Vinita Rane Supervisor: Maryza Graham

Transcription

1 Old bug, new tricks Vinita Rane Supervisor: Maryza Graham

2 6 week old female Initial presentation (outside Monash): Unwell since 3/52 old Cough, associated with cyanotic episodes Coryza Lethargy Vomiting and decreased feed intake Admitted Working diagnosis: likely pertussis

3 Other history Term, spontaneous vaginal delivery at 40+6/40 Mother 16 yo, good physical health Father interstate, not involved in care of child Infant also living with grandmother, 14yo uncle, 20 yo aunty Immunisations up to date

4 Examination SpO 2 95%, RR 80 with mild WOB Clinically well hydrated Generalised pustular rash

5 NPA performed Negative for: Pertussis RSV Parainfluenza Influenza A Influenza B

6 Progress Inpatient for two days, then discharged Discharge diagnosis: Scabies Oral thrush

7 4 days later Presents to Monash: By this stage 5/52 cough, coryza No improvement, WOB worsening, feeding about 1/3 of normal

8 Examination Irritable and unsettled HR 140, spo 2 92% RA, RR44 Mild subcostal recession Good AE, no added sounds Throat- NAD Working diagnosis: bronchiolitis

9 Respiratory PCR

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12 Extra history obtained Mum had antenatal HVS thought she was tested for Chlamydia at that time Baby had had severe conjunctivitis in first week of life

13 Maternal result

14 Summary Bronchiolitis attributable to C.trachomatis Baby improved with azithromycin Led to the diagnosis of unrecognised genital chlamydia in mum

15 Cases Age - months Symptoms Symptom duration Co-pathogen Maternal age - years Antenatal Chlamydia screen 2 Conjunctivitis Bronchiolitis 3 IUGR at 20w Bronchiolitis 6 weeks nil 16? 6 days RSV 20 no 2 Bronchiolitis 7 days nil Bronchiolitis Recurrent cough/ bronchiolitis 6 days picornavirus 23 no

16 Other unexpected diagnoses Age (years) Gender Diagnosis Contact with birds 25 M C. psittaci No 61 F C. psittaci No 9 M C. pneumoniae NA

17 Discussion C.trachomatis epidemiology in Australia Neonatal manifestations of C.trachomatis Bronchiolitis & C.trachomatis Implications for screening

18 Chlamydia trachomatis Most common bacterial STI in developed countries >86,000 cases reported in Australia % in young people (age <25) 1 1 NCHECR (2010), The University of New South Wales

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20 Chlamydia not just a disease of young adults Neonatal Chlamydia: Pneumonia/bronchiolitis Well-known but under-recognised cause Conjunctivitis Low birth weight Prematurity

21 bronchiolitis LRTI of infants under the age of 12 months Risk factors for severe bronchiolitis: Young age (<6/52) Ex-prem infants CHD Neurological conditions Chronic respiratory infections Pulm HT

22 Features of bronchiolitis Mild Moderate Severe Behaviour Normal Some/ intermittent irritability Respiratory rate Accessory muscle use Normal None Resp rate Tracheal tug Nasal flaring Moderate chest wall retraction Increasing irritability or fatigue/lethargy Marked increase or decrease Tracheal tug Nasal flaring Marked chest wall retraction Feeding Normal Reduced/difficult feeding Reluctant/unable to feed O 2 requirements No extra requirements (SaO 2 >93%) Mild hypoxaemia corrects with O 2 (Sa %) Hypoxic, may not correct with O 2 alone (SaO 2 <90%) Apnoeic episodes None May have brief Increasingly frequent/prolonged

23 Investigations

24 Bronchiolitis & C. trachomatis Around 7% infants infected with C.trachomatis 2,3 Relatively consistent across studies where antenatal screening not done, even if tested in different ways (serology or PCR) Some older studies suggest up to 30% positivity 2 nd most common pathogen after RSV 3 Persists in tissue for a long time 4 2 Y. Li et al. Infection, Genetics and Evolution (2015) 3 Rours et al. Arch Dis Child (2009) 4 Bell et all, JAMA 1992

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26 C. trachomatis DNA on BAL 182 children Aged 2-15 yrs Chronic respiratory conditions Clinical indication for BAL 77 (42%) positive detected using 16S, then specific primer once 16S positive

27 Colonisation or infection? Very little data Two older case control studies suggest infection

28 Found that cases were more likely to have: Conjunctivitis Ear abnormalities Interstitial infiltrates and hyperexpansion on CXR Eosinophilia

29 Does C. trachomatis cause asthma? Can cause wheeze in infants that mimics asthma 5 Early pneumonia, ARDS caused by C. trachomatis is known to predispose to asthma Association exists between C. pneumoniae & asthma in kids? Treatment in infancy prevents later development of asthma 5 Bavastrelli et al. Lancet 1992

30 Should we screen pregnant women?

31 Current guidelines confusing! RANZCOG Chlamydia Selective testing should be considered for those at increased risk (e.g. less than 25 years) Department of Health Recommendation - Grade C Do not routinely offer. to all women as part of antenatal care. Routinely offer at the 1st antenatal visit to pregnant women younger than 25 years.

32 Overseas just as confusing! US - universal screening of pregnant women under age of 25 British NICE guidelines no evidence of benefit, so do not recommend antenatal screening BUT Old studies ( ) Culture-based method of detection Low positivity rate in placebo arm Not surprising - recent survey of over 1600 O&Gs in Australia, only 20% screened pregnant women <25yo 6 6 Li Z et al. Aust N Z J Obstet Gynaecol 2013

33 Conflicting evidence Difficult to know exactly what impact Chlamydia has on pregnancy and foetal outcomes Older studies suggest less impact on foetus (pre 2000) No studies have looked at women in a higher risk group (ie <25yo) and fetal/neonatal outcomes

34 Assumed prevalence 3% Cost-effective in higher risk groups and antenatal settings, or prevalence >11%

35 C. trachomatis Under-recognised cause of respiratory illness in children May contribute to asthma in children Increase in detection of bronchiolitis attributable to Chlamydial spp following the introduction of respiratory multiplex PCR that includes Chlamydial target Timely diagnosis / treatment of infants may lead to reduction of chronic cough & asthma in children May provide further evidence for the need for targeted antenatal screening

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