Infectious Disease

1
Infectious Disease

• Debbie King FNP
• Nursing 8800

2
Influenza

• Epidemics occur yearly in the US
• Typically 5000-250,000 cases yearly
• With severe outbreaks up to 40,000 deaths have
  occurred.
• More elderly die
• Occurs in winter and spring

3
Influenza

• Patho
• Classic flu is caused by orthomyxovirus influenza
  type A and to lesser extent, influenza type B
• Worse than a cold, can lead to further infection
• May develop into viral pneumonia
• May develop further into a bacterial
  super-infection, esp. with Staph Aureus
• Is important to give/get flu shots yearly
• New vaccine is developed each year due to
  mutations of the major surface proteins-
  hemagglutinin and neuraminidase-rendering protein

4
Influenza

• Presentation
• Abrupt, with fever, chills malaise, myalgia,
  headache, nasal stuffiness, sore throat, and
  maybe nausea.
• Early on there is a nonproductive cough
• Fever is high lasting 3-5 days

5
Influenza

• Diagnostic testing
• presumptive diagnosis requires appropriate
  symptoms at the right time of the year
• may confirm with virology - a nasal swab
  culture

6
Influenza

• Differentials
• Lyme disease
• Atypical mycoplasma pneumonia
• Mono
• Allergic rhinitis
• Cytomegalovirus

7
Influenza

• Management
• Symptomatic care
• Prevention of secondary infection
• rest, older people may need hospitalization,
  antipyretics, and analgesics, careful use of
  cough suppressants
• with type A may use antivirals such as Tamiflu
  75mg bid x 5 days if started early in the illness

8
Influenza

• Education
• The very young and the elderly or immune
  compromised should avoid crowds
• Get the vaccine
• To call or be seen with increased or severe
  symptoms
• Stay home when you are ill
• Except to see your NP

9
Influenza

• Follow up
• Depends on the complications that occur
• To be seen again if any of the following occur
• Sinusitis, OM, bronchitis, pneumonia
• Or if fever persists more than 4 or 5 days
• Order CBC on follow up if pneumonia is suspected

10
Lyme Disease

• Multisystem inflammatory disease of infectious
  etiology
• Caused by a spirochete called Borrelia
  Burgdorferi
• Is named for a town Old Lyme in Connecticut where
  it was isolated in the 1970s
• Found in the eastern US in wooded areas
• Is a tic borne disease

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Lyme Disease

• Epidemiology and Causes
• Unknown actual number of cases
• Exaggerated number of cases
• Over diagnosed and reported
• Affects all demographics
• Multiple strains
• B. burgdorferi in the US
• B. afzelii and B. garinii in Europe and Asia
• The different strains cause different symptoms
• More arthritis and erythema migrans in the US

12
Lyme Disease

• Patho
• Infection connected to the length of time of tick
  exposure
• Tick must feed for 24 to 48 hours to pass the
  spirochete
• Usually from the Ixodes scapularis tick which
  feed on mice, birds, ECT
• Is spread more in the summer when the ticks are
  in the nymphs stage
• Half the ticks in the eastern and mid-western US
  may be infected

13
Lyme Disease

• Patho
• Causative organisms are capable of producing
  systemic tissue injury, with a low microbial load
• At initiation it is believed that the spirochetes
  bind fibronectin and epithelial cell-derived
  proteoglycans in the extracellular matrix
• This causes cutaneous erythema at sites of
  invasion and centrifugal spread from the original
  site

14
Lyme Disease

• Subjective
• Early- flu like illness with fever, chills,
  myalgia. May have a rash or red spot
• Later-comes malaise, fatigue, headache, neck pain
  and stiffness, and generalized pains.
• Untreated even later- progresses to multiple
  joint arthritis
• Late disease- memory loss, cognitive
  disturbances, mood changes, peripheral neuropathy
  plus arthritis

15
Lyme Disease

• Objective
• Early-localized disease, days to 1 month after
  exposure
• Erythema migrans rashes in 90
• Cervical stiffness
• Lymphadenopathy
• Fever

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Lyme Disease

• Differentials
• Rocky Mountain spotted fever
• Viral syndromes
• Influenza
• Chronic Fatigue Syndrome- CFS
• Fibromyalgia Syndrome- FMS

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Lyme Disease

• Early-disseminated disease, occurs days to 10
  months after bite
• Systemic manifestations
• Carditis
• Neurologic manifestations
• Lymphocytic meningitis
• Cranial nerve palsies- VIII most common
• Radiculoneuritis-inflammation of one or more
  roots of the spinal nerves
• With all three of the above, the triad is called
  Bannwarth syndrome, but is more common in Europe

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Lyme Disease

• Late disease- months to years after bite
• Intermittent arthritis- 50
• These patients respond to antibiotic TX
• Arthralgias- 20, 10 of which have monoarthritis
  of the knee
• Tertiary neuroborreliosis
• Encephalopathy, neurocognitive impairment, and
  peripheral neuropathy
• Cutaneous manifestations
• Solitary lymphocyte, usually just in Europe

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Lyme Disease

• Diagnostic Tests
• Cultures of skin lesion- 50 accurate
• Serologic studies- often negative with early
  localized disease
• ELISA tests against Borrelia
• Western blot- has lower sensitivity but more
  specificity
• Measure these test results against CDC standards,
  not the labs standards
• Best to send to a lab or medical center doing
  research on Lyme disease
• Histologic and immunologic staining- low yield in
  diagnostic testing
• IgM and IgG are usually positive by 6-8 weeks
• Early antibiotic treatment may be lead to
  negative results, or may be positive after
  treatment and resolution of the disease

20
Lyme Disease

• Diagnostic testing
• Results of test may be impacted if the patient
  had the LYMErix vaccine (no longer given)
• Borrelia-specific antibody levels- from synovial
  fluid or CSF
• Do not diagnose based on labs alone
• Do not use the test as screening tools, but
  instead only to confirm
• False positives are very common
• Diagnosis based on clear clinical findings
• FYI- new experimental tests being studied

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Lyme Disease

• Management
• Goal is to stop manifestations and prevent
  progression
• 90 of early localized disease responds to
  antibiotic TX
• Early disease treat for 10-14 days
• For more advanced treat for 30 days
• Antibiotics preferred
• Doxycycline 100 mg bid for adults (sun issues)
• Doxycycline 2mg/kg for children over 8 years
• Amoxil, Ceftin , EES, (rashes)
• Patients may develop symptoms of rigors, fever or
  hypotension in first 24 hours of antibiotic
  treatment

22
Lyme Disease

• Management
• For cases with neurologic sequelae may use
  Rocephin IV or Claforan IV for 4 weeks
• May be done on outpatient basis
• Monitor CBC weekly for leukopenia
• Monitor hepatic levels also weekly with Rocephin
• Some symptoms such as HA, fatigue and malaise may
  persist after treatment
• New or increases symptoms warrant more workup

23
Lyme Disease

• Education
• Avoid foliage- esp. ankle level
• Walk in center of paths
• Long sleeves and pants
• Socks and/or boots over the pants
• Button up shirt collars
• Tick repellant
• Inspections of body daily
• Advise on the course of the disease

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Lyme Disease

• Follow up and referral
• Weekly visits may be needed to make the diagnosis
• During treatment visits will vary, with IV
  treatment at least weekly phone calls to discuss
  lab results
• Symptoms may occur for years and need follow up
  on an as needed basis

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Human Immunodeficiency Virus Infection and AIDS

• Will be covered on April 16th this semester by
  an NP working in this field
• This is a required attendance lecture
• The time will be 2-5pm
• There are several questions on the boards
  specific to HIV and AIDS

26
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• CFS is poorly understood
• There is lack of agreement as to its cause, to
  the correct lab markers, and its clinical course
• CFS has an overlap with fibromyalgia- also poorly
  understood
• 70 of patients with FMS meet criteria of CFS
• The majority of patients with CFS meet criteria
  for FMS
• 30 of FMS patients meet criteria for depression,
  dysthymia or anxiety disorders
• Many criticize the history and PE exam-
  diagnostic criteria for both

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Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Epidemiology and Causes
• CFS does not have an accepted working definition
  and is impossible to ascertain its epidemiology
• Chronic fatigue complaints represent up to 25 of
  patient visits
• About 10 of these meet diagnostic criteria
• It is thought it affects women 2x more than men
• Hypothesized to autoimmune and infections
• Is a Diagnosis of exclusion

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Chronic Fatigue Syndrome Fibromyalgia Syndrome

• FMS has more info published
• Prevalence is 0.5 of men and 3.4 of women
• Prevalence for women ages 60-79 is more than 7
• 11 million people in the US have FMS with 80 90
  being women
• Up to 20 of all rheumatology practice visits are
  for FMS
• Is now considered the most common cause of
  generalized musculoskeletal pain in women aged
  20- 55 years old
• Some studies show up to 50 of patients with FMS
  have a history of sexual or violent abuse

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Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Patho is still unclear
• Hypothesized that both syndromes may be disorders
  of muscle energy metabolism, inflammatory or
  immunopathologic diseases of muscle
• No studies have confirmed etiologies
• There is debate whether CFS and FMS overlap with
  depression and anxiety or one leads to the other

30
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Patho- studies underway
• Exploring potential infectious etiology
• Epstein-Barr, retroviruses, human herpesvirus
• Looking at differences in immune function
• Reduced numbers of natural killer cells with
  depressed function, reduced levels of If
  molecules and immune complexes, and increased
  numbers of cell surface adhesion molecules, ECT
• Studies are looking at neuroendocrine differences
  between affected patients and controls
• Others are studying adrenocorticotropin hormone
  (ACTH) and reduced serum cortisol levels

31
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Patho studies
• May be related to chronic hypoxia of muscular
  tissue
• Most current thoughts are FMS patients suffer a
  disproportionate perceptions to pain, exacerbated
  by muscle inactivity and deconditioning
• First degree relatives of patients with FMS have
  been found to have lower thresholds to pain

32
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Patho
• It is known that in FMS patients there is an
  alteration of sleep and mood, decreased blood
  flow to pain centers in the brain, and
  alterations in serotonin secretions and
  alterations in the pituitary hypothalamic-
  adrenal neuroendocrine axis. It is also known
  that autonomic dysregulation of heart rate and
  systemic blood pressure occurs with tilt test in
  these patients. It is also known that there is
  not an inflammatory component, which is why
  NSAIDs and steroids do not help these patients

33
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Subjective
• Report- post exercise malaise, fatigue,
  multiple-joint pain, headaches, impaired memory,
  mood, concentration and cognitive disturbances,
  sore throat, restless, disordered sleep, and
  myalgias
• Report- have often seen other providers in the
  past with the same SX ( were blown off by other
  providers)

34
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Objective
• Tends to target once active, highly functional
  adults so the exam is most often normal
• Onset of CFS may be preceded by
  mononucleosis-like illness or by GI symptoms
• FMS may have the same history
• Patients appear tired, pale, may or may not have
  memory deficits on the MMSE (Mini-Mental state
  exam). May or may not have enlarged lymph nodes
• Positive trigger points of 11 out of 18 for FMS

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Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Diagnostic criteria for fibromyalgia
• Widespread pain
• Right and left side of body
• Above and below the waist
• Some axial skeletal pain
• Digital palpation of trigger points with at least
  4kg of pressure causes pain
• Tender is not painful
• If painful it is a positive point
• Positive exam when 11 out of 18 points induce
  pain with palpation

36
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Trigger Point locations to test- bilaterally
• Occiput
• Low cervical
• Trapezius
• Supraspinatus
• Second rib
• Lateral epicondyle
• Gluteal
• Greater trochanter
• Knee

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Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Differentials
• Lupus
• Rheumatoid arthritis
• Endocrinologic disorders
• Thyroid diseases
• Infectious diseases
• Lyme disease, flu
• Psychotic illness
• Irritable bowel
• Cancer
• Parkinsonism
• Sjögren's with anhydrosis (inability to sweat)

38
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Diagnostic criteria for CFS
• Fatigue persists or relapses for 6 months
• Plus -four of the following
• Concurrent symptoms of impaired memory or
  concentration, sore throat, tender cervical or
  axillary lymph nodes, muscle pain, multiple-joint
  pain, new headaches, restless sleep, and post
  exertion malaise

39
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• CDCs criteria for CFS
• Persistent or relapsing fatigue clinically
  evaluated with out explanation and at least four
  of the following self reported symptoms
• Impaired concentration/short-term memory, sore
  throat, tender cervical/axillary nodes, muscle
  pain, arthralgias without redness or swelling,
  poor sleep, new onset headache or headache of a
  new or worsening pattern, and malaise following
  activity and that lasts at least 24 hours.
• If patients do not fit these criteria they are
  diagnosed with idiopathic chronic fatigue

40
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Diagnostic tests
• Test for all the reasonable differentials to rule
  them out
• Do not use CT or MRI unless there are physical
  findings to support the testing
• Do not order virus specific test unless the
  history or PE supports the possibility
• Do not test for Lyme disease unless the history
  confirms the need, this is often a false result
• ANA is often misleading, it can be positive but
  without other Lupus tests being positive, it is
  not Lupus, the patient may be labeled as such
  anyway
• Specifically for FMS screen the muscle enzymes
• Creatine kinase and aldolase

41
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Management is controversial
• Goal of management is to enable the patient to
  have the best quality of life possible, within
  the limitations of the chronic disability related
  to pain
• Two therapies help with symptoms but are not a
  cure
• Cognitive behavioral therapy
• Changes beliefs, and behaviors that are barriers
  to recovery
• Graded exercise
• Do not encourage more bed rest
• Encourage low impact aerobic exercise

42
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• A supportive approach to the patient-clinician
  relationship is critical
• Reinforces the diagnosis, if the criteria are
  met, and thus avoids the debate if its
  psychologic or organic
• Pharmacotherapies- inconsistent success
• Reminyl
• IVIG
• Acyclovir
• SSRIs- esp. Celexa, Prozac, Paxil
• Corticosteroids may have some benefit for some
• Chiropractic and massage therapies help some
• Ultraviolet light helps some patients
• Vitamin therapy helps some patients

43
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• For FMS
• Tylenol 650 mg qid and Ultram 75 mg qid as a
  combo TX
• Elavil 75 mg daily in divided doses works for
  about 3 months
• Flexeril starting at 5 mg up to 10mg helps for
  about 3 months
• Most promising is Cymbalta at 40-60mg qd
• Klonopin at 0.5 mg q.h.s. may be helpful

44
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Education
• Instruction of coping methods
• Disease process
• Chronicity
• Remind them its not fatal
• Explain that stress can worsen symptoms

45
Chronic Fatigue Syndrome Fibromyalgia Syndrome

• Follow up
• Based on symptoms
• Patients usually know when they need to be seen
• May need referral to a rheumatologists initially
  to confirm diagnosis
• Psychiatric referral may be warrant in some
  patients

46
TB

• TB
• Testing
• Tuberculin skin test remains the standard test
  for determining infection with Mycobacteria
  tuberculosis, but does not distinguish between
  active and latent infection
• Who to test
• Patient with signs and symptoms, known contact,
  high risk, people suspected to have, abnormal
  chest x-ray, medical conditions that increase
  risk, pt with HIV, immigrant, medically
  underserved, high-risk minority, resident or
  employee in a prison or long term care facility,
  employee on a health care facility

47
TB

• Interpretation of TB skin testing
• Greater than 5 mm is positive for the following
• People with HIV, or risk factors for HIV
• People recently exposed to active TB
• Persons with organ transplants
• Persons with chest film indicating healed TB

48
TB

• Greater than 10 mm
• Recent arrivals (less than 5 years)
• Foreign born from Africa, Asia, Latin America
• Medically underserved low income population and
  high risk racial ethnic minority populations
• IV drug users
• Residents and employees of high risk congregate
  setting
• Mycobacteriology lab personnel
• Persons with medical conditions known to increase
  risk of TB

49
TB

• Greater than 15 mm
• Everyone else

50
Antibiotic Resistance A Mandate for Change
CME/CE Arjun Srinivasan, MD Posted
12/17/2010

• There is an urgent need to improve antibiotic use
  and it is driven by 4 key truths. The first is
  that antibiotics are misused. The second is that
  antibiotic misuse every day adversely affects
  patients and society. Third, improving antibiotic
  use improves patient outcomes and saves money at
  the same time. And finally, improving antibiotic
  use is a true public health imperative.

51
CDC- on inappropriate antibiotic use

• CDC Here are 4 communication strategies that
  clinicians can use to help prevent patient
  requests for an inappropriate antibiotic or to
  respond to such requests
• Provide a specific diagnosis to help patients
  feel validated. For example, say "viral
  bronchitis" instead of referring to an illness as
  "just a virus."
• Recommend symptomatic relief and share normal
  findings as you go through your examination.
• Discuss potential side effects of antibiotic use,
  including adverse effects and resistance. Many
  patients don't realize that antibiotics can be
  harmful.
• Lastly, explain to the patient or parent what to
  expect over the next few days -- including that
  you will reevaluate their situation and prescribe
  antibiotics if it becomes medically appropriate.
• More information about appropriate antibiotic use
  and tools, including a symptomatic prescription
  pad can be found on CDC's Website