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Recognizing and Treating New and Emerging Infections Encountered in Everyday Practice
Recognizing and treating new and emerging infections encountered in everyday practice STEVEN M. GORDON, MD NFECTIOUS DISEASES, pre- MiikWirj:« Although infectious diseases were once considered a dicted earlier in this cen- diminishing threat, new pathogens are constantly challenging tury to be eliminated as a the health care system. This article reviews the clinical presen- public health problem, re- tation, diagnosis, and treatment of seven emerging infections I main the chief cause of death that primary care physicians are likely to encounter. worldwide and a significant cause of death and morbidity in i Parvovirus B19 attacks erythrocyte precursors; the United States.1 Challenging infection is usually benign and self-limiting but can cause the US public health system are aplastic crises in patients with chronic hemolytic disorders. several newly identified patho- Hemorrhagic colitis due to Escherichia coli 0157:H7 infection gens (eg, human immunodefi- can lead to the hemolytic-uremic syndrome, especially in chil- ciency virus [HIV], Escherichia dren; it also can cause thrombotic thrombocytopenia purpura. coli 0157:H7, hepatitis C) and a Chlamydia pneumoniae causes a mild pneumonia that resem- resurgence of old diseases pre- bles mycoplasmal pneumonia. Bacillary angiomatosis primar- sumed to be under control (eg, ily affects immunocompromised patients, especially those tuberculosis, syphilis). Further, infected with human immunodeficiency virus (HIV). At least multiple-drug resistance in two organisms can cause bacillary angiomatosis: Bartonella hense- strains of pneumococci, gono- lae and Bartonella quintana. Hantavirus pulmonary syndrome cocci, enterococci, staphylo- is spread by exposure to the droppings of infected rodents. cocci, salmonella, and mycobac- Contrary to previous thought, HIV continues to replicate teria undermines efforts to throughout the course of the illness and does not have a latency control the diseases they cause.2 phase. -
Blood Smear Analysis in Babesiosis, Ehrlichiosis, Relapsing Fever, Malaria, and Chagas Disease
REVIEW STEVE M. BLEVINS, MD RONALD A. GREENFIELD, MD* MICHAEL S. BRONZE, MD CME Assistant Professor of Medicine, Section Professor of Medicine, Section of Infectious Professor of Medicine, Section of Infectious CREDIT of General Internal Medicine, Department Diseases, Department of Medicine, University Diseases, Chair of Department of Medicine, of Medicine, University of Oklahoma of Oklahoma Health Sciences Center and the University of Oklahoma Health Sciences Center Health Sciences Center, Oklahoma City Oklahoma City Veterans Administration and the Oklahoma City Veterans Administration Medical Center Medical Center Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease ■ ABSTRACT LOOD SMEAR ANALYSIS, while commonly B used to evaluate hematologic condi- Blood smear analysis is especially useful for diagnosing tions, is infrequently used to diagnose infec- five infectious diseases: babesiosis, ehrlichiosis, relapsing tious diseases. This is because of the rarity of fever due to Borrelia infection, malaria, and American diseases for which blood smear analysis is indi- trypanosomiasis (Chagas disease). It should be performed cated. Consequently, such testing is often in patients with persistent or recurring fever or in those overlooked when it is diagnostically impor- who have traveled to the developing world or who have tant. a history of tick exposure, especially if accompanied by Nonspecific changes may include mor- hemolytic anemia, thrombocytopenia, or phologic changes in leukocytes and erythro- 1 hepatosplenomegaly. cytes (eg, toxic granulations, macrocytosis). And with certain pathogens, identifying ■ KEY POINTS organisms in a peripheral blood smear allows for a rapid diagnosis. In the United States, malaria and American This paper discusses the epidemiology, trypanosomiasis principally affect travelers from the clinical manifestations, laboratory findings, developing world. -
Lyme Disease Weather Also Means That Ticks Become More Active and This Can Agent by Feeding As Larvae on Certain Rodent Species
Spring and summer bring warm temperatures, just right for small and medium sized animals, but will also feed on people. walking in the woods and other outdoor activities. Warm These ticks typically become infected with the Lyme disease weather also means that ticks become more active and this can agent by feeding as larvae on certain rodent species. increase the risk of a tick-borne disease. The tick-borne dis- In the fall, the nymphs become adults and infected nymphs eases that occur most often in Virginia are Lyme disease, become infected adults. Adult blacklegged ticks prefer to feed Rocky Mountain spotted fever, and ehrlichiosis. on deer. However, adult ticks will occasionally bite people on warm days of the fall and winter and can transmit Lyme disease Lyme Disease at that time. Lyme disease is caused by infection with a bacterium called Borrelia burgdorferi. The number of Lyme disease cases Transmission of Lyme disease by the nymph or adult ticks reported in Virginia has increased substantially in recent years. does not occur until the tick has been attached and feeding on a human or animal host for at least 36 hours. The Tick The blacklegged tick (Ixodes scapularis), formerly known as The Symptoms the deer tick, is the only carrier of Lyme disease in the Eastern Between three days to several weeks after being bitten by an U.S. The blacklegged tick's name comes from it being the only infected tick, 70-90% of people develop a circular or oval rash, tick in the Eastern U.S. that bites humans and has legs that are called erythema migrans (or EM), at the site of the bite. -
Reportable Disease Surveillance in Virginia, 2013
Reportable Disease Surveillance in Virginia, 2013 Marissa J. Levine, MD, MPH State Health Commissioner Report Production Team: Division of Surveillance and Investigation, Division of Disease Prevention, Division of Environmental Epidemiology, and Division of Immunization Virginia Department of Health Post Office Box 2448 Richmond, Virginia 23218 www.vdh.virginia.gov ACKNOWLEDGEMENT In addition to the employees of the work units listed below, the Office of Epidemiology would like to acknowledge the contributions of all those engaged in disease surveillance and control activities across the state throughout the year. We appreciate the commitment to public health of all epidemiology staff in local and district health departments and the Regional and Central Offices, as well as the conscientious work of nurses, environmental health specialists, infection preventionists, physicians, laboratory staff, and administrators. These persons report or manage disease surveillance data on an ongoing basis and diligently strive to control morbidity in Virginia. This report would not be possible without the efforts of all those who collect and follow up on morbidity reports. Divisions in the Virginia Department of Health Office of Epidemiology Disease Prevention Telephone: 804-864-7964 Environmental Epidemiology Telephone: 804-864-8182 Immunization Telephone: 804-864-8055 Surveillance and Investigation Telephone: 804-864-8141 TABLE OF CONTENTS INTRODUCTION Introduction ......................................................................................................................................1 -
Lyme Disease Rocky Mountain Spotted Fever Tick Paralysis Haemobartonellosis Tularemia Ehrlichiosis Anaplasmosis
Fall is the beginning of tick season in our area. However, you can find ticks all year round if you like to hike or camp in the woods, or other type of outdoor activities. Ticks are not as easy to kill as fleas, but there are several different ways to control ticks from oral to topical medications and well as collars. If you find a tick embedded in your pet and you choose to try and remove it, be aware that you can accidentally leave the head behind. This can cause a local irritation even possibly an infection. We will be happy to assist with removing a tick for you to help prevent any problems. Protecting your cat or dog (or both) from ticks is an important part of disease prevention. In fact, there are several diseases that can be transmitted to your pet from a tick bite. Some of the most common tick-borne diseases seen in the Western United States are: Lyme Disease Rocky Mountain Spotted Fever Tick Paralysis Haemobartonellosis Tularemia Ehrlichiosis Anaplasmosis Lyme Disease Also called borreliosis, Lyme disease is caused by the bacteria Borrelia burgdorferi. Deer ticks carry these bacteria, transmitting them to the animal while sucking its blood. The tick must be attached to the dog (or cat) for about 48 hours in order to transmit the bacteria to the animal's bloodstream. If the tick is removed before this, transmission will usually not occur. Common signs of Lyme disease include lameness, fever, swollen lymph nodes and joints, and a reduced appetite. In severe cases, animals may develop kidney disease, heart conditions, or nervous system disorders. -
Tick-Borne Relapsing Fever CLAY ROSCOE, M.D., and TED EPPERLY, M.D., Family Medicine Residency of Idaho, Boise, Idaho
Tick-Borne Relapsing Fever CLAY ROSCOE, M.D., and TED EPPERLY, M.D., Family Medicine Residency of Idaho, Boise, Idaho Tick-borne relapsing fever is characterized by recurring fevers separated by afebrile periods and is accompanied by nonspecific constitutional symptoms. It occurs after a patient has been bitten by a tick infected with a Borrelia spirochete. The diagnosis of tick-borne relapsing fever requires an accurate characterization of the fever and a thorough medical, social, and travel history of the patient. Findings on physical examination are variable; abdominal pain, vomiting, and altered sensorium are the most common symptoms. Laboratory confirmation of tick-borne relapsing fever is made by detection of spirochetes in thin or thick blood smears obtained during a febrile episode. Treatment with a tetracycline or macrolide antibiotic is effective, and antibiotic resistance is rare. Patients treated for tick-borne relapsing fever should be monitored closely for Jarisch- Herxheimer reactions. Fatalities from tick-borne relapsing fever are rare in treated patients, as are subsequent Jarisch-Herxheimer reactions. Persons in endemic regions should avoid rodent- and tick-infested areas and use insect repellents and protective clothing to prevent tick bites. (Am Fam Physician 2005;72:2039-44, 2046. Copyright © 2005 American Academy of Family Physicians.) S Patient information: ick-borne relapsing fever (TBRF) develop with TBRF, with long-term sequelae A handout on tick-borne is transmitted by Ornithodoros that may be permanent. Reviewing a broad relapsing fever, written by 1,3-6 the authors of this article, ticks infected with one of sev- differential diagnosis (Table 1 ) for fever is provided on page 2046. -
Lyme Disease and Tick-Borne Infections User Manual
SCOTTISH MICROBIOLOGY REFERENCE LABORATORY, INVERNESS: LYME DISEASE AND TICK-BORNE INFECTIONS USER MANUAL 1 Amended 23 September 2020 CONTENTS Section Page 1 Introduction 3 2 Contact details and key personnel 3 3 Opening hours 4 4 Service provided 4 4.1 Samples and turnaround times 4 4.2 Laboratory tests 5 4.3 Specialist advice 5 5 Clinical Information 6 6 Referral criteria 6 7 Specimen and request form labelling 7 8 Specimen transportation 8 9 Charges 8 10 Results 8 11 Treatment 8 12 Prevention 8 13 SLDTRL request form 8 (Form MF023) 14 SLDTRL developments 9 15 References 9 16 Laboratory diagnosis of Lyme borreliosis algorithm Appendix 2 Amended 23 September 2020 1.0 Introduction The newly established Scottish Lyme Disease and Tick-borne Infections Reference Laboratory (SLDTRL) is provided by NHS Highland at Raigmore Hospital, Inverness. The aim of SLDTRL is to provide more comprehensive and standardised testing for Lyme disease and other tick-borne infections and to improve the epidemiological data provided to Health Protection Scotland (HPS). Lyme disease is caused by bacteria from the Borrelia burgdorferi sensu lato complex. In the UK the bacteria is transmitted to humans through the bite of infected, hard bodied, Ixodes ricinus ticks. Borrelia miyamotoi disease, which presents as a relapsing fever, can also be transmitted by Ixodes ricinus ticks. It is an emerging disease caused by B. miyamotoi bacteria, which are from the relapsing fever group of borrelia, genetically distinct from those that cause Lyme disease. Human granulocytic anaplasmosis (HGA), also an acute febrile illness transmitted by Ixodid ticks, is an infection caused by the bacterium Anaplasma phagocytophilum. -
Melioidosis in Northern Tanzania: an Important Cause of Febrile Illness?
Melioidosis and serological evidence of exposure to Burkholderia pseudomallei among patients with fever, northern Tanzania Michael Maze Department of Medicine University of Otago, Christchurch Melioidosis Melioidosis caused by Burkholderia pseudomallei • Challenging to identify when cultured Soil reservoir, with human infection from contact with contaminated water Most infected people are asymptomatic: 1 clinical illness for 4,500 antibody producing exposures Febrile illness with a variety of presentations and bacteraemia is present in 40-60% of people with acute illness Estimated 89,000 deaths globally Gavin Koh CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=4975784 Laboratory diagnosis of febrile inpatients, northern Tanzania, 2007-8 (n=870) Malaria (1.6%) Bacteremia (9.8%) Mycobacteremia (1.6%) Fungemia (2.9%) Brucellosis (3.5%) Leptospirosis (8.8%) Q fever (5.0%) No diagnosis (50.1%) Spotted fever group rickettsiosis (8.0%) Typhus group rickettsiosis (0.4%) Chikungunya (7.9%) Crump PLoS Neglect Trop Dis 2013; 7: e2324 Predicted environmental suitability for B. pseudomallei in East Africa Large areas of Africa are predicted to be highly suitable for Burkholderia pseudomallei East Africa is less suitable but pockets of higher suitability including northern Tanzania Northern Tanzania Increasing suitability for B. pseudomallei Limmathurotsakul Nat Microbiol. 2016;1(1). Melioidosis epidemiology in Africa Paucity of empiric data • Scattered case reports • Report from Kilifi, Kenya identified 4 bacteraemic cases from 66,000 patients who had blood cultured1 • 5.9% seroprevalence among healthy adults in Uganda2 • No reports from Tanzania 1. Limmathurotsakul Nat Microbiol. 2016;1(1). 2. Frazer J R Army Med Corps. 1982;128(3):123-30. -
IS IT LYME DISEASE, Or TICK-BORNE RELAPSING FEVER?
IS IT LYME DISEASE, or TICK-BORNE RELAPSING FEVER? Webinar Presented by Joseph J. Burrascano Jr. M.D. Joined by Jyotsna Shah PhD for the Q&A January 2020 Presenters Joseph J. Burrascano Jr. M.D. • Well-known pioneer in the field of tick-borne diseases, active since 1985 • Founding member of ILADS and ILADEF • Active in physician education on all aspects of tick-borne diseases Jyotsna Shah, PhD • President & Laboratory Director of IGeneX Clinical Laboratory • Over 40 Years of Research Experience in Immunology, Molecular Biology & Microbiology • Author of Multiple Publications & Holds More Than 20 Patents • Member of ILRAD as a Post-Doctoral Scientist • Started the First DNA Sequencing Laboratory in E. Africa 2 Poll Question Before we begin, we’d like to ask a poll question. Which one of these Borrelia causes Tick-Borne Relapsing Fever (TBRF)? a) B. mayonii b) B. turicatae c) B. burgdorferi d) B. andersonii e) B. garinii 3 Poll Question Before we begin, we’d like to ask a poll question. Which one of these Borrelia causes Tick-Borne Relapsing Fever (TBRF)? a) B. mayonii - Lyme b) B. turicatae - TBRF c) B. burgdorferi - Lyme d) B. andersonii - Lyme e) B. garinii – Lyme strain in Europe 4 What is TBRF? • Has been defined by clinical presentation • Has been defined by tick vector • Has been defined by genetics • Has been defined by serotype BUT • Each of these has exceptions and limitations! 5 Clinical Presentation of Classic TBRF • “Recurring febrile episodes that last ~3 days and are separated by afebrile periods of ~7 days duration.” • “Each febrile episode involves a “crisis.” During the “chill phase” of the crisis, patients develop very high fever (up to 106.7°F) and may become delirious, agitated, tachycardic and tachypneic. -
Tick-Borne Disease Working Group 2020 Report to Congress
2nd Report Supported by the U.S. Department of Health and Human Services • Office of the Assistant Secretary for Health Tick-Borne Disease Working Group 2020 Report to Congress Information and opinions in this report do not necessarily reflect the opinions of each member of the Working Group, the U.S. Department of Health and Human Services, or any other component of the Federal government. Table of Contents Executive Summary . .1 Chapter 4: Clinical Manifestations, Appendices . 114 Diagnosis, and Diagnostics . 28 Chapter 1: Background . 4 Appendix A. Tick-Borne Disease Congressional Action ................. 8 Chapter 5: Causes, Pathogenesis, Working Group .....................114 and Pathophysiology . 44 The Tick-Borne Disease Working Group . 8 Appendix B. Tick-Borne Disease Working Chapter 6: Treatment . 51 Group Subcommittees ...............117 Second Report: Focus and Structure . 8 Chapter 7: Clinician and Public Appendix C. Acronyms and Abbreviations 126 Chapter 2: Methods of the Education, Patient Access Working Group . .10 to Care . 59 Appendix D. 21st Century Cures Act ...128 Topic Development Briefs ............ 10 Chapter 8: Epidemiology and Appendix E. Working Group Charter. .131 Surveillance . 84 Subcommittees ..................... 10 Chapter 9: Federal Inventory . 93 Appendix F. Federal Inventory Survey . 136 Federal Inventory ....................11 Chapter 10: Public Input . 98 Appendix G. References .............149 Minority Responses ................. 13 Chapter 11: Looking Forward . .103 Chapter 3: Tick Biology, Conclusion . 112 Ecology, and Control . .14 Contributions U.S. Department of Health and Human Services James J. Berger, MS, MT(ASCP), SBB B. Kaye Hayes, MPA Working Group Members David Hughes Walker, MD (Co-Chair) Adalbeto Pérez de León, DVM, MS, PhD Leigh Ann Soltysiak, MS (Co-Chair) Kevin R. -
Syphilis Onset Seizures, a Head CT Reveals an Acute CVA • 85 Yo Woman C/O Shooting Pains Down Her Simon J
• 43 yo woman with RUQ pain is found to have a liver mass on U/S, biopsy of the mass reveals granulomas • 26 yo man presents to the ED with new- Syphilis onset seizures, a Head CT reveals an acute CVA • 85 yo woman c/o shooting pains down her Simon J. Tsiouris, MD, MPH Assistant Professor of Clinical Medicine and Clinical Epidemiology arms and in her face for 2 years duration Division of Infectious Diseases College of Physicians and Surgeons • 36 yo man presents to his PMD with an Columbia University enlarging lymph node in his neck 55 yo man presents to the ER with chest pain radiating to his back, 19 yo man is seen at an STD clinic shortness of breath and is found to have this on Chest CT for a painless ulcer on his penis Aortic aneurysm rupture. Axial postcontrast image through the aortic arch reveals an aortic aneurysm with contrast penetrating the thrombus within the aneurysm (open arrow). Note the high attenuation material within the mediastinal fat (arrowheads), representing blood and indicating the presence of aneurysm rupture. 26 yo man presents to an ophthalmologist with progressive loss of vision in his Left eye, his fundoscopic exam looks like the picture on the left: Mercutio: “… a pox on your houses!” Romeo and Juliet, 1st Quarto, 1597, William Shakespeare Normal MID 15 Famous people who (probably) had syphilis • Ivan the Terrible • Henry VIII •Cortes • Francis I • Charles Baudelaire • Meriwether Lewis • Friedrich Nietzche • Gaetano Donizetti • Toulouse Lautrec • Al Capone Old World disease which always existed and happened •… New NewWorld World agent disease which mutatedwhich was and transmitted created a newto the Old Old World World? disease? to flare up around the time of New World exploration? The Great Pox – Origins of syphilis Syphilis in the 1500s • Pre-Colombian New World skeletal remains have bony lesions consistent with syphilis • T. -
Tick-Borne Relapsing Fever Epidemiology
Tick-borne Relapsing Fever Epidemiology Tick-borne Relapsing Fever (TBRF) occurs in the western United States and is usually linked to sleeping in rustic, rodent-infested cabins in mountainous areas and high elevations1,2,3,4. TBRF is not very common in Arizona, and usually sporadic cases occur, with the exception of two small outbreaks in 2005 and 20141,2,3,4. A. Agent: Tick-borne relapsing fever (TBRF) is most commonly caused by Borrelia hermsii, but can be caused by at least 14 other Borrelia species. These bacteria are gram negative spirochetes (cork-screw shaped) and are visible with light microscopy1,2,3,4. B. Clinical Description: Relapsing fever is a systemic spirochetal disease in which periods of fever lasting 2-7 days alternate with afebrile periods of 4-14 days; the number of relapses varies from 1-10 without treatment1,2,3,4. Febrile periods are often associated with shaking chills, sweats, headache, muscle and joint pain, and can be associated with a rash. Photophobia, eye pain, dizziness, dry cough, nausea, vomiting, or lack of appetite can also occur. Symptoms can be more severe without treatment1,2,3,4. Optimal management of TBRF requires both prompt diagnosis and careful observation during the initial phases of treatment1,2,3,4. With appropriate treatment the mortality rate is very low. The mortality rate without treatment is estimated at 5-10%1,2,3,4. TBRF contracted during pregnancy can cause spontaneous abortion, premature birth, and neonatal death1,2,3,4. In general, pregnant women have higher spirochete loads and more severe symptoms than non- pregnant women.