Title: RED BOOK 2006
1RED BOOK 2006
2Japanese Encephalitis
- Japanese encephalitis virus
- Flavivirus
- Culex tritaeniorhynchus
- Amplifier host pig
3Clinical manifestation
- Incubation period 1-2 weeks
- Age 6-14 years
- Asymptomatic
- Acute encephalitis, Acute meningoencephalitis,
Aseptic meningitis
4Clinical manifestation
- 3 stages
- Prodromal stage
- Acute encephalitis stage
- Late stage and sequelae
5Lab investigation
- CBC wbc ?? neutrophil ??
- CSF pressure ?
- wbc 200 (3-4,200) lymp ?
- slightly ? prot level
- sugar ?
6Lab (Dengue and JE)
- Hemagglutination Inhibition Assay (HAI)
- Titer vs DEN-1, DEN-2, DEN-3, DEN-4, JE, CHIK
- ELISA / EIA ?????? OD
- Unit of DEN IgM DEN IgG
- JE IgM JE IgG
7HAI
- No evidence of recent Flavivirus infection
- Undetectable Ab
- Stable titers (lt12560)
- Acute primary Flavivirus Infection
- Fourfold (lt11280)
- Acute secondary Flavivirus infection
- Fourfold (gt11280)
- Recent secondary Flavivirus infection
- No fourfold (?12560)
8Acute Secondary Dengue Infection
9EIA
- IgM ? 40 units is positive
- Dengue IgM / JE IgM
- gt1 Dengue infection
- lt1 JE infection
- Dengue IgM / Dengue IgG
- ?1.8 Primary infection
- lt1.8 Secondary infection
10Treatment and prevention
- Supportive and symptomatic Px
- Vaccine
- Mouse brain-derived inactivated vaccine
- Cell culture-derived, inactivated vaccine
- Cell culture-derived, live attenuated vaccine
11 Viruses
- DNA viruses ??????????????? Double stranded
- ?????? Parvoviridae ???? Single strand
- RNA viruses ??????????????? Single stranded DNA
- ?????? Reoviridae ???? Double strand
-
- (families - viridae)
12 DNA viruses
- Adenoviridae adenovirus
- Hepadnaviridae Hepatitis B
- Papovaviridae Papillomavirus,
- Polyomaviruses
13DNA viruses (cont.)
- Herpesviridae
- Herpes simplex virus type 1
- Herpes simplex virus type 2
- Varicella-zoster virus
- Epstein-Barr virus
- Cytomegalovirus
- Human herpesvirus 6
- Human herpesvirus 7
- Human herpesvirus 8
14DNA viruses (cont.)
- Parvoviridae Parvovirus B19
- Poxviridae Molluscum contagiosum
15RNA viruses
- Coronaviridae Human coronaviruses
- Paramyxoviridae Parainfluenza,
- Mumps, Measles , RSV
- Orthomyxoviridae Influenza
- Piconaviridae Enteroviruses
- (Polio, coxsakievirus, echoviruses,
- enterovirus, Hep A)
16RNA viruses (cont.)
- Flaviviridae Dengue, JE, Yellow fever,
- West Nile, Hep C, Hep
G - Togaviridae Rubella, Chikungunya
- Reoviridae Rotaviruses
- Retroviridae HIV
- Rhabdoviridae Rabies
17Leptospirosis
- bacteria spirochete genus leptospira
- Incubation period 5-14 days(2-30days)
- Clinical presentation
- Anicteric Leptospirosis ?????????
- icteric Leptospirosis or Weils disease
??????????? ????? ??????ARDS - Septicemic phase ??? 1 weeks
- Immune-mediated phase
- fever(biphasic), headache, myalgias aseptis
menigitis - conjuctival suffusion without purulent
discharge, - uveitis, muscle tenderness ,purpuric rash
,LN enlarge
18- Diagnosis test
- 1. ???????????????antigen?????????????
????????darkfield ?????,sens ??? - 2.Serologic diagnosis
- ??????????? Microscopic agglutination
test(MAT) - titer 1400 or 4 fold rising (???????
7 ???) - 3. PCR ?????research lab
- Treatment
- ????????????????. Penicillin iv(25,000-50,000
u/kg/day) - Mild disease doxycycline 2-4 mg/kg/day x7
days
19Rickettsiae
- 1.Spotted fever group Rocky mountain(R.ricketsii)
, Mediterranean(R. conorii) - 2. Typhus group epidermic typhus (R.prowazekii),
murine typhus (R. typhi), scrub typhus (O.
tsutsugamushi) - 3. Ehrlichioses group (Ehrilichi species)
- 4. Q fever (Coxiella burnetii)
20Scrub Typhus
- Orientia tsutsugamushi(Small, gram ve
coccobacilli) - Obligate intracellular pathogen
- Arthropod vectors mite ,Chigger ??????,??????
- ?????????????? ?????????????????????????
- Reservior Rodent
21- Clinical presentation
- ???????????? 6-21 ?????????????
- ?????????? intermittent fever, headache,
myalgias - conjunctiva injection, LN
enlarge, enlarge - liver/spleen , eschar
- ????????????? intermittent fever, respiratory
tract symptom - (pneumonia, ARDS) ,CNS
(Aseptic meningitis - meningoencephalitis),
hepatitis - (systemic capillary and small vessel
endothelial damage)
22Murine typhus
- ??????? R. typhi
- Vector Fleas
- Reservior Rodent, opossum
- Incubation period 1-2 wks
- Clinical fever,headache,MP rash,myalgia
- ??????????????????
- ?????eschar ,???????????
23Lab Diagnosis
-
- 1.???????????????????
- - Culture ??????? ????????????cell,??????
Dx - - PCR ?????????????
- 2. Serology
- ??????????? Indirect immunofluorescence
antibody(IFA) - single serum --IFA IgM and/or IFA IgG
titer 400 - Paired serum -- 4 fold rising and titer???
2???? 1200 - Weil-Felix test ??????????? ?????????
sens/spec ???
24- Treatment
- - Doxycycline 2.2 mg/kg/dose x 2 dose
- then 2.2 mg/kg/day, BID
- ?????????? 2-4 ??? ???????????? 5-7 ???
- - ?????????????????????? chloramphenicol
50-100 - mg/kg/day
- ????????????????????????????????????
Doxycycline
25Melliodosis
- Burkhoderia pseudomallei
- Gram ve bacilli,bipolar staining(safety pin)
- ????????? ??? ????????????????
- ???????????? ?????????????????????????????????????
?? ???? DM,?????
26Clinical presentation
- 1.??????????????????????????????????(Disseminated
septicemic) ????????????????????????????? - ??????????????????2-3 ??? shock
???????????????? - 2. ?????????????????????????????????????(non-disse
minated - septicemic) ?????involvement 1-2 organ
- 3. ????????????????(Localized melioidosis)
parotitis ?????????? - ???????????????? ?????????????????? ??? ????
skin/soft tissue, - LN,CNS
- 4. ?????????????? ??????Ab ???????? B.
pseudomallei
27- Diagnosis test
- 1.Culture ,gram stain
- 2. serology ????????????active/convalescence/subc
linical - infection
- Treatment
- Ceftazidime 120 mg/kg/day iv 10-14 days
????????????????????????????? (?????????? 8
days) - then maintainance???? Bactrimdoxy ??? 8-20wks
- ID
28Infectious Mononucleosis
- Etiology Epstein-Barr virus (EBV)
- Herpesvirus 4
- incubation period 30-50 days
29- CLINICAL MANIFESTATIONS
- Typical fever, exudative pharyngitis,
lymphadenopathy, hepatosplenomegaly, - atypical lymphocytosis.
- Central nervous system (CNS) complications
- (eg. aseptic meningitis, encephalitis,
myelitis, optic neuritis, CN palsies, transverse
myelitis, and Guillain-Barré syndrome) - Hematologic complications
- (eg. splenic rupture, thrombocytopenia,
agranulocytosis, hemolytic anemia, and
hemophagocytic syndrome)
30Diagnosis test
- PCR serum ,tissue
- in immunocompromised ,complex clinical
- Heterophil Ab (non-specific IgM)
- Atypical lymphocyte
- VCA-IgG and VCA-IgM
- -earlier than the heterophile antibody and
more specific
31- Diagnosis test
- Serologic testing
32- Treatment
- Supportive Tx not given ampicillin/amoxycillin
- Steroid prednisolone 1 mg/kg/day,max
- 20mg/day x7 day then
tapering) - - Marked tonsillar inflammation with impending
airway obstruction - - Massive splenomegaly,myocarditis, hemolysis
anemia, - hemophagocytic syndrome
- cytotoxic,immunomodulator Life-threatening
hemophagocytic syndrome
33Salmonella infection
- Family Enterobacteriaceae
- Salmonella enterica serovar
- 3 antigens
- H antigen (flagellar antigen)
- O antigen (somatic antigen)
- Vi antigen (virulence or capsule antigen)
- S. ser Typhi, S. ser Dublin, S. ser Paratyphi C
34Salmonella
- Genus Salmonella
- 2 species enterica bongori
- 6 subspecies enterica salamae
- arizonae diarizonae
- houtenae indica
- 1400 serotype typhi enteritidis
35S. enterica subsp. enterica serotype Typhi
Salmonella Typhi
S. Typhi
36serogroup
- A S. Paratyphi A
- B S. Typhimurium
- S. Paratyphi B
- C S. Choleraesuis
- D S. Typhi
- S. Enteritidis
37Susceptibilities to Salmonella infection
38Clinical presentation
- Acute asymptomatic infection
- Acute gastroenteritis
- Bacteremia with/without metastatic focal
infection - Enteric fever
- Asymptomatic chronic carrier stage
39Treatment
- Gastroenteritis
- Infants lt3 months
- Chronic GI tract disease
- Malignant neoplasm
- Hemoglobinopathies
- HIV infection
- Immunosuppressive illnesses or therapies
- Amoxicillin, bactrim, ceftri/cefo, quinolone x
5-7 days
40Treatment
- Localized invasive disease
- Osteomyelitis, abscess, meningitis, Bacteremia in
HIV infected child - Cefotaxime / Ceftriaxone
- At least 4 weeks (meningitis 6 weeks)
- Invasive, nonfocal infection
- Bacteremia, enteric fever
- 10-14 days
- Chronic carriage
- Children high dose IVampicillin or oral amoxy
probenecid - Adult ciprofloxacin
41Febrile neutropenia
42definition
- Oral temp 38.3 C ????????? 1 ????? ???? 38.0 C
??????? 1 ??????? - Neutropenia
- Neutrophil 500 ???? lt 1000 ????????????????????
500
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50HIV infection
51Prevention of mother to child transmission of HIV
(PMTCT)
GA 28 wk AZT 250-300 mg bid
In labor AZT 300 mg q 3 hr NVP 200 mg stat
Postpartum AZT 100 mg 2 tab q 12 hr x 7 days
3TC 150 mg 1 tab q 12
hr x 7 days
52newborn
- NVP 2 mg/kg single dose
- within 48
hrs - AZT 2 mg/kg/dose q 6 hr
- x 1 wk ?????????????????? 4
wks - x 6 wk ??????????????????? 4
wks
53Diagnosis
54Infancy period
- Bactrim prophylaxis
- Vaccine
55Immunocompromised patient
- Killed vaccine, toxoid OK
- Live attenuated vaccine
- HIV
- BCG ???????????????????????????
- Varicella ???????? CDC class C ???? 3
- MMR ???????? CDC class C ???? 3
- Immunosuppressive drug
- ?????????????????? 3 ?????
- corticosteroid
56Clinical categories for children lt13 yrs
- Category N Not Symptomatic
- Category A Mildly Symtomatic
- Category B Moderately symptomatic
- Category C Severely Symptomatic
A
C
Immunologic categories
57Category A (? 2 ???)
- Parotitis
- Recurrent/persistent URI,sinusitis, OM
- Lymphadenopathy(?0.5cm, 2 sites)
- Hepatomegaly
- Splenomegaly
- Dermatitis
58Category C
- Serious bacterial infection (multiple/recur)
- Candidiasis,esophagus or pulmo(bronchi?)
- Coccidioidomycosis
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis or isosporiasis with diarrhea
gt1 mo - CMV (onset after 1 mo of age)
- Encephalopathy
- HSV mucocutaneous ??? gt1 mo, bronchitis,
pneumonitis,esophagitis in age gt1 mo - Histoplasmosis, disseminated
- Kaposi sarcoma
- Lymphoma, primary, in brain
- Lymphoma,small,noncleaved(Burkitt),immunoblastic,l
arge cell lymphoma of B cell - TB disseminated or extrapulmonary
- NTM disseminated
- PCP
- Progressive multifocal leukoencephalopathy
- Salmonella(nontyphoid) septicemia, recurrent
- Toxoplasmosis of the brain(onset after 1 mo)
- Wasting syndrome(wt.loss gt10, W/A ? ? 2
percentile lines,W/H lt5percentile ??? 2
????????? 1 ????? PLUS chronic diarrhea or fever
gt30days)
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61Appropriate Opportunistic Infection Prophylaxis
- Primary
- gtgtPCP CD4 lt 15 or C --gt TMP/SMX, Dapsone
- gtgtTB Contact with normal CXR--gt INH
- gtgtMAC gt 6 yo lt 50, 2-6 yo lt 75
- 1-2 yo lt 500, lt 1 yo lt750 --gt
Azithro, -
Clarithro - Secondary (Prevent recurrence)
- gtgtPCP gtgtMAC
- gtgtCryptococcosis
gtgtToxoplasmosis - gtgtPenicillosis gtgtCMV
62Parasitic diarrhea in immunocompromised host
63- Dysentery
- Entamoeba histolytica
- Balantidium coli
- Trichuris trichiura
- Watery diarrhea
- Giardia lamblia
- Blastocystis hominis
- Cryptosporidium spp
- Isospora belli
- Cyclospora cayetanensis
- Microsporidia
- Stronggyloides stercoralis
- Capillaria philippinensis
64- Entamoeba histolytica
- Cryptosporidium spp
- Isospora belli
- Cyclospora cayetanensis
- Microsporidium spp.
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68Infective Endocarditis
- Clinical presentation
- generally is indolent
- prolonged low-grade fever
- variety of somatic complaints( fatigue, weakness,
arthralgias, myalgias, weight loss, rigors, and
diaphoresis) - requires careful evaluation for IE in the patient
with underlying heart disease.
69- Most organisms Gram-positive cocci
- viridans streptococci (eg, Streptococcus
sanguis, S mitis group, S mutans, etc),
staphylococci and enterococci - Beyond the first year of life
- viridans group streptococci are the most
frequently isolated organisms - S. aureus is the second most common
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73Treatment
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76Arboviruses
- Arthropodborne viruses (mosquito, tick,
sandflies) - 4 clinical syndrome
- CNS infection
- Undifferentiated febrile illness, rash
- Acute polyarthropathy
- Acute hemorrhagic fever
77Taxonomy of major Arboviruses
- Bunyaviridae
- Togaviridae
- Chikungunya virus
- Flaviviridae
- Japanese encephalitis virus
- Dengue viruses
- Yellow fever virus
- West Nile virus
- Reoviridae
- Rhabdoviridae
78Entamoeba histolytica
- Tissue
- Metronidazole 35-50 MKD tid PO/IVx 7-10 day
- Tinidazole
- Paromomycin
- Intestine
- Diloxanide furoate 20 MKD tid x 10 days
- Iodoquinol
- paromomycin
79Cryptosporidium
- Paromomycin
- 25-35 mg/kg/day tid x 2 weeks
- Nitazoxanide
- 8 mg/kg/dose bid x 3 days
80Isospora spp
- Bactrim
- TMP 4 mg/kg, SMX 20 mg/kg qid x 10 days
- Sulfadoxine pyrimethamine
81Cyclospora
- Bactrim
- TMP 4 mg/kg, SMX 20 mg/kg qid x 10 days
- Normal host bactrim bid x 7 days
82Microsporidium
- Enterocytozoon bieneusi
- Encephalitozoon intestinalis
- Albendazole 7.5 MKDose tid x 2 wks