Title: R2 ??? / Vs. ?????
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2History
- This 12-year-old boy was suffered from fever,
cough, and abdominal pain for 3 days. - He is a victim of acute rheumatic fever,
including arthritis and carditis and received
regular Penicillin-G treatment monthly for 1 year.
3History
- He got an insert bite in his right lower leg with
a small infected wound the wound was treated at
home and improved.
4History
- However, about 1 week later, the symptoms of
low-grade fever, cough and abdominal pain with
fullness sensation were noted. - 3 days later, progressive dyspnea during exertion
was noted and then he was sent to our hospital
for help.
5Physical examination
- The physical examination showed respiratory
distress, bilateral coarse breathing sounds,
grade ?-?/? systolic murmurs over LSB, distended
abdomen, dilated jugular and superficial veins,
hepatosplenomegaly and pitting edema of bilateral
lower legs. - A small healed insert bite wound over right lower
leg.
6Image
- The CXR showed minimal right side pleural
effusion with normal heart size.
7Laboratory data
- WBC14100
- Neutrophil67 (40-74)
- Lymphocyte20 (19-48)
- Monocyte11 (3.4-9)
- CRP8.4 mg/dl (0-0.5)
- Albumin3.0 g/dl (3.4-4.8)
- BUN8 mg/dl (7-20) Creatinine0.5 (0.5-1)
- AST126 U/L (-37) ALT107 U/L (-41)
- Total bilirubin 1.2 mg/dl
- Na135 mmol/L (136-145) K3.4 mmol/L (3.5-5.1)
Cl98 mmol/L
8Admission course
- Echocardiography
- Tricuspid valve regurgitation
- Mitral valve regurgitation
- Pulmonary valve regurgitation
9Admission course
- Abdominal sonography
- Hepatosplenomegaly
- Patent hepatic artery and portal vein
- Mild to moderate ascites
10Subjective findings
- Fever
- Cough
- Abdominal pain with fullness
- Exertional dyspnea
- Insert bite
11Objective findings
- Coarse breathing sounds
- Systolic heart murmurs over LLSB
- Pitting edema over bilateral lower legs.
- Hepatosplenomegaly
- Wound of insert bite
12Objective findings
- Liver function impairment
- Hypoalbuminemia
- Hyponatremia
- Elevated CRP level
- Elevated WBC count
- Pleural effusion
- MR, TR, PR.
13Problems
- R/O Heart failure
- Fever
- Insert bite
- Hepatosplenomegaly
- Impaired liver functions
- Pleural effusion
- Ascites
14Question
- Patient traveling history
- EKG finding (arrhythmia, ST or T wave change)
- Echocardiography findings (compared with
previous) - Arterial blood gas (hypoxia, hypercapnea)
- Bacterial culture (blood,pleural effusion)
- Virus isolation and identification
- Pleural effusion study (transudate or exudate,
AFB stain) - Heart rate, blood pressure (arrhythmia,
hypertension) - Anemia or thrombocytopenia (hematologic
abnormalities) - Urine routine (Proteinuria ,hematuria)
- Indirect fluorescent antibody assay serology
15Causes of splenomegaly
- Infection
- Bacterial Typhoid fever, endocarditis,
septicemia, abscess - ViralE-B virus, CMV, and others
- Protozoal Malaria, toxoplasmosis
- Hematologic processes
- Hemolytic anemia Congenital, acquired
- Extramedullary hematopoiesis thalassemia,
osteopetrosis, myelofibrosis - Neoplasms
- Malignant Leukemia, lymphoma, histiocytoses,
metastatic tumors - Benign Hemagioma, hamartoma
- Metabolic diseases
- Lipidosis Niemann-Pick, Gaucher disease
- Mucopolysaccharidosis infiltration Histiocytosis
- Congestion
- Cirrhosis
- Cysts
- Miscellaneous
16Causes of ascites
- Hepatic (cirrhosis, fibrosis, obstruction)
- Renal (nephrotic syndrome, obstrutive, PD)
- Cardiac (heart failure, constrictive
pericarditis) - Infectious (abscess,TB, Chlamydia, schistosomia)
- Gastraointestinal (infarcted bowel perforation)
- Neoplastic (lymphoma, neuroblastoma)
- Pancreatic (pancreatitis, ruptured pancreatic
duct) - GYN (ovarian tumor, torsion, rupture)
- Miscellaneous (SLE, VP shunt, chylous,
hypothyroidism)
17Heart failure
- Symptoms
- Fatigue, effort intolerance, anorexia, abdominal
pain, dyspnea, cough - Sign
- Engorged jugular vein, hepatomegaly, basilar
rales, edema, cardiomegaly, gallop rhythm,
holosystolic murmur of mitral or tricuspid valve
regurgitation may be heard when ventricular
dilatation is advanced.
18Heart failure
- Sign
- Pitting edema occurred usually in the legs.
- Pitting edema of the arms and face occurs rarely
and then only in the late course of HF. - Ascites occurred most frequently in patients with
tricuspid valve disease or constrictive
pericarditis
19Heart failure
- Chest X ray
- Exaggeration of the pulmonary arterial vessels to
the periphery of the lung fields. (Patients with
cardiomyopathy may have a relatively normal
pulmonary vascular bed early in the course of
disease) - Cardiomegaly is invariable noted.
- Pleural effusion was more frequent in the right
side than in the left side.
20Heart failure
- EKG
- Left or right ventricular ischemic changes may
correlate well with clinical and other non
invasive parameters of ventricular function. - Low voltage QRS morphologic characteristic with
ST-T wave abnormaluties may also suggest
myocardial inflammatory disease but can be seen
with pericarditis - Rhythm disease is also a potential cause of heart
failure.
21Diagnosis of congestive heart failure(Framingham
criteria)
- Major criteria (at least 1)
- Paroxysmal nocturnal dyspnea
- Neck vein distention
- Rales
- Cardiomegaly
- Acute pulmonary edema
- S3 gallop
- Increased venous pressure (gt16 cm H2O)
- Positive hepatojugular reflux
- Minor criteria (at least 2)
- Extremity edema
- Night cough
- Dyspnea on exertion
- Hepatomegaly
- Pleural effusion
- Vital capacity reduced by 1/3 from normal
- Tachycardia (gt120 bpm)
22Acute versus Chronic
- Acute Sudden development of myocardial infection
or rupture of a cardiac valve, no cardiomegaly,
no peripheral edema. - Chronic Dilated cardiomyopathy, multiple
valvular heart disease, cardiomegaly, peripheral
edema.
23Right sided versus left sided
- Left Dyspnea or orthorpnea as the result of
pulmonary congestion. - Right Edema, congestive hepatomegaly, systemic
venous distention.
24Carditis in rheumatic fever
- Rheumatic carditis is characterized by
pancarditis, with active inflammation of
myocardium, pericardium, and endocardium. - Endocarditis, which is manifest by one or more
cardiac murmurs, is a universal finding in
rheumatic carditis. - Most case consist of mitral valvular disease or
combined aortic and mitral valvular disease. - Isolated aortic or right side valvular
involvement is uncommon.
25Rheumatic heart disease
- Mitral valve MR will result in increased atrium
pressure and pulmoary congestion and symptoms of
left side heart failure. Spontaneous improvement
usually occurs with time even in sever cases. In
chronic MR, pulmonary arterial pressure elevated
and right ventricle and atrium become enlarged
and right side heart failure develops. - MS will result in increased pressure and
enlargement and hypertrophy of the left atrium,
pulmonary venous hypertension, increased vascular
resistance and pulmonary hypertension. - Aortic valve AR will lead to volume overload
with dilatation of LV. - Right-sided heart manifestations are rare.
- Tricuspid valve Primary tricuspid involvement is
rare after rheumatic fever. TR is more common
secondary to right ventricular dilatation
resulting from unrepaired left side lesion. - Pulmonary valve PR usually occurs on a
functional basis secondary to pulmonary
hypertension and is a late finding with severe
mitral valve stenosis.
26Pulmonary regurgitation
- Isolated congenital pulmonary regurgitation is
rare. - Pulmoary valvular insufficiency most often
accompanies other cardiovascular disease or may
be secondary to severe pulmonary hypertension.
27Tricuspid regurgitation
- Tricuspid regurgitation usually functional.
- Secondary to marked RV dilatation of any cause
and often associated with pulmonary hypertension. - When volume overload or intrinsic myocardial
disease -gt dilated right ventricle. - Tricuspid regurgitation often accompanies with
right ventricular dysfunction.
28Pulmonary regurgitation Tricuspid regurgitation
- Pulmonary hypertension
- Cardiovascular disease -gt RV dysfunction
29Causes of pulmonary hypertension
- Conditions directly affecting pulmonary
arteriesPrimary pulmonary hypertensionToxin-indu
ced (ie, anorexic agents)VasculitisGranulomatose
s, collagen-vascular disorders, arteritisHepatic
cirrhosis/portal diseaseCongenital heart disease
(Eisenmenger syndrome ASD, VSD,
PDA)InfectionHuman immunodeficiency virus
30Causes of pulmonary hypertension
- Conditions affecting pulmonary
parenchymaChronic obstructive lung
diseaseInfiltrative/granulomatous
diseasesSarcoidosis, pneumoconiosis, radiation,
fibrosis, neoplasm, pneumonia, collagen-vascular
diseasesCystic fibrosisUpper airway
obstructionHigh-altitude diseaseArteriovenous
fistulas within the lungRestrictive lung
diseases
31Causes of pulmonary hypertension
- Conditions affecting the thoracic cage and
neuromuscular systemObesity-hypoventilation/sleep
apneaPharyngeal-tracheal obstructionKyphoscolio
sisPleural fibrosisNeuromuscular
disordersMyasthenia gravis, poliomyelitis,
central respiratory disorders
32Causes of pulmonary hypertension
- Conditions causing left atrial/or pulmonary
venous hypertensionElevated left ventricular
diastolic pressureSystolic failure, diastolic
dysfunction, constrictive pericarditisAortic
valve diseaseMitral valve diseaseCor
triatriatumLeft atrial massesMyxoma or
neoplasm, thrombusFibrosing mediastinitisCongeni
tal pulmonary vein stenosisAnomalous pulmonary
venous connectionPulmonary venoocclusive disease
33Causes of pulmonary hypertension
- Nonvasculitis conditions that result in pulmonary
artery obstructionAcute and chronic
thromboembolismHemoglobinopathies (eg, sickle
cell disease)Primary or metastatic
malignanciesPeripheral pulmonic stenosis - Congenital pulmonary hypoplasia
34Vasculitis syndrome
- Goodpasture disease
- Pulmonary hemorrhage and glomerulonephritis.
- Symptoms signs
- Hemoptysis, hematuria, proteinuria and
hypertension.
35Vasculitis syndrome
- Wegener Granulomatosis
- Fever, myalgia, cough, nasal discharge, hematuria
proteinuria. - Hemoptysis and dyspnea from lung lesion.
- Uveitis, conjuctivitis.
- Peripheral granuloma.
- Palpalbe purpuric nodules and ulcers
36Vasculitis syndrome
- Polyarteritis Nodosa
- Associated with infection of group A
streptococcus, hepatitis B, CMV, parvovirus , TB,
E-B virus. - Symptoms signs.
- Fever
- Abdominal pain (mesenteric arterial inflammation)
- Hypertension, hematuria, proteinuria (renal
vessels) - Purpura, edema, painful nodule (skin involvement)
- Heart failure (myocarditis, myocardial ischemia)
- Elevated liver function (hepatitis B infection
more common in adults) - Elevated ESR, anemia and leukocytosis
37An algorithm for the workup of a patient with
unexplained pulmonary hypertension
38Pulmonary embolism
- Precipitating factor
- CVP insertion, immobility, heart disease, oral
contraceptives, ventriculoatrial shunt, trauma,
infection, dehydration, collagen vascular
disease, shock , obesity, hematologic disorder. - Symptoms
- Chest pain, dyspnea, cough, fever, hemoptysis.
- Signs
- Rales, heart murmurs, tachycardia, fever,
diaphoresis, phlebitis, wheezing.
39Pulmonary embolism
- Lab
- ABG Respiratory alkalosis, arterial hypoxemia
- Elevated WBC count, D-dimer, fibrinogen, protein
C, protein S. - Chest Often normal in patient with PE.
- EKG Nonspecific ST segment change and signs of
cor pulmonale - Ventilation-perfusion image Regional blood flow
and ventilation defects . But normal V-P scan
cant exclude a PE and are interpreted as high
probability, intermediate probability, low
probability, very low probability and normal.
Lung disease can limit the utility of this study.
- Pulmonary angiography is the gold standard
diagnostic test for pulmonary embolism.
40Cause of heart failure in child
- Rheumatic fever
- Acute hypertension
- Thyrotoxicosis
- Hemochromatosis-hemosiderosis
- Cancer therapy (radiation, doxorubincin)
- Sickle cell anemia
- Endocarditis
- Cardiomyopathy (Viral myocarditis, nonviral)
- Myocarditis, hypertrophic, dilated.)
- Cor pulmoale (cystic fibrosis)
41Pulmonary regurgitation Tricuspid regurgitation
- Pulmonary hypertension
- Infection
- Pulmonary embolism
- Cardiovascular disease -gt RV dysfunction
- Rheumatic fever
- Endocarditis
- Cardiomyopathy (carditis, dilated, hypertrophic )
42Acute rheumatic fever
- Major (least 2 major or 12 minor)
- Carditis, polyarthritis, erythema marginatum,
subcutaneous nodules - Minor
- Fever, arthralgia, elevated ESR or CRP, prolonged
PR interval - Supported evidence of GAS infection
- Positive throat culture or streptococcal antigen
test - Elevated or increased streptococcal antibody titer
43Infectious endocarditis
- Etiology Viridans-type streptococci and
staphylococcus aureus are the leading causative
agents responsible for endocarditis in pediatric
patients. - Infective endocarditis is often a complication of
congenital or rheumatic heart disease - Prolonged fever without other manifestation.
- Low grade fever, fatigue, myalgia, arthralgia,
headache, and at times, chills, nausea, and
vomiting. - Splenomegaly and petechiae are relative common.
- Osler nodes (tender, pea-sized intradermal
nodules in the pads of the fingers and toes),
Janeway lesion (painless small erythematous or
hemorrhagic lesion on the palms and soles),
splinter hemorrhages (linear lesions beneath the
nails) - Embolic strokes, cerebral abscess, mycotic
aneurysm, and hemorrhage in staphylococcus
disease.
44Infectious endocarditis
- History
- Congenital or rheumatic heart disease
- Preceding dental, urinary tract or intestinal
procedure - Intravenous drugs abuse
- Central venous catheter
- Prosthetic heart valve
- Symptoms
- Fever, chills, chest and abdominal pain,
arthralgia, myalgia, dyspnea, malaise, night
sweats, weight loss, CNS manifestations
45Infectious endocarditis
- Signs
- Elevated temperature, tachycardia, embolic
phenomena (Roth spots, petechia, splinter nail
bed hemorrahge, Osler nodes, CNS or ocular
lesions), Janeway lesions, New or changing
murmur, splenomegaly, arthritis, heart failure,
arrythmias, Metastatic infection (arthritis,
meningitis, mycotic arterial aneurysm,
pericarditis, abscesses, septic pulmonary
emboli), clubbing - Labs
- Blood culture (), ESR ?, CRP?, anemia,
leukocytosis, immune complexes,
hypergammaglobulinemia, hypocomplementemia,
rheumatoid factor, hematuria, renal failure - Chest X ray bilateral infiltration, nodules,
pleural effusions - Echocardiography valve vegetations, prosthetic
valve dysfunction or leak, myocardial abscess,
new-onset valve insufficiency.
46Infectious endocarditis
- Duke criteria
- Major 1.Blood culture () 2.Evidence of
endocarditis on echocardiography (intracardiac
mass on a valve or other site, regurgitation flow
near a prosthesis, abscess, partial dehiscence of
prosthetic valves or new valve regurgitation
flow) - Minorfever, embolic-vascular signs, immune
complex phenomena (GN, arthritis, rheumatoid
factor, Osler nodes, Roth spots), - 2 major 1 minor
- 1 major 3 minors
- 5 minors
47Infectious endocarditis
- Etiology
- Common Native valve or other cardiac lesions
- Viridans group streptococcus (dental procedure)
- Staphylococcus aureus (drugs abuse)
- Group D streptococcus (GU or GI tract procedures)
- Uncommon Native valve or other cardiac lesions
- Streptococcus pneumoniae
- Haemophilus influenzae
- Coagulase-negative staphylococci
- Coxiella burnetii (tick borne)
- Neisseria gonorrhoeae (in human, sexual ,
intimate contact) - Brucella (zoonotic disease, contact with infected
animals) - Chlamydia psittacli, Chlamydia trachomatis,
Chlamydia pneumoniae (human, sexual,respira) - Legionella (fresh water or aerosols containing
bacteria) - Bartonella (cat scratch)
- HACEK group (H respiratoryAtrauma, aspiration
to lung, ) - Streptobacillus moniliformis
- Pasteurella multocida (chesse, milk )
- Campylobacter fetus
48Myocarditis
- Symptoms
- Fever, severe heart failure, respiratory
distress. - Incubation time1-7 days of the onset of
symptoms. - Signs
- Cyanosis, distant heart sounds, weak pulses,
tachycardia, Gallop rhythm, acidosis, and shock. - Evidence of hepatitis, aseptic meningitis,
associated rash may be present.
49Myocarditis
- Lab
- Elevated CK, LDH
- EKG Sinus tachycardia, reduced QRS voltage,
ST-segment and T-wave abnormalities, arrhythmia. - Echo poor ventricular function, pericardial
effusion, mitral valve regurgitation, absence of
congenital heart lesion or coronary artery
50Etiology of myocardial disease
- Familial-Hereditary (myopathy, cardiomyopathy)
- Infection (Virus, Richettsiae, Bacteria,parasite,f
ungus) - Metabolic, nutritional, endocarine
- Connective tissue-Granulomatous
disease-infiltrative (SLE, vasculitis,
Scleroderma, sarcoidosis, dermatomyositis,
leukemia) - Drugs-Toxins (chemo, alcohol,irradiation.)
- Coronary arteries (Kawasaki disease, meidal
necrosis, anomalous left coronary artery) - Other (anemia, ischemia)
51Etiology of myocardial disease
- Infection
- Virus
- Coxsackievirus A and B
- Adenovirus
- HIV
- Echovirus
- Rubella
- Varicella
- Influenza
- Mumps
- Epstein-Barr
- Measles
- Poliomyelitis.
52Etiology of myocardial disease
- Infection
- Richettsiae
- Psittacosis
- Q fever, Coxiella burnetii(Ticks)
- Rocky Moutain spotted fever. (Tick bites)
- Bacterial
- Diphtheria (respiratory, cutaneous)
- Mycoplasma (airborne, human to human)
- Meningococcus (respiratory)
- Leptospirosis (water or soil contaminated with
rat urine) - Lyme disease (tick bites)
- Typhoid fever (foods or water contaminate with
human feces) - Tuberculosis (airborne, human to human)
- Streptococcus (respiratory, dental procedure)
- Listeriosis (food(cheese, milk) contaminate with
feces of animals)
53Etiology of myocardial disease
- Infection
- Parasites
- Chagas disease (kissing bugs)
- Toxoplasmosis (food or water comtaminated by cat
feces) - Loa loa (biting flies)
- Toxocara canis (dog feces)
- Schistosomiasis (contact water contaminated with
cercaria) - Cysticercosis
- Echinococcus
- Trichinosis. (meat with larvae of trichinella)
- Fungi
- Histoplasmosis.
- Coccidiomyocosis.
- Actiomycosis.
54Differential problems
- R/O Pulmonary hypertension
- R/O Pulmonary embolism
- R/O Cardiomyopathy
- Hepatosplenomegaly
- Insert bite transmitted disease
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58Richettsial infection
- Spotted fever group
- Typhus
- Scrub typhus
- Ehrlichioses and Anaplasmosis
- Q fever
59Richettsial infection
- Spotted fever group
- Rocky Mountain spotted feverr
- Mediterranean Spotted fever
- African tick-bite fever
- Rickettsialpox
- Murine typhus-like
60Spotted fever group
- Rocky mountain spotted fever
- Tick bite transmission disease (HostDogs,
rodents) - United states, southwestern, Canada, Mexico,
Central America, South America - The incubation period 2-14 days (median 7 days)
- Headache, fever, anorexia, myalgia, restlessness.
- GI symptoms(39-63) Nausea, vomiting, diarrhea,
abdominal pain. - Skin rash Maculopapules onset after the 3rd day
of illness -gt petechia or purpura after several
days. (4974) (1st day 14, 3rd day49) - Hepatosplenomegaly (33)
- Clinical triad Headache, fever, rash
- Lab data Low leukocyte count with left shift
low platelet count low serum sodium are clues
for RMSF, impaired liver function (38) - Severe case may present myocarditis, facial
edema, DIC, non cardiogenic pulmonary edema,
respiratory distress. - Diagnosis Immunohistologic demonstration of
specific rickettsial antigen (IFA, DFA, IH
sensitivity 70) (single IFA tiltergt164 or 4
fold increased between acute and convalescent
sera (2-4 wk apart)) - Treatment Doxycycline (2.2mg/Kg/dose
q12h-gt2.2mg/Kg/D divided q12h) - Tetracycline (25-50mg/Kg/D q6h po)
Chloramphenicol (50-100mg/Kg/D q6h iv) at least 5
days until afebrile 2-4 days.
61Spotted fever group
- Mediterranean Spotted fever
- Tick bite transmission disease (Host Dogs,
rodents) - Pathogen R. conorii
- India, Pakistan, Russia, Ukraine, Georgia,
Israel, Ethiopia, Kenya, South Africa, Morocco,
and Southern Europe. - Fever, headache, myalgias, maculopapular rash
which appears 3-5 days after onset of symptoms. - 70 of patient have eschar, tache noire, regional
lymphadenopathy. - 6 of cases Purpuric skin lesion, neurologic
signs,myocarditis, respiratory distress, acute
renal failure, thrombocytopenia. - Diagnosis Immunohistologic demonstration of
specific rickettsial antigen - Treatment tetracycline, doxycycline,
chloramphenichol - Azithromycin (10mg/Kg/D once daily po) and
clarithromycin (15mg/Kg/D bid po)
62Spotted fever group
- Rickettsialpox
- Mite bite transmission disease (Host Mouse,
rodents) - Pathogen R. akari
- United States, Europe, and Asia.
- 90 papular or ulcerative lesion at the initial
site of inoculation. - Varicelliform rash (maculopapular rash may become
vesicular), fever, headache, chills - The infection resolves spontaneously even without
therapy.
63Scrub typhus
- Scrub typhus
- Chigger bite transmission disease (Host Rats, )
- Pathogen Orientia tsutsugamushi
- Southern Asia, Japan, Indonesia, Australia,
Korea, Asiatic Russia, India, China - Incubation period6-21 days.
- lt50 of cases necrotic eschar with an
erythematous rim - Fever, headache, myalgia, cough and GI symptoms.
- Regional or generalized lymphadenopathy is
common. - lt50 of patients presents maculopapular rash.
- Complications Meningoencephalitis, myocarditis,
interstitial pneumonitis. - Diagnosisindirect fluorescent antibody assay or
immunoperoxidase serologic tests of O.
tsutsugamushi antigen - Treatment Doxycycline tetracycline
chloramphenicol at least 5 days until afebrile
2-4 days.
64Typhus Group Rickettsioses
- Murine Typhus
- Rat flea or cat flea feces transmission disease
(Host Rats ) - Pathogen Richesttsia typhi (mouse flea) R.
felis(cat flea) - Distribution Worldwide.
- Incubation period 1 to 2 weeks
- Fever, rash (48-80), myalgias (29-57), vomiting
(29-45), cough (15-40), headache (19-77), and
diarrhea or abdominal pain(10-40) - Usually maculopapule rashs distributed on the
trunk and extremities. - Neurologic involvement(photophobia, confusion,
stupor, coma, seizures, meningismus and ataxia)
may be a frequent finding in adults 17 of
hospitalized and 6 of outpatients of infected
children. - Lab data Leukopenia with left shift(36-40)
thrombocytopenia(43-60) Hyponatremia(20-66)
Hypoalbuminemia (46-87) elevated AST and ALT - DiagnosisIndirect fluorescent antibody assay
serology - Treatmet Doxycycline, tetracycline,
chloramphenicol at least 5 days until afebrile
2-4 days.
65Typhus Group Rickettsioses
- Epidemic typhus
- Louse feces (via wound or conjunctiva) disease
(Host Human ) - Pathogen Richesttsia prowazekii
- Distribution Africa, South Amercia. Central
America. Mexico, Asia. - Incubation periodlt14 days.
- Fever, severe headache, abdominal pain, rash in
most people - Chills(82) myalgias(70) arthralgia(70)
anorexia (48), nonproductive cough (38),
dizziness (35), photophobia (33), nausea (32),
abdominal pain (30), tinnitus (23) meningismus
(17), visual disturbances (15), vomiting (10) - Treatment Doxycycline tetracycline
Chloraphenicol at least 5 days until afebrile 2-4
days.
66Ehrlichioses and Anaplasmosis
- Ehrlichiosis and anaplasmosis
- Tick bite disease (Host Deer, dogs(HME) deer
rodents, ruminants (HGE)) - Pathogen E. chaffeensis (Human monocytic
ehrlichiosis (HME)) - Anaplasma phagocytophilum (Hauman anaplasmosis
Human granulocytic ehrlichiosis (HGE)) - Distribution United states, Europe, Africa
- Incubation period2 days to 3 weeks.
- Fever(97), headache (81), myalgias(68),
malaise (84) anorexia, and nausea or vomiting,
maculopapular rash(2/3 of children with HME),
conjunctivitis, pharyngitis and lymphadenopathy
(minority), - Hepatomegaly and splenomegaly (frequent),
systolic ejection murmur (often) - Lab data leuopenia (58-72) lymphopenia
(75-78) thrombocytopenia(80-92) Granulomas
and granulomatous inflammation in 75 in bone
marrow examinations of HME Elevated transaminase
levels Hyponatremia prolonged PT/PTT Morulae
in peripheral blood monocyte or neutrophil. - Diagnosis The demonstration of morulae, single
high tilter (gt1128) of A. phargocytophilum
antibodies or seroconversion (gt164) - Treatment Doxycycline, Tetracycline at least 5
days until afebrile 2-4 days.
67Q fever
- Acute Q fever
- Inhalation of infectious aerosols, ingestion of
contaminated dairy products, ticks disease (Host
Cattle, sheep, goats, cats, rabbits ) - Pathogen Coxiella burnetii
- Distribution Worldwide
- Incubation day 3-30 days.
- Fever, sever headache, arthralgia, myalgia,
cough, fatigue, vomiting, abdominal pain. - Hepatomegaly and splenomegaly may be detected in
some patients. - Fever (91), respiratory involvement (34) rash
(11), neurologic findings (4) - Lab data Leukopenia with left shift (50),
thrombocytopenia (9-48), reative thrombocytosis
in recovery state results in DVT, Elevated
transaminase levels (62), elevated ESR (50) - Hepatitis (40), Myocarditis, pericarditis.
- Right side endocarditis results in pulmonary
embolism is reported. - Self-limited illness that last for 2-36 weeks.
68Q fever
- Chronic Q fever
- Chronic Q fever occurred months to years after
acute Q fever or even in the absence of any
history of acute Q fever. - Presents with endocarditis, hepatitis,
myocarditis, FUO, pneumonia, osteomyelitis. - Q fever endocarditis Fever may be absent in up
to 15 of cases. More than 75 of all identified
have congestive heart failure. - Data ESR gt 20 mm/hr (80), hypergammaglobulinemia
(54), hyperfibrinogenemia (67). Rheumatoid
factor (gt50) , antiplatelet antibodies,
anti-smooth muscle antibodies, antimitochondrial
antibodies, positive direct Coombs test. - Diagnosis (children with fever of unknown
origin, atypical pneumonia, culture negative
endocarditis) 4-fold increase in indirect
fluorescent antibody tilters to phase 1 and phase
2 antigens in acute and convalescent (2-4 weeks)
sera - Treatment AcuteTreated within 3 days of onset
of symptoms with tetracycline or doxycycline. - ChronicTetracycline or doxycycline rifampin,
ofloxacin or pefloxacin. (18months until phase 1
tilters of lt1200 for IgG and negative IgA
tilters)
69Relapsing fever (Borrelia)
- Human louse, tick disease (Host Human )
- Pathogen Borrelia. Recurrentis
- Distribution Worldwide
- Incubation time 5-15 days(median 8 days)
- Fever lasting 2-9 days then a febrile periods of
2-7 days. - Symptoms High fever, delirium, lethaygy,
headache, myalgia, arthralgia, photophobis,nausea,
vomiting, abdominal pain, productive cough, mild
respiratory distress, bleeding tendency(epistaxis,
hemoptysis, hematuria, hematemesis), skin rash - Sings lymphadenopathy, splenomegaly, hepatic
tenderness with hepatomegaly is a common sign,
jaundice (50) - Severe complication CNS, mycocarditis, hepatic
failure, DIC. - Diagnosis spirochete in Giemsa or Wrights stain
- Treatment Doxycycline (500mg po q6h),
erythromycin (50mg/Kg/D) for lt12 years old
children.
70Lyme disease
- Lyme disease
- Tick bite disease (Host Deer, Rodent)
- Pathogen Borrelia burdorferi
- DistributionWorldwide
- Early localized disease typical annular rash,
erythema migrans(90) occurs in 7-14 days after
the bite, it appear as a target lesion with
central clearing and may be associated with
systemic features including fever, myalgia,
headache, malaise. Without treatment, the rash
will expands to an average diameter of 15cm and
remains present at least 1-2 wks. - Early disseminated disease Multiple skin lesion,
accompanied by fever, myalgia, headache, malaise
conjunctivitis and lymphadenopathy may develop.
Aseptic meningitis, uveitis, focal neurologic
findings, especially cranioneuropathies, carditis
with varying degrees of heart block, palalysis of
the facial nerve is relatively common in
children. - Late disease Arthritis, especially the large
joints (gt 90 in knees) with swollen and tender
joints, chronic demyelinating encephalitis,
polyneuritis, impairment of memories
71Lyme disease
- Diagnosis The presence of EM rashes gt 5cm in
diameter or serologic confirmation of infection
with evidence of at least one manifestation of
musculo skeletal, neurological or cardiovascular
disease . - The culture of B. burgdorferi in
Barbour-Stoenner-Kelly medium from the specimen
of plasma, biopsy samples of erythema migrans
lesions, occasionally from cerebrospinal fluid
samples in patients with meningitis can permit a
definitive diagnosis. - Serologic tests was used as diagnostic method in
public health surveillance and in clinical
diagnosis. This Western Blot detects the presence
or absence of antibodies and is not quantitative.
Antibody can still be detected with Western blot
even after a successful. It was used to confirm
equivocal and positive serology results obtained
by ELISA or IFA. - Treatmentdoxycycline (100mg bid for 14-21 days)
in children older than 8 yr of age Amoxicillin
(50 mg /Kg/D tid po 14-21 days) cefuroxime
(30mg/kg/D bid po for 14-21 days ) erythromycin
(30-50mg/Kg/D qid for 14-21 days.) - Meningitis Ceftriaxone 50-80 mg/Kg/D iv qd for
14-28 days. - Carditis Mild to moderate as EM Severe as
meningitis - Late disease the same as for EM except for 28
days-gtrecurrence choose second dose or
meningitis.
72Chagas disease
- Acute Chagas disease
- Kissing bugs bite transmission disease
- Pathogen Trypanosoma cruzi
- Distribution Western hemisphere (Mixeco, south
America, Brazil, Argentina) - Acute chagas disease mild fever, malaise, facial
edema, lymphadenopathy, local sign of
inflammation at the site entry(chagomas) . - 50 with Romana sign (Unilateral, painless eye
swelling), conjunctivitis, preauricular
lymphadenitis - Lymphadenopathy, hepatosplenomegaly,
meningoencephalitis can occur in children
younger than 2 years old. - The heart is the primarily target organ, 4
chamber dilatation, diffuse myocarditis and
inflammation of the conduction system lead to the
development of fibrosis.
73Chagas disease
- Chronic Chagas disease
- Chronic Chagas disease Cardiomyopathy included
congestive heart failure, arrhythmia and
thrombocytopenia events. EKG will showed complete
A-V block, RBBB, LBBB, left ventricular apical
aneurysm. - Diagnosis Giemsa-stain smear will demonstrate
motile trypanosomes. - These are only seen in the peripheral blood in
the first 6-12 week of the illness. - Specific IgM antibodies in ELISA or IFA in acute
Chagas disease. - Complement fixation is considered the most
reliable immunodiagnostic method for chronic
Chagas disease. - Treatment Nifurtimox (15-20mg/kg/D qid po(1-10
y/o) 12.5-15mg/KG/D (11-16 y/o), 8-10mg/Kg/D(gt16
y/o)) for 90 days and benznidazole (10mg/Kg/D bid
po(lt12y/o) 5-7 mg/kg/D(gt12y/o)) for 60 days
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75Impression
- Q fever
- Rocky mountain spotted fever
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77Diagnosis of Q fever
- Q fever results from infection with C. burnetii.
- This small gram-negative microorganism (0.2 um by
0.7 um) exists in two antigenic forms phase I
and phase II. - The phase I form is extremely infectious and
exists in humans and other animals. Passage in
cell culture or embryonated eggs results in a
shift to the phase II form, which is avirulent.
78Diagnosis of Q fever
- C. burnetii can be isolated from buffy-coat blood
samples or tissue specimens by a shell-vial
technique C. burnetii since it is considered
highly infectious. - PCR can be used to amplify C. burnetii DNA from
tissue or biopsy specimens. This technique can
also be used on paraffin-embedded tissues. - Serology is the most commonly used diagnostic
tool. Three techniques are available complement
fixation, indirect immunofluorescence, and
enzyme-linked immunosorbent assay. - Indirect immunofluorescence is sensitive and
specific and is the method of choice. - Rheumatoid factor should be adsorbed from the
specimen before testing.
79Diagnosis of Q fever
- 4-fold increased in IFA titers to phase I and
phase II antigens between acute and convalescent
sera(2-4wks) - An IgG titer of 1800 to phase I antigen is
suggestive of chronic Q fever. - In almost all instances of chronic Q fever, the
antibody titer to phase I antigen is much higher
than that to phase II antigen. - The reverse is true in acute Q fever. In
addition, in acute Q fever, it is usually
possible to demonstrate a fourfold rise in titer
between acute- and convalescent-phase serum
samples. - Elevated phase I IgA antibody are diagnostic for
Q fever endocariditis.
80Diagnosis of RMSF
- The most common serologic test for confirmation
of the diagnosis is the indirect
immunofluorescence assay. - Between 7 and 10 days after onset, a diagnostic
titer of 164 is usually detectable. - The sensitivity and specificity of the indirect
immunofluorescence assay are 94 to 100 and 100 - The only diagnostic test that is useful during
the acute illness is immunohistologic examination
(immunofluorescence or immunoenzyme staining) of
a cutaneous biopsy of a rash lesion for R.
rickettsii. - Examination of a 3-mm punch biopsy of such a
lesion is 70 sensitive and 100 specific.