Transcript Severe disease

Bites That Suck
(Mosquito Borne Illness in the US)
Jesus Seda MD
Objectives
• Review presentations of some Mosquito born illnesses
• Review ED evaluation and treatment
• Review Diagnostic Testing
• Treatment of Local Reactions
• Think Warm Thoughts
Case 1
5 yo M presents in July
with swelling to arm for a
few hours after spending
day outside.
P: local pain
E: erythema
S: STS
T: Tingling / paresthesia
Local reaction
• Reaction varies by biting species
• Wanes over years
• Immune response dominant
• Local wheal & flare develops over 36 hours
• Bacterial superinfection uncommon!
• Usually takes days
• Zyrtec effective for itching & swelling
• Steroids
• No specific studies
• Topical first or 7 day oral treatment
• No antibiotics if within hours
• Low grade fever
(Karppinen, 2002)
Case 2
• 25 yo M p/w fever, nausea HA
and fatigue
• Returned from Medical Mission
in Haiti 1 month prior
• Trip of 5 weeks duration
• Rural village, no infrastructure
• Noncompliant with prophylaxis
Initial Presentation
• Usually present due to high fevers
• Headache, malaise, rash
• Symptoms similar to viral illness/influenza
• Elicit travel history
• where, when, activity, length, bites
• VFR vs military travel
• Prophylaxis does not prevent disease
Malaria:
Historically in
the USA
• 1 million deaths per year globally
• 1500 cases in US per year
• 2011 1900 cases
• 1947 15,000
• Famous Sufferers:
• George Washington
• Abraham Lincoln
• Andrew Jackson
• Jesse James
Malaria:
transmission
• Caused by protozoa plasmodium
• Transmitted by anopheles mosquito
• Plasmodium falciparum
• >2% RBC load
• Severe : (pulmonary edema, ARF)
• Vivax, malariae and ovale
• Usually less severe disease
• Can lay dormant in liver for years
• Knowlesi: newly described in Asia
Malaria: species distribution
Malaria: Signs/Symptoms
• Fever
• 35% no fever (Svenson 1995)
• Fever cycles
• Hemolysis
• Jaundice
• Anemia
• Myalgias
• GI symptoms
• “Partial Immunity”
Severe disease
• Cerebral malaria
• Seizures, decreased LOC
• Acute Kidney Injury
• Lactic acidosis
• Hypoglycemia
• Pulmonary edema
• Severe anemia (Hgb <5)
• DIC
• Hemorrhagic shock
Malaria:
diagnosis
• Thick/thin smear
• 11% miss rate in US
• May need multiple smears (x3
minimum)
• Quantify parasite load
• Binaxnow antigen testing
• Sensitivity 96% , specificity 98%
• Start treatment prior to final diagnosis
Malaria: Treatment
• ABCs
• Symptomatic care
• Aggressive blood sugar monitoring
• Transfusion if less than 7
• No evidence for exchange
• Symptomatic seizure tx
• Empiric antibiotics
• 8% bacterial coinfection
• 3% bacteremia (Marks 2014)
• If unknown species
• Atovaquone-proguanil (malarone)
• 4 tabs daily for 3 days
• If unknown and chloroquine sensitive
• Chloroquine vs hydroxychloroquine (plaquenil)
• If vivax/ovale
• Add primaquine to prevent relapse
Complicated/Severe
• Quinidine + doxycycline
• Loading dosing/continuous infusions
• Once parasite load <1% can switch to oral
• 7 days total
• BP, QT and BS monitoring
• Artesunate - available through CDC only
• 7 day dose
Case 3
• 25 yo F p/w fever
• Headache, myalgias, dark
urine
• Returned from trip to
Hawaii one day prior
Dengue:
Prevalence
• Most prevalent mosquito born disease
• Increasing every year
• 50 million /year
• 500k severe
• 20K deaths
• 2011-> ~ 1750 cases
• 1500 Puerto Rico
• 250 United States
• Hawaii outbreak
• Local outbreak
• 9/2015 – current date
• 182 confirmed cases
Dengue: Distribution
red = dengue blue = aedes
Dengue:
Transmission
• Transmitted by aedes aegypti/ albopictus
• Endemic to southern united states
• Difficult to control
• Potential for autochthonous outbreaks
• Four serotypes
• Antibody mediated immune response
• Cytokine storm with repeat infection
Dengue: Signs/Symptoms
• Unpredictable course
• 3 phases (lasting 48 hours)
• Febrile
• Fever, headache, retro-orbital pain
• Critical phase
• Vascular permeability
• Pleural effusion
• Abdominal thirds spacing
• Thrombocytopenia
• Recovery phase
• 10% progress to severe (Kalayanarooj 2011)
• Dengue shock syndrome
• Narrow pulse pressure
• Warning signs for admission
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Abdominal pain or tenderness
Persistent vomiting
Clinical extravascular fluid accumulation
Mucosal bleeding
Lethargy, restlessness
Liver enlargement > 2 cm
Increase in HCT with rapid decrease in platelet
count
Dengue:
Diagnosis
• WHO criteria 2 of the following
• Rash
• Arthralgia
• Nausea/vomiting
• Leukopenia
• Positive tourniquet test
• IgM/IgG and subtype serology available
• Doesn’t change management
• Important for epidemiology
Dengue: Treatment
• Proper hydration
• Watch for warning signs
• Outpatient treatment w/ 24 follow up
• Daily CBC’s
• Avoid NSAID’s
• Avoid fluid overload during recovery
phase
• No benefit from steroids
• Increased morbidly and GI bleeding
• Crystalloid more cost effective than
colloids
• Colloids if not responding
• Transfuse
• Vaccines in phase 3 trial
Case 4
• 60 yo F
• HA for 1 week, BIB family
due to decreased LOC
• No significant travel history
West Nile
Virus:
Distribution
• Endemic in all 48 states
• Transmitted by Culex
• Highest infection rates in summer/fall
• 2014  2205 total cases
• 1347 neuro-invasive
• Birds are reservoir
West Nile Virus: Signs/Symptoms
• Invades CNS through unclear
mechanism
• Cell lysis causes flaccid paralysis,
impaired cognition
• Flaccid paralysis
• Damaged anterior horn cells
• GBS like demyelinating syndrome
• Most cases asymptomatic
• <1% neuro-invasive
• Definitive diagnosis serum/CSF IgM
• No efficacy of IVIG, steroids
• Symptomatic treatment
• Empiric antibiotics/antiviral for meningitis
Case 5
• 45 yo F
• 2 days of Fever, Rash,
Arthralgia
• Travel to Puerto Rico 3
days prior
Chikungunya
• Dengue like (same vector)
• Generally Milder
• Severe arthralgia
• Chronic relapsing arthralgia
• Prior to 2013 only seen in Africa/Asia
• 2014  2.7K travel related cases
• Florida 12 local cases
• PR 4000 local cases
• 2015  no local cases
• Reportable disease
• CDC ELISA testing
• Symptomatic care
• Prevent local outbreaks
Chikungunya: Outbreak in Americas
References
Caraballo, Hector, and Kevin King. "Emergency Department Management Of Mosquito- Borne Illness: Malaria, Dengue, And West Nile Virus." EBmedicine.net. Emergency
Medicine Practice, May 2014. Web. 30 Dec. 2015.
Feder, Henry. "Fever in Returning Travelers: A Case-Based Approach." Am Fam Physician 88.8 (2013): 524-30. - American Family Physician. 15 Oct. 2013. Web. 30 Dec.
2015.
Harter, Katherine, Sanjay Bhatt, Hyung Kim, and William Mallon. "Chikungunya Fever in Los Angeles, California." Western Journal of Emergency Medicine WestJEM 15.7
(2014): 841-44. Web.
Karppinen, A., H. Kautiainen, L. Petman, P. Burri, and T. Reunala. "Comparison of Cetirizine, Ebastine and Loratadine in the Treatment of Immediate Mosquito-bite Allergy."
Allergy 57.6 (2002): 534-37. Web.
Kalayanarooj S. Clinical manifestations and management of dengue/DHF/DSS. Trop Med Health. 2011;39(4 Suppl):83-87.
Marks, Michael, Margaret Armstrong, David Walker, and Tom Doherty. "Imported Falciparum Malaria among Adults Requiring Intensive Care: Analysis of the Literature."
Malar J Malaria Journal 13.1 (2014): 79. Web.
Noyd, David. "Recent Advances in Dengue: Relevance to Puerto Rico." Puerto Rico Health Science Journal 34.2 (2015): 65-70. Web.
Patel, Hetal, Beate Sander, and Mark P. Nelder. "Long-term Sequelae of West Nile Virus-related Illness: A Systematic Review." The Lancet Infectious Diseases 15.8 (2015):
951-59. Web.
Simons, F.estelle R., and Zhikang Peng. "Skeeter Syndrome." Journal of Allergy and Clinical Immunology 104.3 (1999): 705-07. Web.
Svenson JE, MacLean J, Gyorkos TW, Keystone J. Imported Malaria: Clinical Presentation and Examination of Symptomatic Travelers. Arch Intern Med. 1995;155(8):861868.
Thiberville, Simon-Djamel, Nanikaly Moyen, Laurence Dupuis-Maguiraga, Antoine Nougairede, Ernest A. Gould, Pierre Roques, and Xavier De Lamballerie. "Chikungunya
Fever: Epidemiology, Clinical Syndrome, Pathogenesis and Therapy." Antiviral Research 99.3 (2013): 345-70. Web.
Tither, Pauline Herold. "Preventing Dengue and Chikungunya Fever among International Travelers." Journal of the American Association of Nurse Practitioners 26.11 (2014):
584-94. Web.
QUESTIONS?