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RED BOOK 2006

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RED BOOK 2006 Japanese Encephalitis Japanese encephalitis virus Flavivirus Culex tritaeniorhynchus Amplifier host : pig Clinical manifestation Incubation period 1-2 ... – PowerPoint PPT presentation

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Title: RED BOOK 2006


1
RED BOOK 2006
2
Japanese Encephalitis
  • Japanese encephalitis virus
  • Flavivirus
  • Culex tritaeniorhynchus
  • Amplifier host pig

3
Clinical manifestation
  • Incubation period 1-2 weeks
  • Age 6-14 years
  • Asymptomatic
  • Acute encephalitis, Acute meningoencephalitis,
    Aseptic meningitis

4
Clinical manifestation
  • 3 stages
  • Prodromal stage
  • Acute encephalitis stage
  • Late stage and sequelae

5
Lab investigation
  • CBC wbc ?? neutrophil ??
  • CSF pressure ?
  • wbc 200 (3-4,200) lymp ?
  • slightly ? prot level
  • sugar ?

6
Lab (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

7
HAI
  • 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)

8
Acute Secondary Dengue Infection
9
EIA
  • 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

10
Treatment 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

13
DNA 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

14
DNA viruses (cont.)
  • Parvoviridae Parvovirus B19
  • Poxviridae Molluscum contagiosum

15
RNA viruses
  • Coronaviridae Human coronaviruses
  • Paramyxoviridae Parainfluenza,
  • Mumps, Measles , RSV
  • Orthomyxoviridae Influenza
  • Piconaviridae Enteroviruses
  • (Polio, coxsakievirus, echoviruses,
  • enterovirus, Hep A)

16
RNA viruses (cont.)
  • Flaviviridae Dengue, JE, Yellow fever,
  • West Nile, Hep C, Hep
    G
  • Togaviridae Rubella, Chikungunya
  • Reoviridae Rotaviruses
  • Retroviridae HIV
  • Rhabdoviridae Rabies

17
Leptospirosis
  • 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

19
Rickettsiae
  • 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)

20
Scrub 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)

22
Murine typhus
  • ??????? R. typhi
  • Vector Fleas
  • Reservior Rodent, opossum
  • Incubation period 1-2 wks
  • Clinical fever,headache,MP rash,myalgia
  • ??????????????????
  • ?????eschar ,???????????

23
Lab 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

25
Melliodosis
  • Burkhoderia pseudomallei
  • Gram ve bacilli,bipolar staining(safety pin)
  • ????????? ??? ????????????????
  • ???????????? ?????????????????????????????????????
    ?? ???? DM,?????

26
Clinical 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

28
Infectious 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)

30
Diagnosis 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

33
Salmonella 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

34
Salmonella
  • Genus Salmonella
  • 2 species enterica bongori
  • 6 subspecies enterica salamae
  • arizonae diarizonae
  • houtenae indica
  • 1400 serotype typhi enteritidis

35
S. enterica subsp. enterica serotype Typhi
Salmonella Typhi
S. Typhi
36
serogroup
  • A S. Paratyphi A
  • B S. Typhimurium
  • S. Paratyphi B
  • C S. Choleraesuis
  • D S. Typhi
  • S. Enteritidis

37
Susceptibilities to Salmonella infection
38
Clinical presentation
  • Acute asymptomatic infection
  • Acute gastroenteritis
  • Bacteremia with/without metastatic focal
    infection
  • Enteric fever
  • Asymptomatic chronic carrier stage

39
Treatment
  • 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

40
Treatment
  • 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

41
Febrile neutropenia
42
definition
  • Oral temp 38.3 C ????????? 1 ????? ???? 38.0 C
    ??????? 1 ???????
  • Neutropenia
  • Neutrophil 500 ???? lt 1000 ????????????????????
    500

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HIV infection
51
Prevention 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
52
newborn
  • 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

53
Diagnosis
  • HIV serology
  • PCR

54
Infancy period
  • Bactrim prophylaxis
  • Vaccine

55
Immunocompromised patient
  • Killed vaccine, toxoid OK
  • Live attenuated vaccine
  • HIV
  • BCG ???????????????????????????
  • Varicella ???????? CDC class C ???? 3
  • MMR ???????? CDC class C ???? 3
  • Immunosuppressive drug
  • ?????????????????? 3 ?????
  • corticosteroid

56
Clinical 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
57
Category A (? 2 ???)
  • Parotitis
  • Recurrent/persistent URI,sinusitis, OM
  • Lymphadenopathy(?0.5cm, 2 sites)
  • Hepatomegaly
  • Splenomegaly
  • Dermatitis

58
Category 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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Appropriate 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

62
Parasitic 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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Infective 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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Treatment
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Arboviruses
  • Arthropodborne viruses (mosquito, tick,
    sandflies)
  • 4 clinical syndrome
  • CNS infection
  • Undifferentiated febrile illness, rash
  • Acute polyarthropathy
  • Acute hemorrhagic fever

77
Taxonomy of major Arboviruses
  • Bunyaviridae
  • Togaviridae
  • Chikungunya virus
  • Flaviviridae
  • Japanese encephalitis virus
  • Dengue viruses
  • Yellow fever virus
  • West Nile virus
  • Reoviridae
  • Rhabdoviridae

78
Entamoeba 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

79
Cryptosporidium
  • Paromomycin
  • 25-35 mg/kg/day tid x 2 weeks
  • Nitazoxanide
  • 8 mg/kg/dose bid x 3 days

80
Isospora spp
  • Bactrim
  • TMP 4 mg/kg, SMX 20 mg/kg qid x 10 days
  • Sulfadoxine pyrimethamine

81
Cyclospora
  • Bactrim
  • TMP 4 mg/kg, SMX 20 mg/kg qid x 10 days
  • Normal host bactrim bid x 7 days

82
Microsporidium
  • Enterocytozoon bieneusi
  • Encephalitozoon intestinalis
  • Albendazole 7.5 MKDose tid x 2 wks
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