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Resident Board Review. Joseph G. Timpone Jr. MD Georgetown University Hospital. Case One.

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resident board review

Resident Board Review

Joseph G. Timpone Jr. MD

Georgetown University Hospital

case one
Case One
  • An 80 y.o. female presents to the ER with a 3 day history of fatigue, abdominal cramps and bloody diarrhea. She denies any fevers and states that 10 days ago she was at a State Fair where she ate hotdogs, baked beans, coleslaw, and drank fresh apple cider. PEX: T=37 BP=140/90 P=100 ABDON: generalized tenderness LABS: WBC 12.0 HCT 19.0 PLTS 90,000 BUN/Cr 50/3.0 LDH 400 T.Bili 4.0
the most likely causative pathogen is
The most likely causative pathogen is:
  • A) S. aureus
  • B) B. Cereus
  • C) Norwalk virus
  • D) Listeria
  • E) E.coli O157:H7
e coli 0157 h7
E. Coli 0157:H7
  • 21,000 Cases/YR; 6% pts. Develop HUS; 12% Mortality
  • Epidemiology: Young children & elderly; undercooked ground beef, unpasteurized milk, apple cider, water/vegetables contaminated with manure.
  • Incubation 3-4 days; ABD. cramping; bloody diarrhea (35 - 90%); fever uncommon (30%)
  • HUS: MAHA, Thrombocytopenia, ARF, can also see TTP.
  • Diagnosis: colorless, Sorbitol non-fermenting colonies on Sorbitol-Maconkey agar; 0157 Antisera Agglutination test.
  • Treatment: antibiotic use may increase risk of HUS
case two
Case Two
  • A 30 y.o. healthy male is brought to the ER by his co-workers after a syncopal episode at work. In the ER the pt is arousable and noted to be afebrile. BP=70/40 P=40 EKG:3° Heart block. The pt states that he had recently returned from a hiking trip in New England one month ago.
the most likely causative pathogen is6
The most likely causative pathogen is:
  • A) S. aureus
  • B) B. Burgdorferi
  • C) S. pyogenes
  • D) R. rickettsii
  • E) Coxsackie virus
lyme disease
Lyme Disease
  • North America: Borrelia Burgdorferi; Europe: B. Afzelii; Asia: B. Garinii
  • Southern New England, Middle Atlantic, Wisconsin, Minnesota, California
  • Ixodes Scapularis (Deer Tick): Nymphal stage must be attached for > 72 Hrs. to result in transmission
  • Stage 1: Viral-like illness associated with erythema migrans (60 - 80%). Expanding annular lesion with central clearing (at least 5cm by CDC criteria)
acute disseminated lyme disease stage 2
Acute Disseminated Lyme Disease (Stage 2)
  • Neurologic (occurs in 15% of patients)
    • Lymphocytic meningitis
    • Cranial Neuritis (Bell’s Palsy)
    • Motor-sensory polyradiculo neuritis
    • Mono-neuritis multiplex; myelitis
  • Cardiac (occurs in 5% of patients)
    • Atrio-ventricular block
    • Myo-pericarditis
    • Cardiomegaly/LV dysfunction (rare)
chronic lyme disease stage 3
Chronic Lyme Disease (Stage 3)
  • Arthritis: (60% of untreated patients)
    • Oligo-articular/Mono-articular (Kness)
    • Treatment resistant arthritis in 10%
    • More common in North America
  • Neurologic
    • Cognitive dysfunction/encephalopathy
    • Polyneuropathy
    • More common in Europe
  • Chronic Skin Lesions
    • Acrodermatitis chronicum atrophicans
    • Associated with polyneuropathy
lyme disease diagnosis
Lyme Disease: Diagnosis
  • 70% - 80% pts. have (+) IgM by 2 - 4 wks.
  • (+) IgG @ > 4 wks.
  • An isolated (+) IgM in the absence of a (+) IgG after one month of symptoms is likely a false (+) IgM
  • IgM and IgG can remain (+) for years
  • False (+): endocarditis, parvovirus B19, syphilis, EBV, SLE, RA
  • Elisa must be confirmed by W.B.
  • 5% of pts. In non-endemic area can be false (+)
  • PCR -> CSF; C6 Ab
lyme disease treatment
Lyme Disease: Treatment
  • Stage 1 (E.M.): Doxycycline, Amoxicillin, Cefuroxime, Erythromycin for 14 - 21 days
  • Neurologic/cardiac: IV Ceftriaxone, Cefotaxime, PCN
    • Bell’s Palsy -> ? Doxycycline
  • Arthritis: Doxycycline x 30 days or IV Ceftriaxone x 14 - 28 days
lyme disease prevention
Lyme Disease: Prevention
  • Prophylaxis: Doxycycline 200 mg x 1 dose has 87% efficacy for I. scaplilaris tick bits (0.4% vs. 3.2% - Doxy vs. placedo)
  • Recombinant OspA vaccine is 78% effective (0, 1, 12 mos. Or 0, 1, 2 mos.)

Steere NeJM vol. 345; July 12, 2001

Nadelman , et.al NeJM vol. 345; July 12, 2002

case three
Case Three
  • A 75 y.o. male with a history of HTN presents with a 1 wk history of fevers and fatigue. His PCP obtains some labs which reveal WBC 5.0 HCT 20.0 PLTS 40,000 AST 100 ALT 50 T.Bili. 3.5 LDH 525. The pt recently returned from his summer home in Nantucket.
the most likely causative organism is
The most likely causative organism is:
  • A) B. Burgdorferi
  • B) B. Microti
  • C) F. Tularensis
  • D) R. Rickettsii
  • E) E. Chaffeensis
babesioses
Babesioses
  • Caused by B. microti and B . equi
  • Vector: Ixodes scapularis
  • N.E. (Cape Cod), California
  • Can be transmitted by transfusions
  • Elderly, splenectomized pts.
  • Fever, myalgias, H/A, hemolytic anemia, thrombocytopenia, elevated LFTs
  • Diagnosis: Peripheral smear, serology, PCR
  • Treatment: Quinine + Clindamycin; Atovaquone + Azithromycine; exchange transfusion
  • 20% co-infection with B. burgdorferi
case four
Case Four
  • A 29 y.o. female presents to the ER with fevers, cough, and S.O.B. PEX: T 39.5 BP 110/80 P 120 O2 SAT. 88% CXR: diffuse pulmonary infiltrates LABS: WBC 25.0 HCT 55.0 PLTS 50,000 PT/PTT 16/60

The pt recently traveled to Arizona where she stayed on an Indian reservation to learn how to make jewelry.

the most likely causative organ
The most likely causative organ
  • A) S. pyogenes
  • B) Listeria
  • C) C. Immitis
  • D) C. Neoformans
  • E) Hanta Virus
hantavirus
Hantavirus
  • Hanta virus: RNA virus; Bunyaviridae(Sin NOMBRE virus)
  • Hantavirus Pulmonary Syndrome
  • S.W. U.S. (New Mexico, Arizona, Utah, Colorado) has been reported in all States
  • Rodent exposure (Peromyscus maniculatus)
  • 4 Phages: febrile, shock, diuresis, convalescent
  • Clinical: fever, myalgias, cough, dyspnea, H/A, GI symptoms
  • Labs: leukocytosis, hemoconcentration, thrombocytopenia, prolonged PT/PTT
  • Rapidly progressive pulmonary edema with hypotension
  • Diagnosis: IFA of sputum, lung tissue
  • Treatment: ? Ribavirin
  • Case Fatality 76%
case five
Case Five
  • A 32 y.o. male presents to the ER with fever and a ulcerative skin lesion on his arm. In the ER he has a T=103, and you notice ipsilateral axillary lymphadenopathy. Ten days ago he returned from a hunting trip where he killed and skinned a rabbit, fox, and deer.
the most likely causative pathogen is25
The most likely causative pathogen is:

A) B.burgdorferi

B) B. anthracis

C) Y. Pestis

D) V. Vulnificus

E) F. Tularensis

tularemia francisella tularensis
Tularemia: Francisella Tularensis
  • Gm (-) coccobacillus; requires cysteine for growth
  • Contact with infected animals (rabbits, squirrels, cats), inhalation, tick bite
  • Peak occurs with tick-borne exposure and hunting season
  • Southcentral and Southwestern United States- Oklahoma, Arkansas, Texas
  • Hunters, trappers, lab workers
tularemia incidence
Tularemia: Incidence
  • 1990-2000 – 1368 cases.
  • Approximately 124 cases/year reported to the CDC.
  • 56% cases were reported from Arkansas, Missouri, South Dakota, and Oklahoma.
  • Endemic on Martha’s vineyard.
  • 70% cases between May and August.

(MMWR 2002 Mar 8; 51 (9) 182-184)

francisella tularensis
Francisella Tularensis
  • Small non-motile gm (-) cocci bacillus.
  • Can survive for weeks at low temperatures in water, moist soil, hay and decaying animal carcasses.
  • Voles, mice, rabbits, hares, squirrels are reservoirs.
  • Vectors: Ticks, flies, mosquitoes.
  • Human infection
  • Tick bites
  • Handling infected animals or animals products.

• Ingestion.

• Inhalation.

tularemia clinical
Tularemia: Clinical
  • 50% of patients with ulcer node disease
  • Patients develop ulcerative lesion at site of exposure which is associated with ipsilateral lymphadenopathy
  • Bacteremia, pneumonia, oculo-glandular disease
    • Pneumonia in gardeners on Martha’s Vineyard
pneumonic tularemia clinical
Pneumonic Tularemia: Clinical
  • Fever and non-productive cough
  • 3 -5 day incubation period (range 1- 14 days)
  • CXR: pneumonia, pleural effusion, and hilar lymphadenopathy
diagnosis treatment and prevention
Diagnosis, Treatment and Prevention
  • Diagnosis: grows on media enriched with cysteine; serology
  • Treatment: streptomycin, gentamicin, doxycycline, ciprofloxacin
  • P.E.P.: doxycycline or ciprofloxacin
  • Live attenuated vaccine: lab workers
  • Respiratory isolation not needed
case six
Case Six
  • A 25 y.o. male presents to the ER with fevers, myalgias, LBP, nausea, and vomiting. In the ER he has a T=39.5, BP 80/40, P=120 and you notice a rash. Labs: WBC 25,000, HCT 45, PLT 40,000, BUN/Cr 40/2.2. The patient has returned from a camping trip in North Carolina one week ago.
the most likely causative pathogen is39
The most likely causative pathogen is:

A) B. burgdorferi

B) S. Pneumoniae

C) R. Rickettsii

D) B. Microti

E) Leptospiria

rocky mountain spotted fever
Rocky Mountain Spotted Fever
  • Caused by Rickettsia rickettsii
  • D. andersoni & D. variabilis
  • South Atlantic Coastal, western and south central states (North Carolina, South Carolina, Oklahoma, and Tennessee)
  • > 95% cases April - September
  • Dogs, wooded areas, males
rmsf clinical
RMSF: Clinical
  • Incubation 5 - 7 days (2 to 14 days)
  • Fever, H/A, malaise, nausea, vomiting, abd. pain
  • Rash: 1 - 5 days after onset of illness; macules on wrists & ankles; spread to trunk, palms, and soles; 10% pts. without rash
  • Thrombocytopenia, DIC, elevated [email protected] ARF, ARDS
rmsf diagnosis treatment
RMSF: Diagnosis & Treatment
  • Mortality: 5 - 25%
  • Diagnosis: DFA of skin biopsy - Serology
  • Treatment: Tetracyclines & chloramphenicol
case seven
Case seven
  • A 50 y.o. male with a history of hemachromatosis was brought in by his friends with fevers, diarrhea, & severe weakness. They had recently returned from a boating trip on the Chesapeake bay where they ate fresh crab and other assorted shellfish. On exam T=39 BP 70/40 P130
the most likely causative pathogen is45
The most likely causative pathogen is:
  • A) S. aureus
  • B) Campylobacter jejuni
  • C) Shigella
  • D) Mycobacterium marinum
  • E) Vibrio vulnificus
vibrio vulnficus
Vibrio Vulnficus
  • Seawater or raw seafood/shellfish (oysters)
  • Chesapeake bay, Gulf coast (hurricane Katrina)
  • Liver disease, cirrhosis, hemachromatosis, ETOH
  • Septicemia with metastatic skin lesions
  • Diarrhea
  • rapidly progressive cellulitis
  • 50% mortality
  • Tetracycline/doxycycline; combination therapy with doxycycline + 3rd generation sephalosporin (ceftriaxone, cefotaxime)
a trip to the zoo

A Trip to the Zoo

Joseph G. Timpone, M.D.

Division of Infectious Diseases

slide48
A 35 year old male is brought to a NYC E.R. with fevers H/A and (R) inguinal pain. In the E.R. he is noted to have T = 40oC, P = 120, and BP = 80/40. There is a 3x3 cm tense lymph node in (R) inguinal region. WBC = 25,000, PLTs = 60,000, Bun/Cr = 40/2.0.
slide49
The patient reports that he is visiting from Colorado where he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.
the most likely causative agent would be
The most likely causative agent would be:
  • a.) Sin Nombre Virus
  • b.) Francisella Tularensis
  • c.) Coxiella Burnettii
  • d.) Yersinia Pestis
  • e.) Bacillus Anthracis
plague yersinia pestis
Plague: Yersinia Pestis
  • gm(-) Cocco-Bacillus (bipolar appearance - “safety pin”)
  • Rats, ground squirrels, prairie dogs, cats
  • Rodent Flea: Xenopsylla cheopis
  • S.W. US (New Mexico, Arizona, Colorado, California)
  • Recreational/occupational : hunting, camping, military
plague clinical
Plague: Clinical
  • Incubation: 2 -6 days
  • Bubonic: Tense, Tender, Fluctuant nodes (inguinal, axillary, cervical)
  • Pneumonic: cough, hemoptysis, watery sputum; patchy/lobar infiltrates
  • Septicemic: hypotension, DIC, gangrene
  • Meningitis, Pharyngitis
plague diagnosis
Plague: Diagnosis
  • 50% mortality with out treatment: 5% with treatment
  • Aspirate/culture of Bubo -> Wayson’s stain (bipolar staining - “safety pin”)
  • DFA staining
  • PCR
  • Serology
plague treatment
Plague: Treatment
  • Streptomycin or gentamicin
  • Alternative: Doxycycline, Ciprofloxacin
  • P.E.P: Doxycycline
  • respiratory isolation x 48 - 72 hrs.
slide56
A 28 year old male presents to the E.R. with fevers, H/A, Rash, Dyspnea and a dry, non-productive cough of 3 days duration. His PEx reveals a T = 40oC, P = 60, and 02SAT = 95%. There are crackles at the (R) Lung base; (+) Splenomegaly, and a pink macular rash on his face and trunk.
slide57
His CXR reveals a (R) lower lobe consolidation. He reports that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.
the most likely causative pathogen is58
The most likely Causative Pathogen is:
  • a.) Histoplasma Capsulatum
  • b.) Cryptococcus Neoformans
  • c.) Chlamydophila Psittaci
  • d.) Legionella Pneumophila
  • e.) Mycoplasma Pneumoniae
chlamydophila
Chlamydophila
  • Obligate intra-cellular pathogen
  • Parrot, finch families, turkeys, pigeons, poultry
  • Transmission: aerosolized secretions, excrement
  • Pet owners, pet shops, vets, abattoir workers, farmers
c psittaci clinical
C. psittaci Clinical
  • Incubation 5 - 15 days post exposure
  • Fever, H/A, dry cough, and SOB
  • Splenomegaly
  • Horders spots: pink macular rash on face, trunk
  • CXR lower lobe consolidation
  • Labs: nl WBC, elevated LFTs
c psittaci
C. psittaci
  • Diagnosis: serology, culture (lab hazard)
  • Treatment: doxycycline x fourteen - 21 days; Macrolides, quinolones
  • Miscellaneous; Meningitis, Myocarditis, Pericarditis
case 4
Case 4
  • A previously healthy male presents to the ER with fevers, H/A and cough. He is employed as a detective and his hobbies include hiking, camping, and hunting. His most recent camping trip was approximately 8weeks ago. Ten days ago, he was playing poker in his friend’s basement, and witnessed the birth of a litter of kittens. In the ER, he has a T=102, P=80, and BP=130/60. Crackles are heard at the bases. WBC 5.0 Hct 42 Plts 105,000 AST 68 ALT85. CXR reveals bilateral lower lobe airspace disease. The pt. reports that all of his buddies have been diagnosed with pneumonia.
the most likely explanation for the cluster of pneumonia cases is
The most likely explanation for the cluster of pneumonia cases is:

A. An act of bioterrorism

B. Inhalation of infected birth products

C. Ingestion of poorly cooked Mexican cheese (on the nachos at the poker game)

D. Participation in a bachelor party at “Good Guys”

E. Water exposure while camping

poker player s pneumonia
Poker Player’s Pneumonia
  • Q - Fever pneumonia (Coxiella Burnetii)
  • Urban outbreak amongst poker players
  • Exposure: parturient Cat -> kittens
q fever background
Q Fever: Background
  • 1935: Derrick described febrile illness in abattoir workers in Australia
  • Q Fever - (query)
  • MacFarlane-Burnet and Freeman isolated organism from guinea pigs inoculated with blood of febrile patients
  • Cox and Davis isolated GM(-) organism from ticks in Montana
  • Coxiella burnetii
q fever microbiology
Q Fever: Microbiology
  • Caused by C.burnetii
  • SmallGM(-) bacterium that grows exclusively in eukaryotic cells
  • Gamma subgroup of proteobacteria; related to Legionella
  • LPS -> antigenic shift/phase variation
  • Phase 1-> infectious form
q fever epidemiology
Q Fever: Epidemiology
  • Cattle, goats, sheep, cats, rabbits, dogs, birds, ticks
  • Farmers, veterinarians, abattoir workers
  • Transmission via inhalation of organisms or ingestion of raw milk
  • Parturient cats and farm animals
  • Worldwide geographic distribution
q fever clinical
Q Fever: Clinical
  • 54% of cases are asymptomatic
  • Incubation period 2-6 weeks
  • Abrupt onset of fever and headache
  • Fever (90%), Pneumonia (45%), and Elevated LFTs (69)
  • Atypical Pneumonia
  • Granulomatous Hepatitis
  • Maculopapular/purpuric rash in 20% (Leukocytoclastic Vasculitis)
q fever chronic
Q Fever: Chronic
  • Culture (-) endocarditis of damaged or prosthetic valves
  • Decreased cell-mediated immune response to C.burnetii
  • Clubbing, hepatomegaly, splenmegaly, purpuric rash, and arterial emboli
  • Hypergammaglobulinemia, microscopic hematuria, elevated ESR
q fever miscellaneous
Q Fever: Miscellaneous
  • Myocarditis/pericarditis
  • Meningoencephalitis
  • Osteomyelitis
  • Hemolytic anemia
  • Epididymitis/orchitis
q fever laboratory
Q Fever: Laboratory
  • Normal white blood cell count (90%)
  • Thrombocytopenia (25%)
  • Increased transaminase levels (70%)
  • Smooth muscle autoantibodies (65%)
  • Anti-phospholipase antibodies (50%)
q fever diagnosis
Q Fever: Diagnosis
  • Cell culture (shell vial -> immunofluorescence)
  • Incubation period 8-12 days
  • Culture of buffy-coat and biopsy specimens
  • PCR of biopsy specimens
  • Granuloma: “doughnut” appearance
q fever serology
Q Fever: Serology
  • CF, IFA, and ELISA
  • IFA phase II antigen > 1:200
    • IgG > 1:200
    • IgM > 1:50
  • Serology (+) at 2-4 weeks
  • IgM serology (+) for 6-8 months
q fever treatment
Q Fever: Treatment
  • Doxycycline, TMP/SMX, Ciprofloxacin, Rifampin
  • Acute: duration 15-21 days
  • Chronic: duration (?) 3 years
  • Relapses are common
  • (?) Hydroxychloroquine + Doxycycline
case 5
Case 5
  • Dan Rather presents for evaluation of a skin lesion. He reports that he recently returned from Afghanistan where he was in hot pursuit of Usama Bin Laden. He states that he had to sleep on the floors of caves, wade across some murky waters, an use a camel for transportation. His diet consisted of nuts, berries and insects. His exam reveals an eschar on the dorsum of his right hand with surrounding edema. His only other complaint is that he is very depressed due to some comments that he received in his fan mail.
the most likely causative pathogen is77
The most likely causative pathogen is:

A. Bacillus anthracis

B. Variola

C. Bartonella henselae

D. Borrelia burgdorferi

E. Histoplasma capsulatum

anthrax microbiology
Anthrax: Microbiology
  • Aerobic
  • Nonmotile
  • Spore forming
  • Gram + bacillus
  • Spores survive > 30 yrs in soil
anthrax epidemiology
Anthrax: Epidemiology
  • Zoonotic disease in herbivores
  • Human infection can occur via contact with infected animals or animal products, ingestion or inhalation
    • NO person-to-person transmission
  • Early 1900s: 130 cases annually in the US
    • >95% of disease is cutaneous
    • Last naturally occurring cutaneous case 1992
  • 20th century 18 inhalation cases
    • Last naturally occurring inhalation case 1976
  • 2001 Bioterrorism threat in Postal Workers, News Reporters, and Federal Government Employees
cutaneous anthrax
Cutaneous anthrax
  • Direct contact with spores
  • Does not affect intact skin
  • Commonly seen on the head, forearms or hands
  • Incubation 1-12 days
  • Localized itching, followed by a papular lesion  vesicular  painless depressed black eschar
  • Mortality up to 20% without abx; rare with abx
  • Abx do not change the progression of the lesion
  • DDX: Spider bite, Ecthyma gangrenosum, tularemia, plague, cellulitis

JAMA 1999; 281:18

inhalational anthrax
Inhalational anthrax
  • Incubation period avg 1-7d
  • Flu-like prodrome
  • Brief improvement
  • Abrupt respiratory failure and collapse
  • CXR: widened mediastinum, pleural effusions, infiltrates, ? consolidation
  • 50% hemor. meningitis
  • Mortality: 89%
  • DDX: atypical pneumonia, tularemia, Q fever, fungal pneumonia
travel niblets

TRAVEL NIBLETS

Joseph G. Timpone Jr., MD

Georgetown University Hospital

slide83
A 28 y.o. male PCV has returned from a two year assignment in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

WBC 15,000, AST 80, ALT 90, ALK PHOS 250.

slide85
The most appropriate diagnostic study would be:

A) stool for O and P

B) Blood cultures

C) Aspiration of the liver lesion

D) Serology

E) ERCP

amebiasis
Amebiasis
  • Entamoeba histolytica causative agent
  • 90 % of infections asymptomatic, remaining 10 % produce spectrum of clinical syndromes
  • Acquired by ingestion
  • 10 % of world's population is infected
    • Third most common cause of death from parasitic disease (after schistosomiasis and malaria)
  • Invasive amebiasis have unique virulence properties compared with noninvasive
intestinal amebiasis
Intestinal Amebiasis
  • Asymptomatic cyst passage most common
  • Symptomatic colitis develops 2 to 6 weeks after the ingestion of infectious cysts
  • Stools contain little fecal material and consist mainly of blood and mucus
  • Rare intestinal forms:
    • Fulminant intestinal infection
    • Toxic megacolon
    • Chronic amebic colitis (confused with IBD)
amebic liver abscess
Amebic Liver Abscess
  • Always preceded by intestinal colonization
  • 95 % occur within 5 months of exposure
  • Majority present with fever and RUQ pain
  • Only 1/3 of patients have active diarrhea
  • 10 to 15 % present only with fever
  • Complications of amebic liver abscess:
    • Pleuropulmonary involvement (20 to 30 %)
    • Rupture into peritoneum
    • Rupture into pericardium
diagnostic tests
Diagnostic Tests
  • Stool examinations:
    • Positive test for heme
    • Paucity of WBC’s
    • Important to examine 3 fresh stools
    • Confirms diagnosis in 75 to 95 % of cases
    • Cysts must be differentiated from Entamoeba hartmanni, Entamoeba coli & Endolimax nana
  • Serologic tests
    • 70 % positive with colitis or 90% positive for abscess
    • Suggest active disease because serologic findings usually revert to negative within 6 to 12 months
  • Noninvasive imaging of the liver
  • Treatment: metronidazole + paronomycin
  • Stool antigen for E.Histolytica
slide93
A 20 y.o. male presents with watery diarrhea. He has had recurrent infections with the pathogen shown on the previous slide.
slide94
The most likely cause of recurrent infection is:

A) Neutropenia

B) HIV infection

C) Lymphocytopenia

D) Compliment deficiency

E) IgA deficiency

giardia lamblia
Giardia lamblia
  • Worldwide distribution
  • Most common intestinal parasite in USA (found in 4 to 7% of O&P specimens)
  • Transmission:
    • Water contamination most common (not killed be standard chlorine concentrations)
    • Person-to-person (daycare, homosexual etc.)
    • Foodborne
  • Hypogammaglobulinemic and achlorhydric patients at greater risk
giardia lamblia96
Giardia lamblia
  • Incubation period of 1 to 2 weeks
  • Spectrum of disease varies widely
  • Of 100 people ingesting cysts:
    • ~5-15% become asymptomatic cyst passers
    • ~25-50% have diarrheal syndrome
    • ~35-70% have no trace of infection
  • Diarrheal syndrome typically acute lasting 1-3 weeks but can be chronic with weight loss
  • Giardia does not invade mucosal tissue
  • Lactase deficiency after infection common
giardia lamblia97
Giardia lamblia
  • Diagnosis:
    • O&P test of choice (90% yield from 3 specimens)
    • Giardia stool antigen (85-98% sensitive)
    • Duodenal sampling (seldom needed)
      • String test
      • Duodenal aspiration/biopsy
  • Therapy:
    • Metronidazole for 7 days (efficacy 80-95%)
    • Furazolidone and paromomycin alternatives
slide99
A 24 y.o. male Marine has recently returned from a tour of duty in Iraq. He reports a month history of a non-healing skin ulcer. He was given two courses of antibiotics (Cephalexin, Levofloxacin) without any improvement. He has no other complains.
slide100
The most likely causative pathogen would be:

A) Group A streptococcus

B) MRSA

C) Bacillus anthracis

D) Herpes simplex

E) Leishmania

leishmaniasis
Leishmaniasis
  • Obligate intracellular protozoa (genus Leishmania)
  • Syndrome caused by ~21 leishmanial species
  • Vector is the sandfly (~30 species)
  • 1.5 to 2 million new cases yearly
  • Three clinical syndromes caused by replication of parasite inside macrophages :
    • Visceral
    • Cutaneous
    • Mucocutaneous
cutaneous leishmaniasis
Cutaneous Leishmaniasis
  • Traditionally classified as New World or Old World
  • Most cases occur in men who have forest-related occupational exposures
    • chiclero ulcer
leishmaniasis104
Leishmaniasis
  • Types: Cutaneous, Mucocutaneous, Visceral
  • Old world: L. tropica; New world: L. braziliensis
  • Cutaneous Leishmaniasis: Chronic non-healing ulcer or nodule
  • Visceral: fevers, N.S. wt. Loss, massive splenomegaly
    • caused by L. donvani (can see L.tropica in Gulf War Vets.)
    • AIDS - defining illness in Southern Europe
  • Treatment: Antimony, AMB, Pentamidine
slide106
A 40 y.o. Peruvian female is brought to the ER by her family because of new onset seizures. She’s currently employed as a daycare worker. She denies any fevers, night sweats, weight loss or other symptoms. She has a negative PPD. In the ER the patient is a febrile and post-ictal.
slide107
The most likely cause of her seizures would be:
  • A) MTB
  • B) N. meningitidis
  • C) T. cruzii
  • D) T. solium
  • E) HSV
t solium and cysticercosis
T. Solium And Cysticercosis
  • Pork tapeworm T. solium causative agent
  • Two distinct forms of infection:
    • Intestinal tapeworms by ingesting undercooked pork
    • Cysticercosis (larval forms in tissues) follows ingestion of T. solium eggs
      • Usually from fecally contaminated food
      • Autoinfection
      • Reflux from intestine into the stomach.
  • Exists worldwide (10% prevalence in some areas)
clinical manifestations
Clinical Manifestations
  • Intestinal infection:
    • Usually asymptomatic
    • Tapeworm ~3 meters in length
    • Normally, only one worm (live up to 25 years)
    • Fecal passage of proglottids may be noted
  • Cysticercosis:
    • Larvae location (most commonly brain and muscle) and size determine clinical presentation
    • Neurologic manifestations most common
diagnosis
Diagnosis
  • Intestinal infections:
    • Detection of eggs or proglottids by O&P
  • Cysticercosis:
    • Definitive diagnosis requires examination of larvae in involved tissue
    • Diagnosis often based on clinical presentation with radiographic studies and serologic tests
treatment
Treatment
  • Intestinal infection treated with praziquantel
  • Asymptomatic patients with calcified lesions generally require no treatment
  • Symptomatic neurocysticercosis:
    • Albendazole treatment of choice (better CSF levels)
    • Praziquantel alternative
    • Treatment provokes inflammation around dying cysticerci  hospitalize and give glucocorticoids
    • Ventricular obstruction may need VP shunting
slide113
A 30 y.o. female has returned from a safari in Kenya. She presents with the abrupt onset of fevers, photophobia, H/A, and diarrhea 48 hours upon return to the US. On the Exam her T=39.5. There is no meningimus or rash. WBC 5.0, HCT 29, PLT 55,000, LDH 400, bili 3.0, BUN/Cr 25/1.8.
slide114
The most appropriate therapy would be:

A) Ceftriaxone + Vancomycin

B) Chloroquine

C) Mefloquine

D) Quinine + Doxycycline

E) Primaquine

fever in travelers
Fever in Travelers
  • Malaria
  • Dengue Fever
  • Typhoid Fever
  • Meningococcemia
  • MTB
  • Leptospirosis
  • SARS
malaria
Malaria
  • P. falciparum, P. vivaz, P.ovale, P. malariae
  • Sub-Saharan Africa, S.E.A., Latin America, Middle East
  • Fever in Travelers: Malaria, Typhoid Fever, Dengue Fever, Meningococcemia
  • Fever, H/A, rigors, photophobia, HSM, hemolytic anemia, thrombocytopenia, hyerbilirubinemia, hypoglycemia, ARF
  • P. falciparum: ARDS, Cerebral Malaria
  • Prophylaxis: Mefloquine, Doxycycline, Proguanil/Atovaquone; Chloroquine in Mexico, Central America, Caribbean
  • Treatment: P. falcip. - Quinine+Doxycycline (Quinidine for severe cases)
slide118
A 60 y.o. male with AML is s/p induction chemotherapy and has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.
slide119
Stool for O & P would most likely yield:

A) S. stercoralis

B) E. histolytica

C) G. lamblia

D) A. lumbricoides

E) A. duodenale

strongyloidiasis
Strongyloidiasis
  • Strongyloides Stercoralis
  • Clinical; diarrhea, ADB. Pain, urticaria, larva currens, pulmonary, infiltrates, eosinophilia
  • O&P, duodenal aspirate (string test)
  • Strongloidis AB
  • Hyperinfection: steroids, chemotherapy, AIDS, transplantation, HTLV infection
    • polymicrobial gm(-) bacteremia
  • Treatment: Ivermectin, Thiabendazole, Albendazole
cryptosporidiosis
Cryptosporidiosis
  • Caused by C. parvum
  • Immunocompromised (AIDS) & Immunocompetent patients
  • Water borne illness (Milwaukee, WI 400,000 cases)
  • Watery diarrhea, abd. Pain, n/v, cholangiopathy in AIDS patients
  • Diagnosis: modified AFB stain
  • Treatment: ? Paronomycin, azithromycin; Nitazoxanide
putting the fun in fungus

PUTTING THE FUN IN FUNGUS

Joseph G. Timpone, Jr. M.D.

Georgetown University Hospital

case one124
CASE ONE
  • A 45 y.o. male with DM and ESRD s/p renal transplant three months ago presents with fevers, n.s. and S.O.B. His meds include CYA, MMF, Prednisone. In the ER T=39, BP=80/40, there are oral ulcers. CXR reveals interstitial infiltrates. WBC 2.0, PLT 50K, INR =3.0, LDH 400. The patient is employed as a chicken farmer.
histoplasmosis etiology
Histoplasmosis: Etiology
  • Histoplasma capsulatum
  • Dimorphic fungus
  • Grows in soil
  • Chicken, starling, & bat excrement
histoplasmosis epidemiology
Histoplasmosis: Epidemiology
  • Endemic in east/central U.S.
  • Ohio and Mississippi River Valleys
  • Farming, rural, urban settings
  • High rate of infection in endemic regions
histoplasmosis clinical features
Histoplasmosis: Clinical Features
  • 90% asymptomatic
  • Fever, night sweats, weight loss
  • Cough, pleurisy, SOB
  • Arthralgias, myalgias
  • Lymphadenapathy
  • E. nodosum/multiforme
risk factors for progressive disseminated histoplasmosis pdh
Risk Factors for Progressive Disseminated Histoplasmosis (PDH)
  • Depressed cell mediated immunity
  • Advanced HIV disease
  • Corticosteroids, Methotrexate
  • Infliximab, Etanercept (Anti-TNF-Alpha therapies)
  • Solid organ transplantation
  • Elderly
  • Defects in the IFN-GAMMA-ILI2 Pathway
  • DM, ESLD, ESRD
pdh clinical features
PDH: Clinical Features
  • Fulminant course in AIDS/Transplant pts.
  • Most common AIDS defining illness in endemic areas
  • Can occur as acute exogenous infection and as reactivation
  • Fever, night sweats, wt. Loss, oral ulcers, lymphadenopathy, Hepatosplenomegaly
  • Pulmonary involvement: CXR with diffuse interstitial infiltrates
  • GI involvement (ILEO-CECAL region; can mimic IBD)
  • Adrenal insufficiency
  • Leukopenia, anemia, thrombocytopenia, DIC, elevated LDH
pdh diagnosis and treatment
PDH: Diagnosis and Treatment
  • Urinary & serum histoplasma Ag (90% urine; 70% serum)
  • 95% sensitivity in HIV (+)
  • 82% in non-HIV immunosuppressed patients
  • Treatment Amphotericin B (Lipid preparation; Itraconazole)
case two133
CASE TWO
  • A 35 y.o. male lumber jack from Wisconsin presents to the ER with a two week history of cough and sputum production. His CXR reveals a dense alveolar inflitrates.
blastomycosis etiology epidemiology
Blastomycosis: Etiology & Epidemiology
  • Caused by Blastomyces dermatitides
  • Isolated from soil and decaying wood
  • Midwest near Great Lakes, Canada, South central states bordering Ohio & Mississippi River Valleys
  • Occupational & recreational exposure near waterways
  • Inoculation via inhalation, skin, dog bites
blastomycosis clinical
Blastomycosis: Clinical
  • Acute Pulmonary Blastomycosis: fever, chills, myalgias, arthralgias, cough, sputum production
  • CXR: alveolar infiltrates in lower lobes
  • Chronic complications
  • Pulmonary
  • Skin: verrucous & ulcerative lesions (40-80%)
  • Bone & joint disease
  • Genitourinary: prostatitis, epididymitis
blastomycosis treatment
Blastomycosis: Treatment
  • Acute pulmonary:
    • Treatment indicated for severe disease only
    • Amphotericin B, 1.5-2.5 gm
  • Chronic:
    • Ketoconazole, 400-800 mg/day x 6 months
    • Itraconazole, 200 mg BID x 6 months
case three139
CASE THREE
  • A 30 y.o. male construction worker presents with fevers and H/A of two weeks duration. His PMH is significant for HIV with a CD4=75. He has refused all medication. In the ER an LP reveals WBC=100, 5% PMN, 70% LY, 25% EOS, T.P=100, GLU=20. His PPD is negative.
  • His most recent work was at a site in Phoenix.
coccidioidamycosis etiology epidemiology
Coccidioidamycosis: Etiology & Epidemiology
  • Caused by Coccidioides immitis
  • Endemic to Southwestern U.S. & Mexico
  • 100,000 new infections per year
  • Arid climate, low altitudes, alkaline soil
coccidioidomycosis acute infection
Coccidioidomycosis: Acute Infection
  • 60% of patients are asymptomatic
  • 40% have viral-like illness (fever, myalgias, H/A, non-productive cough lasting 1-3 weeks)
  • CXR: alveolar infiltrate or solitary pulmonary nodule (5% have persistent CXR abnormalities)
  • Most commonly a self-limited illness
  • Allergic manifestations: E. nodosum & multiforme are good prognostic indicators
coccidioidomycosis disseminated disease
Coccidioidomycosis: Disseminated Disease
  • Occurs in <0.5% of patients
    • Increased risk:
      • African-Americans, Filipinos, Latinos
      • Pregnant women
      • Cytotoxic chemotherapy
      • Glucocorticoids
      • Organ transplantation
      • HIV disease
  • Disseminates to skin, bone, meninges
  • Severe pulmonary disease
coccidioidomycosis meningitis
Coccidioidomycosis: Meningitis
  • Often occurs 6 months after initial infection
  • Causes a basilar meningitis
  • Fever, H/A, confusion
  • CSF:
  • Mononuclear cell pleocytosis with eosinophils
    • (+) CF Ab in 70%
    • (+) Culture in 1/3 of cases
coccidioidomycosis diagnosis
Coccidioidomycosis: Diagnosis
  • Skin test
  • Culture: (+) in sputum, joint fluid, CSF
  • Giant spherule on H&E, Pap, KOH prep
  • Serology:
    • 75% Have (+) IgM @ 2-3 weeks
    • 90% Have (+) IgG CF Ab @ 3 months
  • 95% of patients without disseminated disease with < 1:32
coccidioidomycosis treatment
Coccidioidomycosis: Treatment
  • Acute: No therapy; consider therapy in high risk groups (Amphotericin B, 0.5-1.5 gm or fluconazole, 400-800 mg qd)
  • Single cavitary disease: No therapy
  • Chronic fibrocavitary disease: Ketaconazole or fluconazole
  • Disseminated: Amphotericin B, 2.5 gm
  • Meningitis: Amphotericin B, IV & Intrathecal; fluconazole
  • Skin & Bone: Ketoconazole or fluconazole
case four148
CASE FOUR
  • A 50 y.o. male with ESLD due to HCV is three months S/P OLT. The patient presents with a one week history of low grade fevers and H/A. He’s also noted to have several papular skin lesions. His meds include Tacrolimus and Prednisone. He recently received high dose steroids for a bout of rejection.
recommended management of cryptococcal meningitis in aids patients initial rx
Medical:

Ampho B, 0.7 mg/kg/day x 14 days

Flucytosine, 100 mg/kg/day orally in 2-4 divided doses x 14 days

Consolidation from week 2-10 w/fluconazole, 400 mg once daily

Suspected acute cerebral hypertension:

CT or MRI scan to assess obstructive hydrocephalus

If absent, lumbar puncture; if present, ventriculostomy

If cerebrospinal fluid pressure >25 cm, use large-bore needle to lower CSF pressure until it's stable <25 cm H2O

Recommended Management of Cryptococcal Meningitis in AIDS Patients: Initial Rx
recommended management of cryptococcal meningitis in aids patients
Recommended Management of Cryptococcal Meningitis in AIDS Patients
  • Chronic suppressive management from week 1 0 continued indefinitely: fluconazole, 200 mg qd po.
  • Use of Cryptococcal antigen:
    • Serum: Diagnostic only, should prompt lumbar puncture. If no antigen in CSF and culture of CSF is negative, consider starting fluconazole, 200 mg per day to prevent CNS disease.
    • CSF: Pre-treatment titer>1,1024associatedw/ adverse outcome Post-treatment titer stable or rising suggests relapse
case five153
CASE FIVE
  • A 40 y.o. female with AML is S/P induction chemotherapy and has had an ANC <250 for the past three weeks. She has been treated with Impenem, Vancomycin, and Amphotericin B. She’s developed a cough with hemoptysis.
aspergillosis
Aspergillosis
  • Risk factors: prolonged neutropenia, immunosuppressive therapy, corticosteroids, BMT, organ transplant, hematologic malignancies
  • Highest risk in allogeneic BMT with GVHD
  • Invasive pulmonary disease
  • CNS involvement
  • Diagnosis: BAL, biopsy, serum galactomannan
  • Therapy: Voriconazole, liposomal amphotericin B, itraconazole, caspofungin, surgical resection
case six157
CASE SIX
  • A 60 y.o. diabetic male is brought to the ER by his wife because of mental confusion. She reports that he has been complaining of sinus congestion. In the ER the patient is obtunded and unresponsive. Labs: GLU=450, HCO 3=14, Anion gap=17.
the most likely causative organism is159
The most likely causative organism is:
  • A) Nocardia
  • B) Candida albicans
  • C) Rhizopus species
  • D) Pseudomonas aeruginosa
  • E) MRSA
zygomycosis mucormycosis
Zygomycosis/ Mucormycosis
  • Rhizopus, Absidia, Cunninghamella
  • Broad hyphae (5-15 Mm) without septations
  • Have an enzyme keton-reductase which allows it to thrive in high glucose/ acidic environments
  • Iron overload & deferoxamine therapy promote growth
  • DM, Hematologic malignancies, metabolic acidosis, steroids, AIDS, IDU, trauma/burns, malnutrition
mucormycosis
Mucormycosis
  • DM (DKA), leukemia/neutropenia, transplant, deferoxamine therapy
  • Rhinocerebral Mucormycosis
  • Fever, sinus/facial pain/edema, H/A, CN palsies, retinal vein thrombosis, cavernous sinus thrombosis
  • Surgical debridement & Amphotericin B: Posaconazole (60% response rate)
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