common infections in tropical regionreviews.berlinpharm.com/20180303/common_infections_in... ·...

2/21/2018

1

Methee Chayakulkeeree , MD. PhD.

D i v i s i o n o f I n f e c t i o u s D i s e a s e s & T r o p i c a l M e d i c i n e

D e p a r t m e n t o f M e d i c i n e

F a c u l t y o f M e d i c i n e S i r i r a j H o s p i t a l

M a h i d o l U n i v e r s i t y

Common Infections in Tropical Region

Areas lie between the Tropic of Cancer and Tropic of Capricorn belts

Tropical Region

Warm 25-28 °C

Wet and dry season

Rainy

A 45-year-old female

Poorly controlled type 2 DM presented with a 1-week fever and right upper quadrant abdominal pain. She had a history of chronic intermittent abdominal dyscomfort for a year. CT abdomen showed multiple ring enhancing lesions at the liver and gall stones.

Needle aspiration and stain showed gram-negative rod with bipolar staining, gram-positive cocci and gram-positive bacilli.

Melioidosis titer was positive with titer 1:64. What is the diagnosis?

A. Pyogenic liver abscess

B. Melioidosis

C. Primary bacteremic liver abscess

D. Liver metastasis

E. Fasciola hepatica infestation

A 45-year-old female

Poorly controlled type 2 DM presented with a 1-week fever and right upper quadrant abdominal pain. She had a history of chronic intermittent abdominal dyscomfort for a year. CT abdomen showed multiple ring enhancing lesions at the liver and spleen with gall stones.

Needle aspiration and stain showed gram-negative rod with bipolar staining.

Melioidosis titer was negative. What is the diagnosis?

A. Pyogenic liver abscess

B. Melioidosis

C. Primary bacteremic liver abscess

D. Liver metastasis

E. Fasciola hepatica infestation

Liver Abscess

Pyogenic liver abscess – 80% Direct spread: biliary tract, portal circulation or bowel

Hematogenous seeding

Amoebic liver abscess – 10% E. histolytica

Fungal liver abscess – 10% Candida spp.

Liver Abscess

Pyogenic liver abscess Direct spread: biliary tract, portal circulation or

bowel:

Mixed organisms: E. coli, anaerobes e.g. Bacteroides fragilis, Actinomyces israelii

Hematogenous seeding: - monomicrobial

Burkholderia pseudomallei

Klebsiella pneumoniae

Viridans streptococci: S. anginosus group (S. anginosus, S. intermidius, S. constellatus)

Blood culture and abscess fluid examination

2/21/2018

2

Pus Gram Stain

Polymicrobial

Actinomyces

B. pseudomallei K. pneumoniae

S. intermediate

Pus Gram Stain

Melioidosis

Caused by a gram-negative bacterium

Burkholderia pseudomallei

Category B bioterrerism

N Eng J Med 2012;367:1035-44

Risk factors

Incubation 1-21 days (average 9 days), longest 62 yr.

75 to 81% rainy season

Incidence peaks between age 40 and 60 years

80% of patients have one or more risk factors

Diabetes (23 to 60%)

Heavy alcohol use (12 to 39%)

Chronic pulmonary disease (12 to 27%)

Chronic renal disease (10 to 27%)

Thalassemia (7%)

Glucocorticoid therapy (<5%)

Cancer (in 5%)

Clinical Classification

Disseminated septicemic melioidosis

Non-disseminated septicemic melioidosis

Multifocal localized melioidosis

Localized melioidosis

Probable melioidosis

Subclinical melioidosis

Clinical Manifestations

N Eng J Med 2012;367:1035-44

2/21/2018

3


Pneumonia (51%)

Genitourinary infection (14%)

Skin infection (13%)

Bacteremia without evident focus (11%)

Septic arthritis or osteomyelitis (4%)

Neurologic involvement (3%)

Internal-organ abscesses and secondary foci in the lungs, joints, or both - common


Acute fulminant septic illness to a chronic infection (symptoms for >2 months for 11% of cases)

May mimic cancer or tuberculosis – the great imitator

Over half of patients have bacteremia on presentation, and septic shock develops in approximately one fifth


Suppurative parotitis 40% in children in Thailand and Cambodia (extremely rare in Australia)

Prostatic melioidosis - 20% of male (in Australia)

neurologic melioidosis Brain-stem encephalitis w/wo cranial-nerve palsies (esp. CN VII)

Myelitis with peripheral motor weakness

Recurrent melioidosis occurs 1 in 16 patients, often in the first year About 25% reinfection

75% relapse

Mortality 40%

A 45 years old female, DM

A midddle-age man with diabetes

มงคล แซ่ภู,่มงคล แซ่ภู,่

Mongkol Sae-Phoo,Mongkol Sae-Phoo,

5273809752738097

Page: 20 of 37Page: 20 of 37

Siriraj Hospital Siriraj Hospital

DefinitionDefinition

ABDOMINAL CTAABDOMINAL CTA

28/9/2553 12:03:11 28/9/2553 12:03:11

THK: 7THK: 7

IM: 20IM: 20

cm

cm


Page: 8 of 40Page: 8 of 40 IM: 8IM: 8


Page: 10 of 40Page: 10 of 40 IM: 10IM: 10

A midddle-age man with diabetes

2/21/2018

4

Diagnosis

Culture is a must

Serologic testing alone is inadequate for confirming the diagnosis, especially in endemic regions (> 50% positive)

Empirical therapy for melioidosis should not be continued if B. pseudomallei is not detected in adequate cultures of specimens obtained before therapy

Molecular identification – PCR, sequencing is useful

Treatment

Initial intensive therapy (10-14 days)

Ceftazidime 50 mg/kg of body weight (up to 2 g), every 6–8 hr

Meropenem 25 mg/kg (up to 1 g), every 8 hr

Imipenem 25 mg/kg (up to 1 g), every 6 hr

Oral eradication therapy (3-6 months)

TMP-SMX - based on body weight

> 60 kg: TMP/SMX DS 2 tabs q 12 hr

40–60 kg: TMP/SMX SS 3 tabs q 12 hr

< 40 kg, adult TMP/SMX SS 2 tabs q 12 hr

< 40 kg, child 8 mg of TMP/kg and 40 mg of SMX/kg, every 12 hr

N Eng J Med 2012;367:1035-44

Treatment

≥ 4 weeks IV therapy may be necessary in patients with severe disease

The addition of TMP/SMX 8/40 mg per kg (up to 320/1600 mg) q 12 h should be considered in neurologic, prostatic, bone, or joint melioidosis

Second-line oral therapy

Amoxicillin–clavulanate or doxycycline

Amoxicillin–clavulanate 20 mg of amoxicillin and 5 mg of clavulanate per kg 3 times daily (high rate of relapse)

Community-acquired Klebsiella pneumoniae invasive infection

magA gene is associated with HMKP

Liver abscess, endophthalmitis, osteomyelitis, pneumonia, brain abscess/meningitis

(distinctive syndrome)

Bacteremia-common

Prevalent in East and Southeast Asians: Taiwan, Korea, Thailand, Singapore

Kawai T. Clin Infect Dis 2006;42:1359–61

Klebsiella pneumoniae genotype K1

Hypermucovicous Klebsiella pneumonia (HMKP): K1

String test

A 70-year-old woman

Presented with prolonged fever for 1 month

Significant weight loss

Non-productive cough

Desaturation

AntiHIV-negative

2/21/2018

5

Imagings

CXR CT Chest

Serum cryptococcal antigen-positive 1:32

A Man with Abdominal Mass

A 66-year-old man

Diagnosed normal pressure hydrocephalus (NPH) and vascular dementia for 2 years post programmable VP shunt

Chronic headache for 1 years

Chronic abdominal pain with palpable mass for 6 months

Imagings

CT abdomen CT brain Aspiration of pseudocyst Culture: Cryptococcus gattii

CSF cryptococcal antigen > 1:1024

Serum cryptococcal antigen 1:8

Progress

A 88-year-old woman

Diagnose vascular dementia for 1 year

Headache and alteration of consciousness for 2 months

Seizure

Brain tissue from autopsy Encapsulated budding yeasts

Identification of C. gattii

C. neoformans vs. C. gattii

L-canavanine glycine bromothymol blue (CGB) agar

1.pptx

1.pptx

2/21/2018

6

C. gattii Gone Wild on World Tour

Springer DJ, et al. Emerging Infectious Diseases 2016;1

C. gattii was thought to be restricted to tropical and subtropical regions, BUT not any more

C. gattii Outbreak in Vancouver Island 1999-2007

Emerg Infect Dis 2010 Feb;16(2):251-7

Characteristic Total

No. of case• Persons living on Vancouver, n(%)

218161 (73.9)

Age, year mean (range) 58.7 (2-92)

Clinical assessment, n(%)• Respiratory syndrome• CNS syndrome• Respiratory and CNS syndrome• Other/unknown• Asymptomatic

167 (76.6)17 (7.8)

22 (10.1)12 (5.5)16 (7.3)

Immunocompromised, n(%) 70 (38)

- Long incubation period: 6 (2-11) months- VGIIa 86.3 %, VGI 6.5%

Clinical Characteristics

C. neoformans C. gattii

Host (mainly in) Immunocompromised Immunocompetent

Organ involvement CNS > Lungs Lungs > CNS

Complications

• Cryptococcoma• Hydrocephalus• Large lesion

Less More

Antifungal susceptibility

More susceptible to fluconazole

Less susceptible to fluconazole

Treatment response Good Required more surgicalintervention and prolonged

antifungal treatment

• Clin Microbiol Rev 2014;27(4):980-1024., IDSA guideline 2010 for cryptococcosis

• Clin Infect Dis 1995;21(1):28-34, Braz J Mcrobiol 2015;46(4):1125–33

A 17-year old man

• β Thal/HbE disease

• Chronic leg ulcer for 2 months after flood

Pythium insidiosum

antibody- Positive

Human pythiosis (Pythiosis insidiosi)

• Organism: Pythium insidiosum

• A water mold closely related to algae more than fungi (Oomycetes)

• Non-septate broad hyphae with branching

• Produce sporangia

• Aquatic motile biflagellated zoospore

Zoospore

http://jcm.asm.org/content/vol42/issue9/images/large/zjm0090445630001.jpeg

http://jcm.asm.org/content/vol42/issue9/images/large/zjm0090445630001.jpeg

zoospore_01.mpg

zoospore_01.mpg

2/21/2018

7

Epidemiology & Pathogenesis of Human Pythiosis

Tropical and subtropical regions

Mostly in Thailand

Direct contact to contaminated sources

Risk factors

Hematological diseases

Thalassemia-hemoglobinopathy syndrome – mostly

Non-thalssemia: PNH, AA, AML, ITP

Mechanism: unknown (may be related to iron overload?)

No underlying disease (ocular form)

5 months later

Angiography

Charoen Kladsuk,Charoen Kladsuk,529628565296285615/04/1415/04/1441 YEAR41 YEARFF


Siriraj Hospital Siriraj HospitalLEG CTALEG CTA

AW electronic filmAW electronic film 19/06/55 3:04:33 19/06/55 3:04:33

2258855222588552------------------

IM: 3057IM: 3057

W: 256W: 256C: 128C: 128

Z: 1Z: 1

cm

cm

Angiography

Clinical Syndromes of Pythiosis

Human pythiosis in Thailand (102 cases: 1985-2003)

Localized forms

Cutaneous/subcutaneous pythiosis (5%)

Ocular pythiosis (33%)

Systemic forms

Vascular pythiosis (59%)*

Disseminated pythiosis (3%)

Overall mortality 40%

Limb amputation 78%

Enucleation/evisceration 78% (ocular form)

Human Pythiosis in Thailand. CID 2006:43, 569-76.

Diagnosis of Human Pythiosis

Direct microscopic examination

Culture (gold standard)

Histopathology

Serology***

Immunodiffusion test (ID)

Immunochromatographic test (ICT)

Molecular identification

PCR

zoospore_01.mpg

zoospore_01.mpg

2/21/2018

8

Treatment

Surgical treatment Radical surgery : the main effective treatment

Vascular pythiosis :

Resection of infected arteries

BK, AK amputation

Aneurysmectomy

Thrombo-embolectomy not recommended

Grossly normal looking not indicate adequate excision

Microscopic demonstration of organism-free surgical margin needed***

Medical Treatment

Medical treatment alone is ineffective

Pythium immunotherapy

SSKI (saturated solutions of potassium iodide)

Itraconazole+terbinafine

2-year-old boy with periorbital cellulitisextended to nasopharynx and maxillay sinus

1 year course of Itraconazole

plus terbinafine

Dengue vaccine

Dengvaxia® (CYD-TDV)

Live attenuated vaccine (4 subtypes)

3 injections: 0, 6, 12 months

Approved in 9-45 years old

Moderate efficacy: 65%

DEN3-4 (75%) > DEN1 (50%) > DEN2 (35%)

Higher efficacy in serological evidence of previous dengue exposure

Decreased severity (90%) and decrease hospitalization 80%

Capeding MR, et alLancet. 2014;384(9951):1358-65., Villar L, et al. N Engl J Med. 2015;372(2):113-23.

November 2017Persistent protective benefit against dengue fever in those who had prior infection.

For those not previously infected by dengue virus, in the longer term, more

cases of severe disease could occur following vaccination upon a

subsequent dengue infection.

Malaria

P.ovale: mostly in Africa (especially West Africa) and theislands of the western Pacific

> 90% Pf

> 90% Pv

Mixed

In Thailand: P. vivax 56.8%, P. falciparum 42.5%

Plasmodium Life Cycle

Erythrocytic stage:

P. falciparum - irregular (about 48 h)

P. vivax and P. ovale - 48 h

P. malariae - 72 h

P. knowlesi - 24 h

2/21/2018

9

Morphology of Plasmodium spp.

P. falciparum

IP: 12 days

P. vivax

IP: 13 days

P. malariae

IP: 17 days

P. ovale

IP: 28 days

P. knowlesi

IP: 12 days

Parasitized RBC = normal RBC

RBCs contain immature trophozoites (ring form)

Maurer’s dots

16-32 merozoites/schizont

Parasitized RBC (young) > normal RBC

Trophozoites amoeboid form

RBCs contain all stages

Schuffner’s dots


Hypnozoites in liver*


Trophozoites amoeboid form


Trophozoites – band shape

6-12 merozoites/schizont, Rosette

Parasitized RBC slightly > normal RBC

Oval RBC with fimbriae


Schuffner’s dots (James’ dot)


Hypnozoites in liver


Trophozoites pigment spreads inside

cytoplasm, band maybe seen (like P. malariae)


Multiple invasion and high parasitemia (like P.

falciparum)

Rings Trophozoites Schizonts Gametocytes

IP: incubation period

What you should know?

New species P. knowlesi: Malaysia, Indonesia, Phillippines, Thailand (Yala, Krabi, Prachuab kirikhan, Chantaburi)

Knowlesi malaria can be severe

Erythrocytic stage of P. knowlesi = 24 h (shortest)

P. vivax infection can be severe (increased mortality)

P. vivax and P. ovale relapse weeks to months later (hypnozoites)

Treating the hypnozoite with a second agent (primaquine)

When P. vivax and P. ovale are transmitted via blood, treatment with primaquine is not necessary

No sporozoites that form hypnozoites in blood

Clinical Laboratory

Impaired consciousness

Prostration

Multiple convulsions

Deep breathing and respiratory distress

Acute pulmonary edema and acute respiratory distress syndrome

Circulatory collapse or shock

Acute kidney injury

Clinical jaundice plus evidence of other vital organ dysfunction

Abnormal bleeding

Hypoglycemia (< 40 mg/dl)

Metabolic acidosis

Severe normocytic anaemia (hemoglobin < 5 g/dl)

Hemoglobinuria

Hyperlactataemia (lactate > 5 mmol/l)

Renal impairment (Cr > 3 mg/dl)

Pulmonary oedema (radiological)

Severe Falciparum Malaria

Parasitemia ≥ 5% or schizontemia is

associated with severity

Severe Vivax Malaria

Similar to those of severe P. falciparum malaria and can be fatal

Severe anemia and respiratory distress occur at all ages

Severe anaemia is particularly common in young children

Severe Knowlesi Malaria

P. knowlesi replicates every 24 h rapidly increasing parasite densities

Severe disease and death in some

Severe disease are similar to severe falciparum malaria, with the exception of coma

Patients with P. malariae-like infections (band form) and unusually high parasite densities (parasitemia > 0.5% by microscopy) should be managed as P. knowlesi infection

Definitive diagnosis is made by PCR

Antimalarial Drug Activity in the Life Cycle of Plasmodia

Treat Acute attack- Artesunate- Quinine- Mefloquine- Chloroquine- Tetracycline- Atovaquone- Proguanil

Prevent relapse

Primaquine, proguanil, tetracycline

Prevent

transmission

Primaquine,

Artemisinines

2/21/2018

10

RCPT MoPH

First-line drugs

Artesunate 4 mg/kg/day for 3 days+ mefloquine 25 mg /kg in divided dose

( 3 tabs then 2 tabs)

Second-line drugs

Quinine 10 mg /kg + doxycycline 3 mg/kg OD or BID, or clindamycin 10 mg/kg/ bid 7 days

Artesunate 2 mg/kg/day + doxycycline 3 mg/kg OD or BID, or clindamycin 10 mg/kg/ bid 7 days

Followed by

Primaquine 30 mg once

Dihydroartemisinin (DHA)-Piperaquine (40/320 mg) 3 days <60 Kg 3 tabs OD

60-80 Kg 4 tabs OD

> 80 Kg 5 tabs OD

Followed by

Primaquine 30 mg once

Treatment of Uncomplicated Falciparum Malaria

Artemisinin combination therapy (ACT)

- Artesunate+mefloquine

- DHA-piperaquine

Treatment of Uncomplicated Malaria

Pregnant woman

Quinine+clindamycin (alternative DHA-pip) (MoPH)

Second or third trimester

Artesunate (RCPT)

DHA-piperaquine (MoPH)

Do not use doxycycline or primaquine (even single dose)

Relapsed Pf malaria within 2 months- do not use mefloquine

Use quinine+doxy/clinda or artesunate+doxy/clinda

Treatment of Uncomplicated Malaria

Non- P. falciparum

Chloroquine 4-4-2 tabs (total 10 tabs)

Primaquine for Pv and Po

15 mg OD for 14 day (unknown G-6-PD)

30 mg OD for 14 day (if no G-6-PD deficiency)

45 mg weekly for 8 weeks (if mild G-6-PD deficiency)

Pregnant women

Chloroquine 300 mg weekly suppressive therapy for PV and PO in pregnant women until postpartum then use primaquine

Treatment of Severe Malaria

First-line drugs

Artesunate IV

2.4 mg/kg IV PUSH at 0, 12, and 24 h Day 1 then 2.4 mg/kg once a day, if improved

Change to oral ACT for 3 days (DHA-pip; MoPH, Artesunate-mef; RCPT)

Second-line drugs

Quinine IV

Loading 20 mg/kg IV DRIP > 4 h then 10 mg/kg IV DRIP in 2-4 h q 8 h, if improved

Change to oral ACT for 3 days (DHA-pip; MoPH, Artesunate-mef; RCPT) or

Change to quinine+doxy/clinda or artesunate+doxy/clinda for 7 days

•Doxycycline can be given once daily, starts when the patient has recovered sufficiently•Mefloquine should be avoided due to risk of neuropsychiatric complications in the patient presented initially with impaired consciousness

A 18 years old male, no underlying disease What is the diagnosis ?

A. Infective endocarditis

B. Leptospirosis

C. Dengue hemorrhagic fever

D. Gram-negative sepsis with DIC

E. Scrub typhus

2/21/2018

11

Leptospirosis

Leptospira interrogans

Reservoir: 160 mammals, most important-rodent esp. rat (shed in urine)

Transmission: skin contact with water, soil

Incubation period: 2-26 days (average 10 days)

Four broad clinical categories

(i) a mild, influenza-like illness

(ii) Weil's syndrome characterized by jaundice, renal failure, haemorrhage and myocarditis with arrhythmias

(iii) meningitis/meningoencephalitis

(iv) pulmonary haemorrhage with respiratory failure


Subclinical infection 40-70%

Symptomatic cases – 90% mild or anicteric form

Acute febrile illness with a biphasic course (leptospiremic and immune phases) - good prognosis

Nonspecific signs and symptoms (flu-like)

Severe or icteric leptospirosis (Weil disease)– 10%

Mortality 10%

Multiple organ involvement

Loss of biphasic fever

Anicteric leptospirosis Icteric leptospirosis

(Incubation

period 2-20

days)

Fever

Leptospiremicphase

3-7 days

Immune phase

0-30 days

Leptospiremic phase

3-7 days

Immune phase

0-30 days

Associated symptoms

Myalgia

Headache

Nausea,

Vomiting

Abdominal pain

Conjunctival suffusion

Meningitis

Uveitis

Rash

Jaundice

Hemorrhage

Acute renal failure

Myocarditis

Hemorrhagic pneumonitis

Meningoencephalitis

Hypotension

Leptospires present in

Blood Blood

CSF CSF

Urine Urine

Clinical Course

Siriluck Anunnatsiri (with permission)

Diagnosis

Antibody detection (IgG, IgM) IFA

Need 4-fold rising for diagnosis

Single cutoff titer varies (for IFA ≥ 1:400)

PCR

Treatment

Mild leptospirosis

Doxycycline, ampicillin, or amoxicillin

Severe leptospirosis

Intravenous penicillin G - drug of choice

Third-generation cephalosporins: cefotaxime and ceftriaxone

2/21/2018

12

A 42 years old

A farmer

Fever with headache for 10 day

Myalgia

The diagnosis is…….

Scrub typhus

Rickettsioses

Spotted fever group (15 rickettsioses) Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii

Rickettsialpox caused by Rickettsia akari

Thailand: Thai tick typhus (R. honei)

R. helvetica , R. conorii, R. felis

Typhus group Epidemic (louse-borne) typhus caused by Rickettsia prowazekii

Endemic (murine) typhus caused by Rickettsia typhi

Scrub typhus group Caused by Orientia tsutsugamushi

Clinical Characteristics

Small, painless, gradually enlarging papule, which leads to an area of central necrosis and is followed

by eschar formation (30-50%)

At axilla, perineum, groin, under breast line

Chigger Eschar

Eschars

Cutaneous anthrax Plague

Scrub typhus Ecthyma grangrenosum

Severe Scrub Typhus

Pneumonitis, ARDS

Encephalitis, aseptic meningitis

Rarely, acute renal failure, shock, and disseminated intravascular coagulation (DIC)

Cardiac involvement is often minor and rare, but can cause fatal myocarditis

Severe Scrub Typhus

Pneumonitis, ARDS

Encephalitis, aseptic meningitis

Rarely, acute renal failure, shock, and disseminated intravascular coagulation (DIC)

Cardiac involvement is often minor and rare, but can cause fatal myocarditis

2/21/2018

13

Diagnosis and Treatment

Diagnosis: Serology by IFA

- IgM titer ≥ 1:400, IgG titer ≥ 1:1,600 or

- 4-fold rising 14 D apart with titer ≥ 1:200

Treatment:

- Doxycycline 100 mg po bid 3 days after symptoms resolve

- Azithromycin (in pregnancy or IV azithromycin in severe form)

Murine typhus

Headache, fever, muscle pain, joint pain, nausea and vomiting

MP rash 40-50% - about six days after the onset

Neurological signs 45% - confusion, stupor, seizures or imbalance

Symptoms may resemble those of measles or rubella

Investigation and treatment

Same as scrub typhus

A woman with severe murine typhus and ARDS

วราภรณ์ วิมลสริิสุข,วราภรณ์ วิมลสริิสุข,

WARAPORN WIMOLSIRISUKWARAPORN WIMOLSIRISUK

5333247553332475

20/12/250120/12/2501

Age: 56 YEARAge: 56 YEAR

FF


SIRIRAJ HOSPITAL (PORTABLE)SIRIRAJ HOSPITAL (PORTABLE)

CHESTCHEST

8/2/2558 6:31:498/2/2558 6:31:49

2366515623665156

------

------

------

IM: 1001IM: 1001

W: 1024W: 1024C: 512C: 512Z: 0.58Z: 0.58S: 552S: 552

cm

cm

วราภรณ์ วิมลสริิสุข,วราภรณ์ วิมลสริิสุข,

WARAPORN WIMOLSIRISUKWARAPORN WIMOLSIRISUK

5333247553332475

20/12/250120/12/2501

Age: 56 YEARAge: 56 YEAR

FF


SIRIRAJ HOSPITAL(R228)SIRIRAJ HOSPITAL(R228)

CHESTCHEST

12/2/2558 10:38:2612/2/2558 10:38:26

2367091423670914

------

------

------

IM: 1001IM: 1001

W: 1024W: 1024C: 512C: 512Z: 0.48Z: 0.48S: 310S: 310

cm

cm

5 days after treatment

A man post liver transplantation

Date 17/6/56 18/6/56 19/6/56 20/6/56 21/6/56 22/6/56 23/6/56

Meropenem

Vancomycin

Ganciclovir

Cotrimoxzole

• CMV viral load < 20 copies/mL

• Serum gallactomanan: negative • Serum cryptococcus Ag: negative

Bronchoscopy

Lab 18/6/56 23/6/56

Hb (g/dL)/Hct(%)

12.1/35.1 9.6/28.1

WBC (/mm3) 6,140 3,130

N (%) 92.5 62

L (%) 5 27.8

M (%) 2.3 8.9

E (%) 0 0.3

B (%) 0.2 1

Platelets (/mm3) 56,000 93,000

BUN/Cr (mg/dL) 14.6/1.42 28.1/2.22

TB/DB (mg/dL) 0.5/0.31 0.9/0.8

AST/ALT (mg/dL)

55/38 1,545/488

ALP (U/L) 96 616

Alb/Glob (mg/dL)

2.6/2.5 2.1/3.1

Date 19/6/56

IFA (IgG+M) Leptospira spp.

IgG <1:50

IgM <1:50

IFA (IgG+M) O. tsutsugamushi

IgG <1:50

IgM <1:50

IFA (IgG+M) R. typhi

IgG 1:800

IgM 1:800

A man post liver transplantation Intestinal nematodes

Trichuris trichiura

Chronic diarrheaRectal prolapse

Enterobius vermicularis

AsymptomaticAutoinfection

Ascaris lumbricoides

Abdominal painSmall bowel obstruction Lung migration (larva)- Eosinophilic

pneumonitis (LÖffler’s syndrome)

Hookworm

Abdominal pain, Iron-def anemia

Treatment: Albendazole 400 mg x 1 day

2/21/2018

14

Capillaria philippinensis

Undercooked fish

Symptoms

Chronic voluminous diarrhea

Malabsorption syndrome

Size 40x20 µ

Dx

Peanut-shaped egg

Flatten bipolar plugs

Rx

Albendazole 400 mg PO x 10 D

Mebendazole 200 mg BID x 20 D

Strongyloides stercoralis

Acute infection:

1/3 - asymptomatic

larva currens, LÖffler’s syndrome, diarrhea

Chronic persisting infection: 1/3-asymptomatic

Triad: urticaria, abdominal pain, diarrhea

Hyperinfection syndrome: Exacerbation of GI, pulmonary symptoms and increased numbers of larvae in stool and sputum

Complication: Gram negative bacteremia

Rx - Ivermectin 200 µg/kg PO ODx2d

: For hyperinfection: repeat treatment every 15 days while stool positive,

then 1 more treatment cycle

: Hyperinfection in immunocompromised: 200 µg/kg OD until neg. for 2 wks

- Albendazole 400 mg PO BID x 7 d (less effective)

Gnasthostoma spinigerum

Eating Raw fish or contaminated water with cyclops

Larval gnasthostomiasis

Intermittent subcutaneous migratory swelling

Ocular gnathostomiasis

Eosinophilic myeloencephalitis

Dx: antibody detection (ELISA)

Rx: Surgery

Albendazole 400 mg/d x 21 d or

Ivermectin 150-200 µg/kg single dose

J Travel Med. 2016;24(1). doi:10.1093/jtm/taw074

Angiostrongylus cantonensis

Angiostrongyliasis

Eosinophilic meningoencephalitis

Dx: antigen detection (ELISA)

Rx: No specific treatment, CSF removal

Prednisolone 60 mg/day x 14 days

Undercooked snails,crabs,

freshwater shrimps

Third stage larvae

Visceral Larva Migrans

Ingest egg of dog/cat ascarids

Toxocara canis, Toxocara cati

Mostly asymptomatic

Visceral /ocular larva migrans

Dx: Toxocara antibody (ELISA)

Rx: Supportive

Prednisolone

Albendazole 800 mg bid x 5-20 d (intestinal parasites only)

Cutaneous Larva Migrans

- Raised, erythematous, serpiginous, tunnel-like lesion 2-3 mm

- Containing serous fluid

Etiology

Ancylostoma braziliense (cat, dog hookworm) Ancylostoma caninum(dog hookworm)

Human hookworm

Strongyloides stercoralis (larva currens)

Rx: - Albendazole 200-400 mg PO bid x 3-5 d

- Ivermectin 200 mcg/kg PO once

2/21/2018

15

Taeniasis

Eat undercooked pork (cysticercus cellulosae)

Taenia solium(pork tapeworm)

Eat undercooked beef(cysticercus bovis)

Taenia saginata(beef tapeworm)

Rx of intestinal parasite:- Praziquantel 10 mg/kg PO once

Taenia egg:Diameter 40 µ

Round shaped-eggThick shell with radial striation

Eat Taenia solium egg or autoinfection

Neurocysticercosis

Vesicular cyst Colloidal cyst

Granular stage Calcifications

Cysticercosis

Multiple rice-grain like cacification

Treatment of Neurocysticercosis

Anticonvulsant therapy: mainstay of management of neurocysticercosis-associated seizure disorders

Antiparasitic therapy

Symptomatic patients with multiple, live cysticerci cyst reduction, fewer and decreased seizure recurrences

Not benefit in patients with calcified cysts

Concomitant steroids

Dexamethasone 0.1 mg/kg/d 1 day prior antiparasitic drugs x10 D

Combined albendazole (15 mg/kg /day) plus praziquantel (50 mg/kg/ day)

Higher rate of complete resolution of brain cysts at 6 mo compared to standard dose of albendazole (64% vs. 37%, RR 1·75, 95% CI 1·10–2·79, p=0·014)

Flukes

Paragonimus westermani

Paragonimus heterotremus

Eat metacercaria in undercooked shrimp, crab

Symptoms

Pulmonary paragonimiasis

Cerebral and spinal paragonimiasis

Migratory subcutaneous paragonimiasis

Rx: Praziquantel 25 mg/kg PO tid x 2 D

Opisthorchis viverrini

Undercooked fish

Symptoms

Early: asymptomatic

Abdominal pain

Relapsing cholangitis

Cholangiocarcinoma

Rx: Praziquantel 25 mg/kg PO tid x 2 days

Fasciolopsis buski

Giant intestinal fluke (largest human parasite)

Eat water contaminated with metacercaria

Symptoms

abdominal pain and diarrhea

Rx: Praziquantel 25 mg/kg PO tid x 1 days

Liver fluke Intestinal fluke Lung fluke

Schistosomiasis (Blood flukes)

Mesenteric venule:

S. japonicum, S. mansoni, S. mekongi

Venule of lower urinary tract :

S. haematobium

Thailand: S. japonicum

Clinical form:

- Schistosome dermatitis

- Acute schistosomiasis:2-8 wks

- Chronic schistosomiasis

Schistosoma mansoni- Non-operculum, oval

- Lateral spine

Schistosoma haematobium- Non-operculum, oval

- Terminal spine

Schistosoma japonicum- Non-operculum, round

- Lateral knob

Schistosoma mekongi- Non-operculum, round

- Lateral knob

Rx: Praziquantel 20 mg/kg PO TID x 1 d

Rx: Praziquantel 20 mg/kg PO BID x 1 d

Intestinal Protozoa

Protozoa Treatment

Cryptosporidium spp. No effective treatment (Nitazoxanide)

Cyclospora cayetanensis,

Cystoisospora belli

TMP-SMX DS 1 tab bid x 7-10 days

HIV: TMP-SMX DS 1 tab qid x 3-4 weeks

Giardia lambia Tinidazole 2 g po x 1

Metronidazole 250 mg po tid x 5-7 days

Albendazole 400 mg po OD x 5 days

Cryptosporidium parvum

4-6 µM 6-10 µM 15-30 µM

Giardia lambia

10-14 µM

Cystoisosporabelli

Cyclosporacayetanensis

common infections in tropical regionreviews.berlinpharm.com/20180303/common_infections_in... ·...

Documents