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Reportable Infectious Diseases. Chp. 153. 1/19/06 Dr. Batizy Bogdan Irimies PGY-3. Introduction. CDC in Atlanta publishes a list of notifiable infectious diseases.

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Reportable infectious diseases l.jpg

Reportable Infectious Diseases

Chp. 153.

1/19/06 Dr. Batizy

Bogdan Irimies PGY-3


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Introduction

  • CDC in Atlanta publishes a list of notifiable infectious diseases.

  • Requirement to report these diseases is mandated by state or territory laws and regulations. Therefore, the list differs from state to state

  • The following case definitions establish uniform criteria.


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AIDS

  • For patients 13 years or older reporting is required if the patient demonstrates:

    • 1. CD4 T-cell count <200

    • 2. CD4 T-cell percentage of total lymphocyte <14%

    • 3. Any of the following: pulmonary TB, recurrent pneumonia, cervical cancer or the 23 other AIDS defining conditions.


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Anthrax

  • Caused by Bacillus anthracis

  • Cutaneous form is characterized by a skin lesion evolving over 2-6 days from papule to vesicle to depressed black eschar.

  • Inhalation form characterized by brief URI, hypoxia, dyspnea, mediastinal widening from adenopathy on CXR.


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Anthrax

  • Intestinal form is characterized by fever, sepsis, crampy abdominal pain.

  • Oropharyngeal form characterized by mucosal lesion in oral cavity, cervical adenopathy, edema, fever.

  • Lab diagnosis (Dx:)

    • 1. Isolation of B. anthracis from clinical specimen

    • 2. anthrax electrophoresis/immunoflurescence


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Botulism: 3 forms

  • Foodborne: acute illness manifested by diplopia, blurred vision, bulbar weakness or symmetric paralysis of rapid onset.

  • Infant: constellation of symptoms in infant under 1 y/o including constipation, poor feeding, failure to thrive, progressive weakness, impaired respirations and death


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Botulism

  • Wound: symptoms similar as for food borne.

  • Lab Dx:

    • botulinum toxin in serum, stool, food.

    • Positive culture for C. botulinum from stool


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Brucellosis

  • Infection w/Brucella characterized by fever, night sweats, fatigue, anorexia, weight loss, headache (HA), arthralgias.

  • Lab Dx:

    • Culture positive from specimen

    • Increase in Brucella agglutination titers

    • Positive immunofluorescence of Brucella in clinical specimen


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Chancroid

  • STD caused by Haemophilus ducreyi

  • Painful genital ulcer w/inflamed inguinal lymph nodes.

  • Isolation from clinical specimen confirms Dx.


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Chlamydia Trachomatis

  • Causes urethritis, epididymitis, cervicitis, salpingitis, conjunctivitis, pneumonia, or maybe asymptomatic.

  • Lab Dx:

    • Positive culture

    • Detection of the antigen or nucleic acid on immunofluorescence.


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Cholera

  • Manifested by diarrhea and vomiting

  • Lab dx:

    • Isolation of toxigenic Vibrio cholerae O1 or O139 from stool or emesis


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Coccidioidomycosis

  • Caused by fungus Coccidioides immitis, endemic to SW U.S.

  • Causes influenza like respiratory illness:

    -Fever, cough, chest pain, myalgias, arthralgias, HA, pneumonia on CXR, erythema nodosum or erythema multiforme rash, meningitis, or involvement of bones, joints, viscera or lymph nodes.


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Coccidioidomycosis

  • Lab Dx:

    • Culture, histopathology, or molecular evidence of C. immitis

    • Serologic tests such as IgM by immunodiffusion, ELISA, latex agglutination

    • Coccidiodal skin test conversion after onset of symptoms


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Cryptosporidiosis

  • Caused by protozoa Cryptosporidium parvum

  • Signs & Symptoms (S/Sx:)

  • Fever, nausea, vomiting, abdominal cramps, loss of appetite

  • Lab Dx:

    • Detection of oocysts in stool

    • demonstration of organism in intestinal fluid or small bowel biopsy

    • detection of Cryptosporidium antigen in stool


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Cyclosporaisis

  • Intestinal illness caused by protozoa Cyclospora cayetanensis

  • S/Sx:

    • watery diarrhea, weight loss, flatus, nausea, fatigue, vomiting, anorexia, abdominal cramping and fever


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Cyclosporaisis

  • Lab Dx:

    • Detection of oocysts in stool

    • Detection of Cyclospora in intestinal fluid or small bowel biopsy

    • Demonstration of sporulation

    • Detection of DNA by PCR


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Diptheria

  • Caused by Cornynebacterium diptheriae

  • S/Sx: URI like, sore throat, fever, adherent membrane to tonsils, pharynx or nose.

  • Lab dx:

    • Isolation of organism from specimen or histopathologic diagnosis


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Ehrlichiosis

  • Tick borne illness presents as flu-like illness w/fever, HA, myalgias, malaise, nausea, vomiting or rash.

  • May see thrombocytopenia, leukopenia, elevated LFTs

  • Three categories need to be reported:

  • 1. HME caused by Ehrlichia chaffeensis 2. HGE caused by E. phagocytophila 3. Ehrlichiosis, Human


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Arboviral Encephalitis/Meningitis

  • S/Sx:

    • Arboviral meningitis: fever, HA, stiff neck, pleocytosis.

    • Arboviral encephalitis: febrile illness assoc w/neurologic s/sx’s such as HA, mental status change, confusion, nausea/vomiting, meningismus, CN palsy, paresis or paralysis, sensory deficit, seizures, or coma.


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Arboviral Encephalitis/Meningitis

  • Lab Dx:

    • Fourfold rise in antibody titer

    • Isolation of virus or viral antigen from tissue, serum or CSF

    • IgM antibody detection


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Enterohemorrhagic E. Coli

  • S/Sx: caused by E. Coli 0157:H7 in foodborne outbreaks

    • Enterohemorrhagic illness w/bloody diarrhea, abdominal cramping and may have HUS or TTP

  • Lab Dx: isolation of E. coli 0157:H7 or a shiga toxin producing E. coli


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Giardiasis

  • Caused by protozoan Giardia lamblia

  • S/Sx’s: diarrhea, abdominal cramps, weight loss, malabsorption

  • Lab Dx: G. lamblia cysts or trophozoites in stool or antigen in stool by specific immunodiagnostic test


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Gonorrhea

Caused urethritis, cervicitis, salpingitis, disseminated disease or maybe asymptomatic

Observation of gram neg. intracellular diplococci


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Haemophilus Influenzae Invasive Disease

  • Invasive diseases are: meningitis, bacteremia, epiglottitis, or pneumonia

  • Lab Dx: isolation of H. Flu from blood CSF or joint fluid


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Hansen Disease(Leprosy)

  • Caused by organism Mycobacterium leprae

  • Four clinical forms of disease:

    • Tuberculoid leprosy: one or few well demarcated, hypopigmented and anesthetic skin lesions

    • Lepromatous form: number of erythematous papules & nodules that affect the face, hands and feet in a symmetric pattern


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Hansen Disease(Leprosy)

  • Dimorphous form: skin lesions characteristic of the tuberculoid and lepromatous forms

  • Indeterminate form: hypopigmented macules that do not have characteristics of tuberculoid or lepromatous forms

  • Lab Dx: demonstration of acid fast bacilli in skin or dermal nerves requiring a skin biopsy.


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Hantavirus Pulmonary Syndrome

  • S/Sx’s: prodrome of fever, chills, myalgias, HA, and GI symptoms that progress to bilateral pulmonary infiltrates, respiratory compromise, ARDS. May see hemoconcentration, WBC count w/left shift, neutrophilic leukocytosis & thrombocytopenia

  • Lab Dx: Hantavirus specific IgM or rising titers of IgG, PCR, or Hanta virus antigen


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HUS, Postdiarrheal

  • HUS present as acute onset of microangiopathic hemolytic anemia, renal injury and thrombocytopenia usually w/in 3 weeks of diarrheal illness.

  • TTP w/similar features but also fever and CNS involvement

  • Lab Dx: anemia of microangiopathic changes(schistocytes, burr cells, helmet cells) and renal failure.


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Legionella

Causes 2 diseases: Legionaires’ disease and Pontiac fever.

Fever,myalgias, cough, pneumonia.

Lab dx:

Isolation of Legionella from respiratory secretions, lung tissue, pleural fluid or sterile bodily tissue

Demonstration of rising antibody titer

Detection of L. pneumophilia serotype 1 in body fluids

Detection of L. pneumophilia serotype 1 antigen in urine


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Listeriosis

  • Listeria monocytogenes caused meningitis and/or bacteremia

  • Lab Dx:

    • Isolation of L. monocytogenes from sterile body fluids, fetal tissue or placenta


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Lyme Disease

  • Tick borne illness caused by Borrelia burgdorferi

  • S/Sx: fever, fatigue, HA, stiff neck, arthralgias/myalgias, erythema migrans, high degree heart block, myocarditis, meningitis/encephalitis

  • Lab Dx: isolation of organism or identification of antibody(IgM or IgG) in serum or CSF


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Malaria

  • Caused by Plasmodium species, present w/fever, HA, chills, myalgias, nausea/vomiting, diarrhea, cough, renal failure, pulmonary edema and coma/death

  • Malaria parasites can be seen on blood smear.


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Measles(Rubeola)

  • S/Sx: Generalized rash >3 days, temp. >38.3, cough, coryza, conjunctivitis

  • Lab Dx:

    • Positive serology for IgM

    • Rise in measles antibody titer

    • Isolation of measles virus from specimen


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Meningococcal Disease

  • S/Sx’s: meningitis, meningococcemia, purpura fulminans, shock, death

  • Lab Dx:

    • Isolation of Neisseria meningitidis from blood or CSF


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Mumps

  • S/Sx: unilateral or bilateral tender, self-limited swelling of parotid or other salivary gland for > 2 days w/out other cause.

  • Lab Dx:

    • Isolation of mumps virus from specimen

    • Rise in serum IgG or IgM


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Pertussis

  • S/Sx: 2 week history of paroxysmal cough, inspiratory whoop or posttussive vomiting.

  • Lab Dx:

    • Isolation of Bordetella pertussis from clinical specimen

    • Positive PCR for B. pertussis


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Plague

  • S/Sx: fever, chills, HA, malaise, prostration , leukocytosis.

  • Different forms:

    • Bubonic plague: regional lymphadenitis

    • Septicemic plague: sepsis

    • Pneumonic plague: pneumonia from inhaled droplets

    • Pharyngeal plague: pharyngitis and cervical lymphadenitis


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Plague

  • Lab Dx:

    • Increase in serum antibody titers to Yersinia pestis fraction 1 antigen

    • Detection of fraction 1 antigen by fluorescent assay

    • Confirmation w/isolation of Y. pestis in clinical specimen


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Paralytic Poliomyelitis

  • S/Sx: illness of acute onset characterized by flaccid paralysis of one or more limbs, DTR’s are absent, no sensory abnormalities, and no other apparent cause for above.

  • Clinical case definition is sufficient for reporting


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Psittacosis

  • S/Sx: disease of birdhandlers, fever, chills, HA, photophobia, cough, myalgia

  • Lab dx:

    • Isolation of Chlamydia psittaci from respiratory secretions

    • 4 fold rise in serum antibody titers

    • Detection of serum IgM to C. psittacci


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Q Fever

  • S/Sx’s: acute infection with Coxiella burnetti, fever, myalgias, malaise, retrobulbar HA, hepatitis, pneumonia, meningoencephalitis

  • Lab Dx:

    • fourfold rise in antibody titer

    • Isolation of C. burnetti from specimen

    • Demonstration of C. burnetti by antigen or nulceic acid testing


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Rabies

  • S/Sx: acute encephalomyelitis, coma, death w/in first 10 days of first symptom

  • Lab Dx:

    • Direct fluorescent antibody of viral antigen

    • Isolation in cell culture or lab animal of rabies virus from saliva, CSF, or CNS tissue

    • Identification of rabies neutralizing antibody titer in serum or CSF in a previous unvaccinated person


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Rocky Mountain Spotted Fever

  • S/Sx: tick born disease characterized by HA, myalgia, fever, petechial rash on palms and soles

  • Lab Dx:

    • Rise in antibody titer to Rickettsia rickettsii antigen

    • Positive PCR

    • Positive immunoflourescence of skin lesion biopsy or organ tissue biopsy

    • Isolation of R. rickettsii from clinical specimen


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Rubella

  • S/Sx: acute onset of generalized maculopapular rash, temp.>37.2, arthralgias, arthritis, lymphadenopathy, conjunctivitis.

  • Lab Dx:

    • Isolation of rubella virus

    • Rise in serum IgG titers

    • Positive IgM


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Salmonellosis

  • S/Sx: Salmonella causes nausea, vomiting, abdominal pain and diarrhea

  • Lab Dx:

    • Isolation of Salmonella from specimen


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Shigellosis

  • S/Sx: same as Salmonella

  • Lab Dx:

    • Isolation of Shigella from specimen


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Invasive Group A Streptococcal Disease

  • Diseases include: pneumonia, bactermia assoc. with cutaneous infection(cellulitis, wound infection), myositis/necrotizing fasciitis, meningitis, peritonitis, osteomyelitis, septic arthritis, postpartum sepsis, neonatal sepsis

  • Lab Dx:

    • Isolation of Group AStreptococci (Strep. Pyogenes)


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Streptococcal Toxic Shock Syndrome

  • S/Sx: Group A strep infection associated w/a cutaneous lesion

    • All of following must be present w/in 48 hrs.: hypotension, two or more multiorgan involvement such as renal failure, coagulopathy/DIC, LFT’s 2 x normal, ARDS, generalized maculopapular rash/desqumation, necrotizing fasciitis or gangrene

    • Lab Dx: isolate Group A Strep from sterile site


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Syphilis

  • S/Sx: primary (genital chancres), secondary mucocutaneous lesions, tertiary neurosyphilis, skin, bone and cardiovascular

  • Lab Dx:

    • Primary or secondary syphilis: demonstrate Treponema pallidum on dark field microscopy or direct fluorescent antibody(DFA-TP)


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Syphilis

  • Latent or Tertiary syphilis lab Dx:

    • Reactive VDRL or RPR

    • Reactive treponemal test(FTA-ABS or MHA-TP)

    • History of syphilis therapy w/a fourfold rise in antibody titer


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Tetanus

  • S/Sx: acute onset of hypertonia, painful muscular contractions of body and jaw

  • Clinical diagnosis is sufficient


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Toxic Shock Syndrome

  • Caused by Staph aureus

  • S/Sx: temp. >38.8, hypotension, diffuse macular erythroderma, desquamation, 3 or more multisystem involvment such as vomiting or diarrhea, myalgias/CPK increase, mucous membrane involvement, increase in renal function, increase LFT’s , thrombocytopenia, CNS effects(MS change)

  • Dx: clinical case


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Trichinosis

  • S/Sx: caused by ingestion of Trichinella larvae. May see fever, myalgia, periorbital edema, eosinophilia

  • Lab Dx:

    • Trichinella larvae in tissue muscle biopsy

    • Serologic test is positive


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Tuberculosis

  • Following criteria must be met:

    • Positive tuberculin skin test

    • Clinical evidence of disease w/positive CXR

    • Treatment w/2 or more anti-TB drugs

    • Completed diagnostic evaluation

      • Isolation of TB from clinical specimen

      • Detection of TB by nucleic acid test

      • Acid fast bacilli from clinical specimen


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Tularemia

  • S/Sx: caused by Francisella tularensis. Several different forms:

    • Ulceroglandular: cutaneous ulcer w/regional lymphadenopathy

    • Glandular: regional lymphadenopathy w/out ulcer

    • Oculoglandular: conjunctivitis w/preauricular lymphadenopathy


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Tularemia

  • Oropharyngeal: tonsillitis, stomatitis, pharyngitis, cervical lymphadenopathy

  • Intestinal: abd. Pain, vomiting, diarrhea

  • Pneumonic: primary pleuropulmonary disease

  • Thyroidal: febrile illness w/out local S/Sx’s.

  • Lab Dx: isolation of F. tularemia in clinical specimen or rise in antibody titer to F. tularemia antigen


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Typhoid Fever

  • S/Sx: Caused by bacteria, Salmonella typhi, acute onset of fever, HA, malaise, anorexia, bradycardia, GI symptoms, cough

  • Lab dx:

    • Isolation of S. typhi from blood, stool or other clinical specimen.


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Yellow Fever

  • S/Sx: mosquito born viral illness characterized by acute onset of fever, HA, myalgia’s, conjunctivitis, hepatitis, albuminuria, jaundice, renal failure, generalized hemorrhage

  • Lab Dx:

    • Fourfold rise in yellow fever antibody titer

    • Yellow fever virus antigen in tissues or other bodily fluids


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Questions:

  • 1. AIDS case reporting is required if which of the following are present:

    • A. CD4 T-cell count <200

    • B. CD4 T-cell percentage of total lymphocyte <14

    • C. Any of the 23 AIDS defining conditions

    • D. All of the above


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Questions

  • 2. Which of the following are forms of Botulism

    • A. Food borne

    • B. Infant

    • C. Wound

    • D. All of above


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Questions

  • 3. If Dr. Batizy just returned from visiting his family in Arizona and he developed a influenza like febrile respiratory illness, which of the following would be on your D/Dx:

    • A. Coccidioidomycosis

    • B. Giardiasis

    • C. Malaria

    • D. Lyme disease


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Questions

  • 4. True or False: Group A strep and S. Aureus can cause Toxic Shock syndrome?


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Answers

  • 1.D

  • 2. D

  • 3. A

  • 4. True


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Occupational Exposures, Infection Control and Standard Precautions:

Chp. 154 Tintinalli

Dr. Batizy

Slides by Bogdan

1/19/06


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Occupational Exposures: Precautions:

  • OSHA definition of occupational exposures:

    • “Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potential infectious materials that may result from the performance of the employee’s duties.”


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Occupational Exposures: Precautions:

  • Since health care workers cannot readily identify those who are infected or risky, it is prudent to employ infection control practices and utilize personal protective equipment(PPE) during all patient care activities.

  • Portals for infectious disease entry are percutaneous, mucous membrane (oral, ocular, nasal or rectal), respiratory, and dermal.


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Occupational Exposures: Precautions:

  • The risk of infection in an exposed health care worker depends on the following factors:

    • Route(portal) of exposure

    • Concentration(# of organisms) of pathogens in the infectious material

    • Infectious characteristics(virility) of the pathogen

    • Volume (dose) of infectious material

    • Immunocompetence (susceptibility) of the exposed individual


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Occupational Exposures: Precautions:

  • Percutaneous exposures have the greatest potential for infection than do mucous membrane exposures, respiratory exposures, or dermal exposures.


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Management of Health Care Personnel Potentially Exposed to HBV,HCV, HIV:

  • Once an infectious exposure has occurred, a plan for post-exposure prophylaxis (PEP)medical management should be available to health care providers 24 hrs. a day.

  • The ER physician is usually the first to examine the exposed person and make an assessment of the relative risk of the transmission.

  • See Table 154-3


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Table 154-3 HBV,HCV, HIV:


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Management of Health Care Personnel Potentially Exposed to HBV,HCV, HIV:

  • The exposure event should be evaluated for the potential to transmit HBV, HCV, and HIV based on the type of body substance involved and the route and severity of the exposure.

  • See Table 154-5


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Table 154-5 HBV,HCV, HIV:


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Management of Health Care Personnel Potentially Exposed to HBV,HCV, HIV:

  • Testing to determine the HBV, HCV, and HIV status of an exposure source should be performed as soon as possible.

  • See Table 154-6


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Table 154-6 HBV,HCV, HIV:


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HBV Exposure: HBV,HCV, HIV:

  • Factors to consider in HBV exposure include HBsAg status of source and HBV vaccination status and vaccine response of the exposed person

  • Unvaccinated health care workers exposed to HBV should receive Hep. B vaccine series

  • See Table 154-7


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Table 154-7 HBV,HCV, HIV:


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HCV Exposure: HBV,HCV, HIV:

  • For occupational HCV exposures, the CDC recommends anti-HCV testing of source patient.

  • Immunoglobulin and antivirals are not recommended for PEP after exposure to HCV positive blood


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HIV Exposure: HBV,HCV, HIV:

  • Health care personnel exposed to HIV should receive expedited evaluation(<1hr) and should be tested for HIV at baseline

  • If source patient is HIV negative, baseline testing or further follow-up for exposed persons is not necessary.

  • Factors to consider in HIV exposure include the type of exposure (percutaneous, mucous membrane or dermal), volume of the exposure, and the HIV status of the source patient.

  • See Table 154-8 and Table 154-9


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Table 154-8 HBV,HCV, HIV:


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Table 154-9 HBV,HCV, HIV:


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HIV Exposure PEP: HBV,HCV, HIV:

  • CDC recommends 4 wks of PEP drug treatment.

  • Basic 2 drug regimen is appropriate for most exposures

  • 3 drug regimen is recommended for exposures determined to be at increased risk of transmission

  • See Table 154-10 and Table 154-11


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Table 154-10 HBV,HCV, HIV:


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Table 154-11 HBV,HCV, HIV:


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Standard Precautions HBV,HCV, HIV:

  • Standard precautions are exercised when caring for all patients and include hand washing, gloves, mask and eye protection or face shield, gowns, handling of patient care equipment and linens, environmental controls, workplace controls and patient location or placement.


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Questions: HBV,HCV, HIV:

  • 1. T/F: standard precautions should be used when caring for all patients.

  • 2. T/F: If the source patient is HIV negative, all further testing for HIV can be stopped.

  • 3. T/F: all health care workers should be vaccinated against HBV.

  • 4. Answers: all T!


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CT of Cervical Spine: HBV,HCV, HIV:

  • Indications:

    • Unconscious patient w/suspicious or inadequate c-spine xrays

    • CT is indicated w/all cervical fractures or suspected fractures on initial plain films

    • Delineating injuries to atlantoaxial complex, esp. rotatory subluxation and C-1 ring fractures

    • Used to examine Jefferson Fx, Rotatory dislocation, burst fractures, C-T level injuries


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CT Cervical Spine: HBV,HCV, HIV:


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CT of Cervical Spine: HBV,HCV, HIV:


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CT Cervical Spine: HBV,HCV, HIV:


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