower thresholds to pain

32. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Patho • It is known that in FMS patients there is an alteration of sleep and mood, decreased blood flow to pain centers in the brain, and alterations in serotonin secretions and alterations in the pituitary hypothalamic- adrenal neuroendocrine axis. It is also known that autonomic dysregulation of heart rate and systemic blood pressure occurs with tilt test in these patients. It is also known that there is not an inflammatory component, which is why NSAIDs and steroids do not help these patients

33. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Subjective • Report- post exercise malaise, fatigue, multiple-joint pain, headaches, impaired memory, mood, concentration and cognitive disturbances, sore throat, restless, disordered sleep, and myalgias • Report- have often seen other providers in the past with the same SX ( were blown off by other providers)

34. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Objective • Tends to target once active, highly functional adults so the exam is most often normal • Onset of CFS may be preceded by mononucleosis-like illness or by GI symptoms • FMS –may have the same history • Patients appear tired, pale, may or may not have memory deficits on the MMSE (Mini-Mental state exam). May or may not have enlarged lymph nodes • Positive trigger points of 11 out of 18 for FMS

35. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Diagnostic criteria for fibromyalgia • Widespread pain • Right and left side of body • Above and below the waist • Some axial skeletal pain • Digital palpation of trigger points with at least 4kg of pressure causes pain • Tender is not painful • If painful it is a positive point • Positive exam when 11 out of 18 points induce pain with palpation

36. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Trigger Point locations to test- bilaterally • Occiput • Low cervical • Trapezius • Supraspinatus • Second rib • Lateral epicondyle • Gluteal • Greater trochanter • Knee

37. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Differentials • Lupus • Rheumatoid arthritis • Endocrinologic disorders • Thyroid diseases • Infectious diseases • Lyme disease, flu • Psychotic illness • Irritable bowel • Cancer • Parkinsonism • Sjögren's with anhydrosis (inability to sweat)

38. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Diagnostic criteria for CFS • Fatigue persists or relapses for 6 months • Plus -four of the following • Concurrent symptoms of; impaired memory or concentration, sore throat, tender cervical or axillary lymph nodes, muscle pain, multiple-joint pain, new headaches, restless sleep, and post exertion malaise

39. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • CDC’s criteria for CFS • Persistent or relapsing fatigue clinically evaluated with out explanation and at least four of the following self reported symptoms • Impaired concentration/short-term memory, sore throat, tender cervical/axillary nodes, muscle pain, arthralgias without redness or swelling, poor sleep, new onset headache or headache of a new or worsening pattern, and malaise following activity and that lasts at least 24 hours. • If patients do not fit these criteria they are diagnosed with idiopathic chronic fatigue

40. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Diagnostic tests • Test for all the reasonable differentials to rule them out • Do not use CT or MRI unless there are physical findings to support the testing • Do not order virus specific test unless the history or PE supports the possibility • Do not test for Lyme disease unless the history confirms the need, this is often a false result • ANA is often misleading, it can be positive but without other Lupus tests being positive, it is not Lupus, the patient may be labeled as such anyway • Specifically for FMS screen the muscle enzymes • Creatine kinase and aldolase

41. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Management is controversial • Goal of management is to enable the patient to have the best quality of life possible, within the limitations of the chronic disability related to pain • Two therapies help with symptoms but are not a cure • Cognitive behavioral therapy • Changes beliefs, and behaviors that are barriers to recovery • Graded exercise • Do not encourage more bed rest • Encourage low impact aerobic exercise

42. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • A supportive approach to the patient-clinician relationship is critical • Reinforces the diagnosis, if the criteria are met, and thus avoids the debate if its psychologic or organic • Pharmacotherapies- inconsistent success • Reminyl • IVIG • Acyclovir • SSRIs- esp. Celexa, Prozac, Paxil • Corticosteroids – may have some benefit for some • Chiropractic and massage therapies help some • Ultraviolet light helps some patients • Vitamin therapy helps some patients

43. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • For FMS • Tylenol 650 mg qid and Ultram 75 mg qid as a combo TX • Elavil 75 mg daily in divided doses works for about 3 months • Flexeril starting at 5 mg up to 10mg helps for about 3 months • Most promising is Cymbalta at 40-60mg qd • Klonopin at 0.5 mg q.h.s. may be helpful

44. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Education • Instruction of coping methods • Disease process • Chronicity • Remind them its not fatal • Explain that stress can worsen symptoms

45. Chronic Fatigue Syndrome & Fibromyalgia Syndrome • Follow up • Based on symptoms • Patients usually know when they need to be seen • May need referral to a rheumatologists initially to confirm diagnosis • Psychiatric referral may be warrant in some patients

46. TB • TB • Testing • Tuberculin skin test remains the standard test for determining infection with Mycobacteria tuberculosis, but does not distinguish between active and latent infection • Who to test • Patient with signs and symptoms, known contact, high risk, people suspected to have, abnormal chest x-ray, medical conditions that increase risk, pt with HIV, immigrant, medically underserved, high-risk minority, resident or employee in a prison or long term care facility, employee on a health care facility

47. TB • Interpretation of TB skin testing • Greater than 5 mm is positive for the following • People with HIV, or risk factors for HIV • People recently exposed to active TB • Persons with organ transplants • Persons with chest film indicating healed TB

48. TB • Greater than 10 mm • Recent arrivals (less than 5 years) • Foreign born from Africa, Asia, Latin America • Medically underserved low income population and high risk racial ethnic minority populations • IV drug users • Residents and employees of high risk congregate setting • Mycobacteriology lab personnel • Persons with medical conditions known to increase risk of TB

49. TB • Greater than 15 mm • Everyone else

50. Antibiotic Resistance: A Mandate for Change CME/CE Arjun Srinivasan, MD Posted: 12/17/2010 • There is an urgent need to improve antibiotic use and it is driven by 4 key truths. The first is that antibiotics are misused. The second is that antibiotic misuse every day adversely affects patients and society. Third, improving antibiotic use improves patient outcomes and saves money at the same time. And finally, improving antibiotic use is a true public health imperative.