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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.

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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


Outline
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


Bluf caring for the id patient
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


Common things are common
Common Things are Common

Not this…

Usually this…



Chief complaint
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



History of present illness
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)


History of present illness1
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


Review of systems
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


Past medical surgical history
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.


Medications immunizations
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!


Social history
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”),


Family history
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?


Travel
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?)


Differential diagnosis travel history activities
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.


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


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


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


Schistosomiasis geographic distribution
Schistosomiasis about four weeks ago. Now with: 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


Infectious diseases of returning travelers clues in evaluation
Infectious Diseases of Returning about four weeks ago. Now withTravelersClues in Evaluation


Top 5 illnesses in returning travelers
Top 5 Illnesses in returning travelers about four weeks ago. Now with


Differential diagnosis incubation period
Differential Diagnosis about four weeks ago. Now withIncubation Period


Differential diagnosis exposures and associated infections
Differential diagnosis about four weeks ago. Now withExposures 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


Differential diagnosis exposures and associated infections1
Differential diagnosis about four weeks ago. Now withExposures 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


Clinical syndromes

Clinical syndromes about four weeks ago. Now with


Differential diagnosis clinical syndrome undifferentiated fever
Differential Diagnosis about four weeks ago. Now withClinical syndrome- undifferentiated fever

  • Malaria

  • Leptospirosis

  • Typhoid

  • Dengue

  • Chikungunya

  • Q fever

  • Acute schistosomiasis

  • Brucellosis

  • Amebic liver abscess

  • HIV


Differential diagnosis clinical syndrome fever and hemorrhage
Differential diagnosis about four weeks ago. Now withClinical syndrome- fever and hemorrhage

Viral

  • Yellow fever

  • Dengue

  • Hantaviruses

  • Lassa fever

  • Ebola

  • Marburg

  • CCHR

  • Rift Valley fever

Bacterial

  • Meningococcal

  • Leptospirosis

  • Rickettsial

  • Vibrio vulnificus


Differential diagnosis clinical syndrome fever and cns findings
Differential diagnosis about four weeks ago. Now withClinical 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


Differential diagnosis clinical syndrome fever and respiratory symptoms
Differential diagnosis about four weeks ago. Now withClinical 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


Differential diagnosis clinical syndrome fever and hepatitis
Differential diagnosis about four weeks ago. Now withClinical syndrome- fever and hepatitis

  • Hepatitis A

  • Hepatitis B

  • Hepatitis D

  • Hepatitis E

  • Yellow Fever

  • EBV

  • CMV

  • Q fever

  • Leptospirosis

  • Rickettsial

  • Brucellosis


Differential diagnosis clinical syndrome fever and lymphadenopathy
Differential diagnosis about four weeks ago. Now withClinical syndrome- fever and lymphadenopathy

Localized

  • Tularemia

  • Leishmaniasis

  • Plague

  • Bartonella

  • HSV

  • LGV

  • Syphilis

Generalized

  • Mononucleosis

  • Acute HIV

  • Rickettsial

  • Leptospirosis

  • Brucellosis

  • Relapsing fever

  • Trypanosomiasis

  • Toxoplasmosis


Geographic disease distribution conus oconus
Geographic Disease Distribution about four weeks ago. Now withCONUS / OCONUS


Typhoid fever
Typhoid fever about four weeks ago. Now with

  • 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.


Hepatitis a
Hepatitis A about four weeks ago. Now with


Hepatitis e
Hepatitis E about four weeks ago. Now with


HIV about four weeks ago. Now with


Japanese encephalitis
Japanese Encephalitis about four weeks ago. Now with


Malaria e hemisphere
Malaria – E hemisphere about four weeks ago. Now with


Malaria w hemisphere mefloquine resistant
Malaria– W Hemisphere about four weeks ago. Now withMefloquineResistant


Melioidosis
Melioidosis about four weeks ago. Now with


Meningitis
Meningitis about four weeks ago. Now with


Schistosomiasis
Schistosomiasis about four weeks ago. Now with


Tuberculosis
Tuberculosis about four weeks ago. Now with


Rock mountain spotted fever tularemia
Rock Mountain Spotted Fever / Tularemia about four weeks ago. Now with


Anaplasmosis babesiosis lyme disease
Anaplasmosis / Babesiosis / Lyme Disease about four weeks ago. Now with


Rock mountain spotted fever
Rock Mountain Spotted Fever about four weeks ago. Now with


Rickettsia parki rickettsiosis
Rickettsia parki about four weeks ago. Now with rickettsiosis


Ehrlichiosis stari tularemia
Ehrlichiosis / STARI / Tularemia about four weeks ago. Now with


Rock mountain spotted fever tularemia1
Rock Mountain Spotted Fever / Tularemia about four weeks ago. Now with


Anaplasmosis lyme disease
Anaplasmosis / Lyme Disease about four weeks ago. Now with


Infectious disease emergencies
Infectious Disease Emergencies about four weeks ago. Now with


Infectious disease emergencies1
Infectious Disease Emergencies about four weeks ago. Now with

  • Acute bacterial meningitis

  • Meningococcemia

  • Intracranial subdural empyema

  • Necrotizing soft tissue infections

  • Toxic shock syndrome

  • Neutropenic fever

  • Sepsis in patients with splenectomy (actual/functional)

  • Plasmodium falciparum malaria

  • Cholera

  • Rocky Mountain Spotted Fever

  • Babesiosis


Evaluation of the febrile patient

Evaluation of the febrile patient about four weeks ago. Now with


Evaluation of the febrile patient general approach
Evaluation of the febrile patient about four weeks ago. Now withGeneral approach

  • Careful history and serial physical examination

  • Appropriate/directed laboratory tests

    • Malaria

      • Serial thick and thin smears

      • Rapid diagnostic tests (e.g., BinaxNOW- P. falciparum Sensitivity/Specificity– 99.7% / 94.2%)

    • CBC with diff

    • Liver associated enzymes

  • Appropriate/directed radiographic studies

  • Speed of evaluation contingent upon

    • Tempo of illness

    • Differential diagnosis

    • Immune status of patient


Evaluation of the febrile patient general approach1
Evaluation of the febrile patient about four weeks ago. Now withGeneral approach

  • Develop a management plan

    • Differential diagnosis

    • Clinical data

  • Consider empirical therapies

    • Malaria- must not miss malaria!

    • Meningococcal

    • Rickettsial/leptospirosis

    • Lassa fever

  • Must recognize diseases that require special precautions

    • Hemorrhagic fevers (S, D, C, +/- Airborne)

    • Meningococcal (Droplet)

    • Tuberculosis (Airborne)


Outbreak of falciparum malaria among jtf liberia qrf marines on dot ppx prominent gi sx dx delayed
Outbreak of falciparum malaria among JTF Liberia QRF Marines about four weeks ago. Now withon “DOT ppx;” prominent GI sx dx delayed


Fever resource limited setting
Fever about four weeks ago. Now withResource limited setting

  • Febrile illness is common

    • High mortality rates

  • Diagnostic challenges

    • Clinical history/PE not diagnostic

    • Lack of laboratory services

    • Expensive lab services

    • Unreliable lab services

  • Forced to treat empirically based on febrile syndrome

BMJ 2011; 343:1


Fever resource limited setting1
Fever about four weeks ago. Now withResource limited setting

  • Fever<7d without focus

    • Malaria

    • Bacteremia

    • Meningococcal disease

    • Typhoid

    • Rickettisia

    • Dengue

    • Influenza

    • Leptospirosis

    • HIV- primary

    • Acute schisto

  • Fever>7d without focus

    • TB

    • Typhoid

    • Malaria

    • Osteomyelitis

    • Endocarditis

    • Liver abscess

    • Brucellosis

    • Visceral leishmaniasis

    • Fungi (crypto, cocci, histo)

BMJ 2011; 343:1


Fever resource limited setting2
Fever about four weeks ago. Now withResource limited setting

  • Rapidly assess patient

    • Physical exam

    • Malaria risk

  • Fever from life-threatening cause

    • Neck stiffness

    • Unconsciousness, lethargy, seizure

    • Severe abdominal pain

    • Respiratory distress

  • Immediate management

    • IV fluids, antimalarial, antibiotics, glucose

  • MEDEVAC, hospital admission

http://www.who.int/hiv/pub/imai/acute_care.pdf


Medical history informing diagnosis
Medical History Informing Diagnosis about four weeks ago. Now with


Mandell et al. PPID 7 about four weeks ago. Now withth ed.


Mandell et al. PPID 7 about four weeks ago. Now withth ed.


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