RED BOOK 2006

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RED BOOK 2006
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Japanese Encephalitis

• Japanese encephalitis virus
• Flavivirus
• Culex tritaeniorhynchus
• Amplifier host pig

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Clinical manifestation

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

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Clinical manifestation

• 3 stages
• Prodromal stage
• Acute encephalitis stage
• Late stage and sequelae

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Lab investigation

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

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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

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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)

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Acute Secondary Dengue Infection
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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

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Treatment and prevention

• Supportive and symptomatic Px
• Vaccine
• Mouse brain-derived inactivated vaccine
• Cell culture-derived, inactivated vaccine
• Cell culture-derived, live attenuated vaccine

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Viruses

• DNA viruses ??????????????? Double stranded
• ?????? Parvoviridae ???? Single strand
• RNA viruses ??????????????? Single stranded DNA
• ?????? Reoviridae ???? Double strand
• (families - viridae)

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DNA viruses

• Adenoviridae adenovirus
• Hepadnaviridae Hepatitis B
• Papovaviridae Papillomavirus,
• Polyomaviruses

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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

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DNA viruses (cont.)

• Parvoviridae Parvovirus B19
• Poxviridae Molluscum contagiosum

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RNA viruses

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

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RNA viruses (cont.)

• Flaviviridae Dengue, JE, Yellow fever,
• West Nile, Hep C, Hep
  G
• Togaviridae Rubella, Chikungunya
• Reoviridae Rotaviruses
• Retroviridae HIV
• Rhabdoviridae Rabies

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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

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• 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

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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)

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Scrub Typhus

• Orientia tsutsugamushi(Small, gram ve
  coccobacilli)
• Obligate intracellular pathogen
• Arthropod vectors mite ,Chigger ??????,??????
• ?????????????? ?????????????????????????
• Reservior Rodent

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• 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)

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Murine typhus

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

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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 ???

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• 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

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Melliodosis

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

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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

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• 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

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Infectious Mononucleosis

• Etiology Epstein-Barr virus (EBV)
• Herpesvirus 4
• incubation period 30-50 days

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• 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)

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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

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• Diagnosis test
• Serologic testing

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• 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

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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

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Salmonella

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

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S. enterica subsp. enterica serotype Typhi
Salmonella Typhi
S. Typhi
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serogroup

• A S. Paratyphi A
• B S. Typhimurium
• S. Paratyphi B
• C S. Choleraesuis
• D S. Typhi
• S. Enteritidis

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Susceptibilities to Salmonella infection
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Clinical presentation

• Acute asymptomatic infection
• Acute gastroenteritis
• Bacteremia with/without metastatic focal
  infection
• Enteric fever
• Asymptomatic chronic carrier stage

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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

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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

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Febrile neutropenia
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definition

• Oral temp 38.3 C ????????? 1 ????? ???? 38.0 C
  ??????? 1 ???????
• Neutropenia
• Neutrophil 500 ???? lt 1000 ????????????????????
  500

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HIV infection
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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
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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

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Diagnosis

• HIV serology
• PCR

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Infancy period

• Bactrim prophylaxis
• Vaccine

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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

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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
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Category A (? 2 ???)

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

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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

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Parasitic diarrhea in immunocompromised host
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• Dysentery
• Entamoeba histolytica
• Balantidium coli
• Trichuris trichiura
• Watery diarrhea
• Giardia lamblia
• Blastocystis hominis
• Cryptosporidium spp
• Isospora belli
• Cyclospora cayetanensis
• Microsporidia
• Stronggyloides stercoralis
• Capillaria philippinensis

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• 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.

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• 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

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Taxonomy of major Arboviruses

• Bunyaviridae
• Togaviridae
• Chikungunya virus
• Flaviviridae
• Japanese encephalitis virus
• Dengue viruses
• Yellow fever virus
• West Nile virus
• Reoviridae
• Rhabdoviridae

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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

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Cryptosporidium

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

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Isospora spp

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

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Cyclospora

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

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Microsporidium

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