SELECTED INFECTIONS ACQUIRED DURING TRAVELLING IN NORTH AMERICA. Lin Li, MD August, 2012

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1 SELECTED INFECTIONS ACQUIRED DURING TRAVELLING IN NORTH AMERICA Lin Li, MD August, 2012

2 Case 1 32 year old male working in Arizona; on leave back in Singapore Presented to hospital A for fever x (7-10) days, and a bilateral, intense and throbbing HA; Signed out AMA; travelled back to AZ but was admitted to a local hospital with seizure. CSF: protein: 27 g/l; glucose 2.1 mg/dl, WBC = 120, 75% lymph CT: hydrocephalus

3 Coccidioidal Meningitis Clinical Features Occurs in 30-50% of cases of dissemination CSF culture is positive: 30% CSF Complement-fixing antibodies are found in > 90% Epidemiology Organism: Coccidioides immitis CDC. Summary of notifiable diseases - United States, MMWR Morb Mortal Wkly Rep Jul 5;60(53):1-117.

4 /detail/?imageid=143 Gram stain of centrifuged CSF showing mycelia, possibly with maturing arthroconidia

5 Clinical course Received intensive medical care including intubation Ampho B and Fluconazole was started (almost immediately) VP shut Discharged on Fluconzaole 800 mg with a plan of continued at 400 mg daily indefinitely. Patient was well at year 5.

6 Case 2 65 year old women previously lived in Northeast USA was treating by an acupuncturist for migrating joint swelling and pain x 4 months 2 years ago, she noticed a expanding rash x 2 wks; HA and stiff next 2 month later 12 month ago, brief episode of left ankle pain and swelling 6 month ago right shoulder and elbow pain x 6 weeks. 6 month ago left knee pain and swelling x 2 months Confirmed Lyme Arthritis by a Rheumatologist, treated with a course of antibiotic Symptoms recurred while on treatment, antibiotic course prolonged. Well thereafter.

7 Stages of Lyme Disease Early localized: Single EM Early disseminated: Multiple EM, cardiac or neurologic manifestations Late Lyme disease: arthritis, certain rare enurologic manifestations, acrodermatitis chronica atrophicans. Clinical Infectious Diseases 2006; 43:

8 Lyme Disease Caused by spirochete known as Borrelia burggorferi Transmitted by certain Ixodes species tick Most common vector-borne infection Blacklegged Tick Ixodes scapularis Northeast/Upper midwest Also transmit: Anaplasmosis, Babesiosis and Powassan disease. Western Blackegged Tick Ixodes pacificus Along the Pacific coast, particularly northern California Also transmit Anaplamosis

9 Lyme Disease. Incidence (per 100,000 population) or reported confirmed cases US 2011 Approximately 95% of confirmed cases were reported from states in the Northeast, mid- Atlantic and upper Midwest. CDC. Summary of notifiable diseases - United States, MMWR Morb Mortal Wkly Rep Jul 5;60(53):1-117.

10 Lyme Arthritis Monoarticular or oligoarticular arthritis typically involving the knee Large knee effusions; Baker s cysts may form Untreated typically intermittent with episodes of joint inflammation spontaneously resolving after a few weeks to months. Treatment: Doxycycline/amoxicillin/cefuroxime x 28 days (w/o CNS disease) Ceftriaxone x 28 days (w/ CNS disease)

11 Differential Diagnosis Monoarticular: acute injury Olignoarticular: spondyloarthropathy or pauciarticular junvenile rheumatoid arthritis Not usually resemble Septic joints Rheumatoid arthritis

12 Laboratory Testing Early stage: may be serologically negative Late stages: IgG positive PCR useful in synovial fluid

13 U.S. Tickborne Diseases Lyme Disease ( 300,000 /yr) Rocky Mountain Spotted Fever Anasplasmosis, Ehrlichiosis Babesiosis Tularemia Colorado Tick Fever Tickborne Relapsing Fever Tick-borne encephalitis, e.g. Powassan Disease Southern tick associated rash illness (STARI)

14 Case 3 24 year old male, visiting his brother in a college in North Carolina in early September Was hiking in the state Present with fever, myalgia, headache for 3 days Examination: T= 39C Faint petechial rash on the wrists and legs.

15 MMWR Recomm Rep Mar 31;55(RR-4):1-27.

16 SPOTTED FEVER RICHKETTSIOSIS, Number of reported cases, by county US 2011 CDC. Summary of notifiable diseases - United States, MMWR Morb Mortal Wkly Rep Jul 5;60(53):1-117.

17 Ticks transmit RMSF American Dog Tick Dermacentor variabilis Brown Dog Tick Rhipicephalus sanguineus Rocky Mountain Wood Tick Dermacentor andersoni Some also transmit: Tularemia

18 Rocky Mountain Spotted Fever Signs & Symptoms Fever, Chills Severe headache Malaise Myalgia GI symptoms Cough Conjuctival injection +/- photophobia Altered mental status Focal neurologic deficits Maculopapular or petechial rash General Lab Findings Thrombocytopenia Mildly elevated transaminases Hyponatremia

19 Risk Factors For Fatal RMSF Children (age < 10), elderly ( age > 70) Delayed diagnosis and treatment Non-tetracycline use Dahlgren, et al. Fatal Rocky Mountain Spotted Fever in the United States, Am. J. Trop. Med. Hyg., 86(4), 2012, pp

20 CDC. Summary of notifiable diseases - United States, MMWR Morb Mortal Wkly Rep Jul 5;60(53):1-117.

21 Summary Many infections have features that resembles local diseases. Travel history and recreation/occupational activities are important for correct diagnosis Some of the diseases are life threatening, early treatment is key for better survival.

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