Diverticulitis

1
Hospitalist Conference

• 17 y.o. male
• CC Fever and rash
• PMHx
• RLL Pneumonia 1998
• Mononucleosis 2005
• MEDs
• None
• Allergies
• Penicillins - rash
• Social Hx
• Lives with parents
• Junior in High School
• Works on family farm
• Alcohol None
• Tobacco 1 pack/wk
• Family Hx
• Hypertension Father
• Colon Cancer PGF

2
Case Conference

• 17 y.o. male
• CC Fever and rash
• PMHx
• RLL Pneumonia 1998
• Mononucleosis 2005
• MEDs
• None
• Allergies
• Penicillins - rash
• Social Hx
• Lives with parents
• Junior in High School
• Works on family farm
• Alcohol None
• Tobacco 1 pack/wk
• Family Hx
• Hypertension Father
• Colon Cancer PGF

• HPI
• Felt well until 1 week ago
• Developed headache and neck pain
• No vision changes, mild sore throat
• After 3 days, noted fevers to 100.6
• Seen in New Ulm ED

3
Case Conference

• 17 y.o. male
• CC Fever and rash
• PMHx
• RLL Pneumonia 1998
• Mononucleosis 2005
• MEDs
• None
• Allergies
• Penicillins - rash
• Social Hx
• Lives with parents
• Junior in High School
• Works on family farm
• Alcohol None
• Tobacco 1 pack/wk
• Family Hx
• Hypertension Father
• Colon Cancer PGF

• HPI
• Felt well until 1 week ago
• Developed headache and neck pain
• No vision changes, mild sore throat
• After 3 days, noted fevers to 100.6
• Seen in New Ulm ED

• HPI Continued
• Throat culture and mono spot negative
• LP not done
• Discharged with Tylenol and Advil
• 3 days later, fever to 102 with nausea
• Diffuse, non-pruritic rash blotches
• no raised lesions or blisters
• Rash involved trunk, back and thighs
• Recurrent fever to 102.7 returned to ED

Labs
CXR No acute disease
4
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5
Case Conference
17 y.o. male CC Fever and rash

• HPI Continued
• Discharged from ED
• Thought to be viral etiology
• Slept 20 hours next day
• Fevers to 104.4
• PMD referred pt to ANW ED

• ROS
• Positive for fatigue, fevers and chills,
  decreased appetite, nausea, vomiting and diarrhea
• No cough or sputum, no SOB
• No recent sick contacts
• No recent tick bites or travel

Exam Vitals HR 105 BP 124/58 T 102.8 RR 16
O2 97 HEENT no scleral icterus, injected
bilaterallyResp CTACV Tachycardic,
regularAbdomen soft, non-tender, bowel sounds
presentNeuro Alert and oriented x3, CN II-XII
intact, strength 5/5 bilaterally, reflexes
2 Skin Diffuse erythematous rash on chest,
back, abdomen with reticular appearing rash on
arms
6
Case Conference
17 y.o. male CC Fever and rash
Labs
Hepatitis Serology Negative HIV NegativeBlood
Cultures No Growth Ehrlichia Negative West Nile
IgM, IgG Negative
Alk Phos 214 AST 305 ALT 277 T. bili 2.0

• HPI Continued
• Seen by ID
• Additional History
• Assisted on a pig farm during the summer
• Bitten by a pig 2 months prior resolved
• 850 pigs died during heat wave when fan in barn
  malfunctioned
• patient assisted with disposing of dead pigs
  did not use gloves or mask
• Empirically started on Doxycycline for presumed
  Leptospirosis
• IgG and IgM serology, Lepto urine and blood
  cultures

7
Case Conference
17 y.o. male CC Fever and rash
Labs
Hepatitis Serology Negative HIV NegativeBlood
Cultures No Growth Ehrlichia Negative West Nile
IgM, IgG Negative
Alk Phos 214 AST 305 ALT 277 T. bili 2.0
8
Leptospirosis
9
History

• A zoonosis caused by the spirochete leptospira
  interrogans
• 1883 First recognized as an occupational disease
  of sewer workers
• 1886 Weils disease
• Named after Adolph Weil who described the disease
  as an acute infectious disease with enlargement
  of spleen, jaundice, and nephritis
• This is most severe form of leptospirosis
• 1907 Stimpson, first isolate

10
Epidemiology

• Worldwide distribution
• Most cases occur in tropics
• Thailand 30-fold increased in cases from
  1995-2000
• Hypothesis increased rat population and seasonal
  flooding
• In US, most cases are in southern and Pacific
  coastal states
• Hawaii has most cases of any state in US
• Outbreaks can occur
• 12 of athletes participating in Illinois
  triathlon after exposure to lake water in
  swimming phase
• Areas with high rat population and seasonal
  flooding have the highest incidence

11
At Risk Populations

• Occupational Exposure
• Farmers, veterinarians, sewer workers, rice field
  workers
• Recreational Activities
• Fresh water swimming, canoeing, kayaking
• Household Exposures
• Domesticated livestock, infestation by infected
  rodents

12
Pathogenesis

• Humans become infected after exposure to
  environmental sources
• Animal urine (wild and domestic mammals
  especially rodents, cattle, swine, dogs, horses,
  sheep, and goats)
• Contaminated soil or water
• Infected animal tissue
• Portals of entry
• Abraded skin
• Mucous membranes
• Conjunctiva
• Incubation period 7-12 days

13
Clinical Course

• 90 of patients have mild symptoms while 5-10
  have severe form with jaundice (Weils Disease)
• Natural course has 2 distinct phases
• First Stage (Leptospiremic) Lasts 4-7 days
• Non-specific flu-like symptoms
• Fevers, chills, sore throat, headaches, myalgias,
  rash
• Second Stage (Immune or Leptospiruric) Lasts up
  to 30 days
• Circulating antibodies may be detected
• Organism may be isolated from urine
• Meningeal symptoms in 50 of patients
• Viral etiology may be suspected

14
Exam findings

• During First Stage
• Fevers, pharyngeal injection, lymphadenopathy
• Conjunctival suffusion
• Conjunctival redness due to increased blood flow
• During Second Stage
• Adenopathy, rash, fever
• Jaundice, splenomegaly, abdominal tenderness

15
Advanced Disease Weils Syndrome

• Severe form of leptospirosis characterized by
  profound jaundice, renal dysfunction, hepatic
  necrosis, and hemorrhagic diathesis
• Criteria for diagnosis are not well defined
• Complications include
• Renal failure, uveitis, hemorrhage, ARDS,
  myocarditis, rhabdomyolysis, liver failure
• Mortality rate of 5-10
• Some studies suggest case fatality rates of 20-40

16
Laboratory Findings

• Thrombocytopenia
• Leukocytosis with left shift
• Elevations of transaminases (lt200) in 40 of
  patients
• Elevated CK in up to 50 of patients
• UA with proteinuria
• CSF may show a neutrophilic or lymphocytic
  pleocytosis with normal protein and glucose

17
CDC Diagnostic Criteria
18
Diagnosis

• Culture
• Blood
• Positive in 1st 10 days of illness
• Isolation successful in only 50 of cases
• CSF
• Positive in 1st 10 days of illness
• Urine
• Becomes positive in 2nd week of illness
• May remain positive for up to 30 days after
  resolution of symptoms

19
Diagnosis

• Serology
• Microscopic agglutination test (MAT), macroscopic
  agglutination test, indirect hemagglutination,
  and ELISA
• Gold standard is MAT, but is not widely available
• Most common tests used in clinical practice
• Microplate IgM ELISA
• IgM dot-ELISA dipstick
• If one of these is positive, sera for MAT can be
  sent to CDC
• PCR is being explored and showing some promise in
  diagnosis, but is not yet widely available

20
Treatment

• Antibiotic treatment for one week
• Doxycycline 100 mg IV or po q 12 hrs
• Ampicillin 500 - 1000 mg IV q 6 hrs
• Penicillin G 3-4 million units IV q 4 hrs
• Penicillin G 1.5 million units IV q 6 hrs
• Ceftriaxone 1 gram IV qd