Transcript Reportable Infectious Diseases - Cleveland Clinic Regional

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.
► 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.
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.
Anthrax
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.
► Caused
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
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
Botulism
► Wound:
► Lab
symptoms similar as for food borne.
Dx:
 botulinum toxin in serum, stool, food.
 Positive culture for C. botulinum from stool
Brucellosis
w/Brucella characterized by fever,
night sweats, fatigue, anorexia, weight loss,
headache (HA), arthralgias.
► Lab Dx:
► Infection
 Culture positive from specimen
 Increase in Brucella agglutination titers
 Positive immunofluorescence of Brucella in
clinical specimen
Chancroid
caused by Haemophilus ducreyi
► Painful genital ulcer w/inflamed inguinal
lymph nodes.
► Isolation from clinical specimen confirms Dx.
► STD
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.
Cholera
► Manifested
► Lab
by diarrhea and vomiting
dx:
 Isolation of toxigenic Vibrio cholerae O1 or
O139 from stool or emesis
Coccidioidomycosis
by fungus Coccidioides immitis,
endemic to SW U.S.
► Causes influenza like respiratory illness:
► Caused
-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.
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
Cryptosporidiosis
by protozoa Cryptosporidium parvum
► Signs & Symptoms (S/Sx:)
► Fever, nausea, vomiting, abdominal cramps, loss
of appetite
► Lab Dx:
► Caused
 Detection of oocysts in stool
 demonstration of organism in intestinal fluid or small
bowel biopsy
 detection of Cryptosporidium antigen in stool
Cyclosporaisis
► Intestinal
illness caused by protozoa
Cyclospora cayetanensis
► S/Sx:
 watery diarrhea, weight loss, flatus, nausea,
fatigue, vomiting, anorexia, abdominal cramping
and fever
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
Diptheria
by Cornynebacterium diptheriae
► S/Sx: URI like, sore throat, fever, adherent
membrane to tonsils, pharynx or nose.
► Lab dx:
► Caused
 Isolation of organism from specimen or
histopathologic diagnosis
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
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.
Arboviral Encephalitis/Meningitis
► Lab
Dx:
 Fourfold rise in antibody titer
 Isolation of virus or viral antigen from tissue,
serum or CSF
 IgM antibody detection
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
Giardiasis
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
► Caused
Gonorrhea
Caused urethritis, cervicitis, salpingitis,
disseminated disease or maybe
asymptomatic
Observation of gram neg. intracellular
diplococci
Haemophilus Influenzae Invasive
Disease
► Invasive
diseases are: meningitis,
bacteremia, epiglottitis, or pneumonia
► Lab Dx: isolation of H. Flu from blood CSF
or joint fluid
Hansen Disease(Leprosy)
by organism Mycobacterium leprae
► Four clinical forms of disease:
► Caused
 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
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.
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
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.
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
Listeriosis
► Listeria
monocytogenes caused meningitis
and/or bacteremia
► Lab Dx:
 Isolation of L. monocytogenes from sterile body
fluids, fetal tissue or placenta
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
Malaria
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.
► Caused
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
Meningococcal Disease
► S/Sx’s:
meningitis, meningococcemia,
purpura fulminans, shock, death
► Lab Dx:
 Isolation of Neisseria meningitidis from blood or
CSF
Mumps
► S/Sx:
unilateral or bilateral tender, selflimited 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
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
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
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
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
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
Q Fever
acute infection with Coxiella burnetti,
fever, myalgias, malaise, retrobulbar HA,
hepatitis, pneumonia, meningoencephalitis
► Lab Dx:
► S/Sx’s:
 fourfold rise in antibody titer
 Isolation of C. burnetti from specimen
 Demonstration of C. burnetti by antigen or
nulceic acid testing
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
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
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
Salmonellosis
► S/Sx:
Salmonella causes nausea, vomiting,
abdominal pain and diarrhea
► Lab Dx:
 Isolation of Salmonella from specimen
Shigellosis
► S/Sx:
► Lab
same as Salmonella
Dx:
 Isolation of Shigella from specimen
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 A Streptococci (Strep.
Pyogenes)
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
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)
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
Tetanus
► S/Sx:
acute onset of hypertonia, painful
muscular contractions of body and jaw
► Clinical diagnosis is sufficient
Toxic Shock Syndrome
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
► Caused
Trichinosis
caused by ingestion of Trichinella
larvae. May see fever, myalgia, periorbital
edema, eosinophilia
► Lab Dx:
► S/Sx:
 Trichinella larvae in tissue muscle biopsy
 Serologic test is positive
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
Tularemia
caused by Francisella tularensis.
Several different forms:
► S/Sx:
 Ulceroglandular: cutaneous ulcer w/regional
lymphadenopathy
 Glandular: regional lymphadenopathy w/out
ulcer
 Oculoglandular: conjunctivitis w/preauricular
lymphadenopathy
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
Typhoid Fever
Caused by bacteria, Salmonella typhi,
acute onset of fever, HA, malaise, anorexia,
bradycardia, GI symptoms, cough
► Lab dx:
► S/Sx:
 Isolation of S. typhi from blood, stool or other
clinical specimen.
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
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
Questions
► 2.
Which of the following are forms of
Botulism




A. Food borne
B. Infant
C. Wound
D. All of above
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
Questions
► 4.
True or False: Group A strep and S.
Aureus can cause Toxic Shock syndrome?
Answers
► 1.D
► 2.
D
► 3. A
► 4. True
Occupational Exposures,
Infection Control and
Standard Precautions:
Chp. 154 Tintinalli
Dr. Batizy
Slides by Bogdan
1/19/06
Occupational Exposures:
► 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.”
Occupational Exposures:
► 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.
Occupational Exposures:
► 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
Occupational Exposures:
► Percutaneous
exposures have the greatest
potential for infection than do mucous
membrane exposures, respiratory
exposures, or dermal exposures.
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
Table 154-3
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
Table 154-5
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
Table 154-6
HBV Exposure:
► 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
Table 154-7
HCV Exposure:
► 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
HIV Exposure:
► 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
Table 154-8
Table 154-9
HIV Exposure PEP:
► 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
Table 154-10
Table 154-11
Standard Precautions
► 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.
Questions:
► 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!
CT of Cervical Spine:
► 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
CT Cervical Spine:
CT of Cervical Spine:
CT Cervical Spine: