Transcript eo_003.06_treat_mycoplasma,chlamydia


Large group of obligated intracellular parasites
Coccobacille resemble bacteria (egg shape
short thick)
Bacterial endotoxins causes infections

Three species:


Chlamydia trachomatis
 Chlamydia psittaci
 Chlamydia pneumonia


Nongonococal Urethritis (NGU)

Trachoma

Lymphogranuloma venereum




An infection of the urethra
Usually contacted sexually
Neisseria gonorrhea is the most famous
bacterium causing urethritis, but not the most
common.
Urethritis not caused by Neisseria gonorrhea is
called (NGU)
Epidemiology
 Not due to the bacterium Neisseria
gonorrhoeae
 Most common STDs in the USA over 10
million Americans infected

Causal agents include
- Chlamydia Trachomatis
- Mycoplasma genitalium
- Ureaplasma urealyticum

Manifested in male as a urethritis and in
female as a cervicitis
S&S




Clinical manisfestations of urethritis are
usually indistinguishable from gonorrhea and
include
An opaque discharge with moderate or scanty
quantity
Urethral discharge
Burning on urination
Dx
The diagnosis of chlamydial disease
has been clinical
 By smear and culture

Tmt
Tetracycline 500mg four times a day
 Doxycycline 100mg twice a day
 Erythromycin is an alternative drug
and is the drug of choice for the
newborn and pregnant women


Partner must also be treated
Preventive measures

Health and sex education with
emphasis on use of a condom during
sexual intercourse
Epidemiology
Acute Chlamydial disease
of the eye
 Worldwide, occuring as an endemic disease
 Infectious agent

 Chlamydia trachomatis serotypes A-C
Related to lymphogranuloma venerum
Psittacosis

Most contagious in its early stages
S&S
Sudden onset with pain
 Photophobia
 Blurred vision
 Occasionally low-grade fever,
headache, malaise and tender
preauricular lymphadenopathy

Dx


Eye swabs
Conjunctival scrapings
Tmt



Doxycycline 100mg bid x 4 weeks
Tetracycline or erythromycin 250mg six times/day
Azithromycin 20mg/kg single-dose therapy
Preventive Measures


Education on the need for personal hygiene
Improve basic sanitation including
 Availability and use of soap and water
 Avoid common-use of towels


Provide adequate case-findings and treatment
facilities with emphasis on preschool children
Conduct epidemiologic investigation
Epidemiology
Most found in tropical and subtropical areas.
Endemic in Asia and Africa
 Caused by Chlamydia trachomatis types L1-L3
 Acute and chronic sexually transmitted chlamydial
disease
 Characterized by a transitory primary lesion
followed by suppurative lymphadenitis and
lymphangitis and serious local complications

S&S


First symptom is usually a unilateral, tender
enlargement of the inguinal lymph node
Patient may complain






Fever,chills
Malaise
Headaches
Joints pain
Anorexia
Vomitting
Dx

Made by demonstration of chlamydial organisms by
IFA,EIA,DNA probe,PCR,

Culture of bubo aspirate

Specific micro-IFA serologic test
Tmt
Tetracycline 0.25-0.5g four times daily x 21 days
 Doxycycline 0.1g twice daily x 21 days
 Erythromycin 500mg four times a day x 21 days
 Azithromycin 1g orally once weekly x 3/52
 Trimethoprim-sulfamethoxazole 160/800mg twice
daily x 21 days

Preventive measures
Preventive measures are those for sexually
transmitted diseases:
 Patients should be advised to abstain from sexual
intercourse until all lesions are healed
 Investigation of contacts and source of infection of
all identified sexual contacts
 Report to local health authority

Epidemiology

Mycoplasmas are pleomorphic, nonmotile
microorganisms without cell walls
Smallest independently living organisms
Three species are pathogenic to humans
 Ureaplasma urealyticum
 Mycoplasma hominis
 Mycoplasma pneumoniae


Pneumonia

Otitis

Urethritis
Epidemiology
Worldwide; sporadic, endemic and occasionally
epidemic
 Caused by Mycoplasmal pneumoniae
 Spread involves close contact or airborne droplets.
Attaches to and destroys ciliated epithelial cells of
the respiratory tract mucosa
 « Mycoplasmal pneumoniae » is the most common
pathogen of lung infections

S&S


Initial symptoms ressemble influenza
Onset is gradual with
 Headache
 Malaise
 Cough (often paroxysmal )
 Substernal pain ( not pleuritic )

Characteristic feature is High fever with bradycardia
and diarrhea is common
Dx




Diagnosis is based on a rise in antibody titers
between acute and convalescent sera
Use of serologic assays (most practical method to
confirm); Single elevated IgM
Fourfold rise in titer with peak titer > 1:64
Chest X-Ray shows a patchy bronchopneumonia in
the lower lobes
Tmt

Tetracycline 500 mg po q 6 hrs for adults

Erythromycin 30 to 50 mg/kg/day for children < 8
yr

Clarithromycin & Azithromycin also effective
Preventive Measures

Avoid crowded living and sleeping quarters
whenever possible, especially in institutions,
barracks, and ships

Report to local health authority, obligatory report of
epidemics
Epidemiology

Ureaplasma urealyticum and M. hominis are
common parasitic microorganisms of the genital
tract

Their transmission = sexual activity

Mycoplasma can opportunistically cause
inflammation of the reproductive organs of males
and females
S & S (Men)




Generally appear between 7 and 28 days after
intercourse
Usually with mild dysuria and discomfort in the
urethra and a clear to mucopurulent discharge
Discharge is frequently more marked in the morning
S & S (Men cont’d)
 Meatus may be red with evidence of
the dried secretions on underclothes
 Occasionnally onset is more acute with
dysuria frequency and a copious
purulent discharge simulating typical
gonococcal urethritis
 Proctitis and pharyngitis may develop
after rectal and orogenital contact
S & S (Women)
Most women are asymptomatic
Vaginal discharge, dysuria, frequency, pelvic pain,
and dyspareunia as well as symptoms of proctitis
and pharyngitis may occur
 Cervicitis with yellow, mucopurulent exudate and
cervical ectopy are characteristic



Diagnosis (Men)
Gram-stained slides of the urethral discharge
In mild cases, evidence of urethritis may require
examination of urine
 If the Dx is in doubt, examination is made on first-voided,
morning urine
 If infection is present, urethral swabbing usually
produces enough material for laboratory examination to
confirm Dx



Diagnosis (Women)

Detection of mycoplasma or ureaplasma is currently
impractical

Screening for gonococcal co-infections is routine
Treatment

Uncomplicated infections are treated with oral
administration of either
 azithromycin 1g once or
 ofloxacin 300 mg bid, tetracycline 500 mg q 6 h or
 doxycycline 100 mg bid for 7 days
Treatment

Patients who relapse or who develop complications
require longer courses
 tetracycline 500 mg po q 6 h or
 doxycycline 100 mg po bid for 21 to 28 days

In pregnant women
 erythromycin 500 mg po q 6 h for at least 7 days should
be substituted for tetracycline
Prevention

Patients should be advised to abstain from sexual
intercourse until treatment is completed and their
partners examined and treated

Treated persons should be re-examined and tested
for persisting or recurring infection at 8 to 12 wk


Occasionnally, bullae will be seen on the
tympanic membrane
Although it is taught that this represents
infection with Mycoplasma pneumoniae, most
cases involve more common pathogens.
DISEASES OF MYCOPLASMS
Table 4
DISEASE OR
SYMPTOM
Primary atypical pneumonia
Genital infection
Rheumatoid arthritis
Nongonococcal urethritis (NGU)
Stillbirth
Spontaneous abortion
Infertility
AGENT
HOST
Mycoplasma pneumoniae
Man
Mycoplasma genitalium
Man
Mycoplasma fermentans
Man *
Ureaplasma urealyticum
Man *
Mycoplasma hominis
Man *
Mycoplasma hominis
Man *
Mycoplasma hominis
Man *
Variety of diseases manifested by a sudden
onset of
Fever.......1-several week
 Malaise
 Prostration
 Peripheral vasculitis
 Characteristic rashes
 S & S vary from mild to severe


Q fever

Rocky mountain spotted fever

Typhus group
Epidemiology
Worldwide in its distribution
 Characterized by sudden onset of fever, headache,
malaise and interstitial pneumonitis
 Acute disease caused by Coxiella burnetii
(Rickettsia burnetii )
 Transmission is usually by inhalation
 Can also be contracted by ingesting infective raw
milk

S&S
 Incubation period varies from 9 to 28
days and averages 18 to 21 days
 Onset is abrupt
 Fever
 Severe headache
 Chills
 Severe malaise
S&S
 Myalgia
 Chest pain
 Nonproductive cough and
pneumonia develop during 2nd week
 No Rash
Dx

Laboratory findings




Elevated liver function occasionally leucocytosis
Diagnosis rise in compliment-fixing atobodies
Isolation of C burnetii is possible (shell-vial
technique )
Serum ELISAis also available
Dx
 Imaging

Radiographs of the chest show patchy pulmonary
infiltrates, otfen more prominent than the physical
signs
Tmt




Tetracycline 250mg q 4 or 6 h
Doxyccycline 100mg twice a day
Chloramphenicol 50mg/kg/daily in 4 divided doses
given q 6 h
In acute disease, treatment should be continued until
the patient has been afebrile for about 5 days
Preventive measures

Educating the public on sources of infection

Pasteurizing milk from cows, goats and sheep

Immunisation with inactivated vaccine prepared
from C burnetii
Epidemiology




Exposure to tick bite in endemic area
Mode of transmission is usually by bite of an
infected tick
An acute febrile disease caused by Rickettsia
rickettsii
Producing
 High fever
 Cough
 Rash
S&S

Symptoms begin with
 Fever
 Chills
 Headache
 Malaise

Rash appears first on the wrist & ankle then
spreading to the arms, legs and trunk
Dx

Based on serologic response to specific agent

Rickettsia have been identified in skin biopsies using
Indirect Fluorescent antibody test
Laboratory confirmation by agglutination of proteus
OX19 and OX2 and by specific antibodies with
complement fixation and immunoflorescence

Tmt

Chloramphenicol 25-50mg/kg/d orally or
intravenously in four divided doses

Doxycycline 200mg daily orally or intravenously
Treatment is given for 7 days or through the third
day of defervescence

Preventive measures

Best means of prevention remains the avoidance of
tick-infected habitats

Protective clothing

Tick-repellent chemicals

Removal of tick at frequent intervals

Epidemic Typhus

Endemic Typhus

Scrub Typhus
Epidemiology
 Also called Louseborne typhus
 Prevalent
worldwide
 Acute, severe,
febrile disease
caused by
Rickettsia
prowazekii
 Transmission via
louse feces
 Characterized by
prolonged high
fever, intractable
headache &
Symptoms begin with
 Prodromal malaise
 Cough
 Headache
 Arthralgia
 Chest Pain
Followed by an abrupt onset of
 Chills
 Prolonged & high fever
 Prostration with flu-like symptoms
 Delirium & Stupor
 Macular rash
Tmt

Tetracycline 25 mg / kg / d in four divided doses for
4 days

Chloramphenicol 50-100 mg / kg /d in four divided
doses for 4 days

Doxycycline 5 mg / kg as a single dose
Preventive measures

Apply an effective residual insecticide powder at
appropriate intervals by hands or power blower to
clothes and persons of populations living under
favoring lousiness

Improve living conditions with provisions for
bathing and washing clothes

Immunize susceptible persons or groups entering
typhus area
Epidemiology
Also called Murine Typhus or Flea-Borne Typhus
 Worldwide ,case tend to be scattered, but with a
high proportion reported from Texas
 An acute febrile disease simular to but milder than
epidemic typhus caused by Rickettsua typhy (R.
mooseri)
 Transmitted to humans by rat fleas

S&S

Gradual onset, fever and rash are shorter in
duration, and the symptoms are less severe than in
the epidemic typhus

Symptoms may mimic measles, rubella and roseola

Rash is maculopapular and concentrated on the
trunk and fades rapidly
Dx

Clinical differentiation from Rocky Moutain Spotted
Fever is established by the early seasonal onset of it
and the character of rash

Complement-fixing or immunofluorescent
antobodies can be detected in the patient serum with
specific R. Typhi antigens
Tmt

Tetracycline 25-50 mg / kg / d in four divided doses

Chloramphenicol 50-75 mg / kg / d in four divide
doses

Antibiotic treatment is indicated through 3 full days
of defervescence
Preventive measures
Control of rats and ectoparasites (rat fleas) with
insecticides, rat poisons and rat-proofing buildings

Case report obligatory in most states (USA) and
countries
Epidemiology
Also called Mite-borne typhus fever
Exposure to mites in endemic area of Southeast Asia,
the western Pacific and Australia
 Caused by Rickettsia tsutsugamushi (R. orientalis)
 Characterized by fever, a macular rash and
lymphadenopathy
 Human infection follows a chigger (mite larva) bite


S&S



After incubation period of 6 to 21 days
 Malaise
 Chills
 Fever
 Severe headache
 Backache
Macular papular rash primarily on the trunk
Frequent pneumonitis, encephalitis and cardiac
failure
Dx

Made by isolation of the infectious agent by
inoculating the patient ’s blood into mice.

Fluorescein-labeled antirickettsial assays or
commercial dot-blot ELISA dipstick assays are
convenient

PCR may be the most sensitive test
Tmt

Docycycline 100mg twice a day for 3 days

Chloramphenicol 25 mg / kg / d in four doses for 7
days

Azythromycin is the drug of choice for children,
pregnant women, and patient with refractory disease
Preventive measures



Impregnating clothes and blankets with miticidal
chemicals
Application of mite repellents to exposed skin
surfaces
Eliminate mites from the specific sites by application
of chlorinated hydrocarbons to ground and
vegetation in environs camps, mine buildings and
other populated zones in endemic areas

Syphilis

Lyme disease

Relapsing fever
Epidemiology




Contagious systemic disease caused by the
« spirochete Triponema pallidum »
Characterized by sequential clinical stages and by
years of latency
Infection is usually transmitted by sexual contact
Cross placental barrier after 10th week of gestation
Epidemiology (cont)
 Motile slender
spiral shape
 Capable of infecting
any organ / tissue
in the body
 Enters the mucous
membranes or skin,
reaches the regional
lymph nodes and
disseminates
throughout the
body
S&S
Primary stage
 Chancre , regional lymphadenopathy
 Secondary stage
 Rash on palm and soles
 Condyloma latum
 CNS,eyes,bones kidneys and joints can be involved
 Asymptomatic
 Late Latent ( Hidden)
 25% may relapse to 2 stage
 or Tertiary stage
 Symptomatic but not contagious

Dx
Clinical history and physical examination
Serologic tests
Investigation of sexual contact
If appropriate
 Darkfield examination of fluids from lesions
 CSF tests
 Radiologic examination
Two classes of serologic tests for syphilis (STS)
 Veneral Disease Research Laboratory (VDRL)
 Rapid Plasma Reagent ( RPR)





Tmt

Penicillin is the antibiotic of choice for all stages of
syphilis

A serum level of 0.003IU/ml for 6 to 8 days is
required to cure early infectious syphilis

Benzathine penicillin G 2.4 million UIM once
produces a satisfactory blood level for 2 wk (1.2
million U/ each buttock)

Two additional injections of 2.4 million U q 7 days
should be given for secondary and latent syphilis
Preventive measures
 General health promotion measures, health and sex
education
 Protect the community by preventing and
controlling STD in prostitutes and their clients
 Provide facilities for early diagnosis and treatment
 Report to local health authority
 Investigation of contacts and source of infection of
all identified sexual contacts of confirmed cases of
early syphilis should receive treatment
Epidemiology

Caused by a spirochete, Borrelia burgdorferi ,
transmitted primarily by deer tick of the Ixodes
scapularis.

It is an inflammatory disorder causing a rash,
Erythema Migrans (EM) or Erythema
Chronicum Migrans (ECM)

May be followed weeks to months later by
neurologic, cardiac and joints abnormalities
Erythema chronicum migrams (ECM)
starts off as a red (erythematous) flat round rash,
wich spreads out (or migrate) over time
S&S

Erythema migrans, the hallmark and best clinical
indicator of Lyme disease

Begin as a red macule or papule, usually on the
proximal portion of an extremity or on the trunk,
between 3 to 32 days after tick bite (75% of patients)

Musculoskeletal flu-like syndrome commonly
accompanies erythema
Dx


Based on both clinical manifestation and laboratory
findings
Essentials of diagnosis
 Erythema Migrans
 Headache of stiff neck
 Arthralgia, arthritis and myalgia

Laboratory confirmation require detection of
specific antibodies of B burgdoferi in serum
Tmt:EM stage




Tetracycline 250mg 4 times daily for 10 to 30 days
Doxycycline 100mg twice daily for 10 to 30 days
Erythromycin can be used in those who are allergic
to penicillin or cannot take tetracyclines
Later manifestations of the disease require
longer courses of therapy and intravenous
therapy
Epidemiology




Acute disease caused by several species of Borrelia
spirochetes
Infectious organism is a spirochete, Borrelia
recurrentis
Transmitted by lice or ticks
Characterized by recurrent febrile episodes lasting 3
to 5 days, separated by intervals of apparent
recovery
S&S



Sudden chills mark the onset
Followed by
 High Fever
 Tachycardia
 Severe headache
 Vomiting
 Muscle and joint pain
 Often delirium
Erythematous macular or purpuric rash (Trunk &
extremities)
Dx

Suggested by the recurrent fever

Confirmed by the appearance of spirochetes in the
blood during a febrile episode

Spirochetes may be seen on darkfield examination or
Wright ’s or Giemsa-stained thick and thin blood
smear
Tmt

For louse-borne relapsing fever
 Tetracycline or Erythromycin 0.5 g po as a single
dose
 Procaine penicillin G 400,000-600,000 U IM (1 dose)
 Doxycycline 100 mg po bid for 5 to 10 days also
effective

For tick-borne relapsing fever
 Tetracycline or Erythromycin 0.5 g po four
times/day for 5 to 10 days
Preventive measures

Control lice by measures prescibed for louse-borne
typhus fever

Control ticks by measures prescribed for Rocky
Moutain spotted fever

Use personal protection measures, including
repellents on clothing and bedding for persons with
exposure in endemic foci
Preventive measures

Control lice by measures prescibed for louse-borne
typhus fever

Control ticks by measures prescribed for Rocky
Moutain spotted fever

Use personal protection measures, including
repellents on clothing and bedding for persons with
exposure in endemic foci

Question?