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Division of INFECTIOUS DISEASES Randall S. Edson, MD, MACP Professor of Medicine Mayo Clinic College of Medicine Internal Medicine Program Director, CPMC.

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Presentation on theme: "Division of INFECTIOUS DISEASES Randall S. Edson, MD, MACP Professor of Medicine Mayo Clinic College of Medicine Internal Medicine Program Director, CPMC."— Presentation transcript:

1 Division of INFECTIOUS DISEASES Randall S. Edson, MD, MACP Professor of Medicine Mayo Clinic College of Medicine Internal Medicine Program Director, CPMC San Francisco, CA ©2011 MFMER | slide-1

2 Disclosures, etc No financial disclosures or discussion of off-label drugs, etc. ©2011 MFMER | slide-2

3 Coming clean…………………….. Went through express lane with > 12 items Forgot to return shopping cart to corral on one occasion Deliberately avoids using the stairs at all costs, despite ubiquitous signage and propaganda

4 ©2012 MFMER | 3220467-4 Public Service Announcement

5 Learning objectives Recognize important travel-acquired infections Understand the approach to the diagnosis of LTB Diagnose CNS infection based on pattern recognition Review updated guidelines for UTI management Diagnose a mystery rash ©2011 MFMER | slide-5

6 25 yr old ♂ with three week history: fever, sore throat, fatigue, sweats. Grad student; just returned from 3 week trip to Southern Africa. Ate local food, swam in fresh water, took brief course of ciprofloxacin for traveler’s diarrhea Exam: Appears ill; T 38.8 0 ; oral ulcers, exudative pharyngitis, post-cervical nodes, rash rash Lab: HCT 38%; WBC 12,000( ↑ lymphs, “atypical”); mild ↑ AST; Mono spot neg; HIV Ab negative

7 ©2012 MFMER | 3220467-7

8 Which of the following would most likely establish diagnosis? a. EBV serology b. CMV serology c. Dengue serology d. PCR for HIV RNA e. Rickettsia africae serology

9 Acute HIV: Don’t miss!!! Occurs in 30-50% of HIV-infected patients “Hyper-transmitters” with formidable viral load Should be suspected in sexually active patients with prolonged “mono” syndrome Negative HIV antibody common (too early) Order PCR/quantitative HIV test Ann Int Med 1996;125:257 NEJM 1998;339:33

10 ©2012 MFMER | 3220467-10 Symptom onset within 2 weeks of acquisition Peak viremia 10 fold + ↑ risk of transmission JID 2010:202(Suppl 2):S270

11 ©2012 MFMER | 3220467-11 >50,000 new cases of HIV/year in US What’s in your travel kit??

12 STD in Returning Travelers Casual sex: 5-51% of short term travelers, ↑ among long term travelers Meta analysis: 20% have casual sex abroad;50% unprotected* Not usually addressed in pre-travel consults * Intern J of Inf. Dis 2010;14(10):e842-51 CID 2001;32:1063 J Travel Med 2009;16:79

13 ©2012 MFMER | 3220467-13 Geo Sentinel Surveillance database; Lancet ID 2013;13:205 Distribution of STD’s in ill travelers:1996-2010

14 Pre-employment evaluation ♀ 28 yr. old ♀ respiratory tech about to begin work at your hospital Mild asthma, controlled with occasional albuterol; otherwise healthy Immigrated to US from Philippines 3 years ago Cervical cytology, all adult immunizations current; received BCG as a child ©2012 MFMER | 3177424- 14

15 Your hospital requires screening for LTB Which of the following would be the most appropriate screening test for latent TB? a) Chest x-ray b) Interferon-γ release assay c) PPD(5 TU) d) PPD(10 TU) ©2012 MFMER | 3177424- 15

16 TB and Latent TB 1/3 of world population infected with TB Latent TB develops in ≈ 30% exposed Estimated cases of LTB in US ≈11 million Lifetime risk of reactivation 5-10% Most clinical TB in US occurs in immigrants from high prevalence countries Herrera et al.Clin Inf Dis 2011;52(8):1031

17 Screening options for Latent TB* TST(PPD) Interferon γ release (IGRA) assays QuantiFERON®-TB Gold (QFT-GIT) T-SPOT®. TB test (T-Spot) Mechanism of action Patient’s WBC + MTB antigens: ↑ γ-IFN ©2012 MFMER | 3177424- 17 * Targeted screening only for those at highest risk

18 ©2012 MFMER | 3220467-18 IGRA Single visit Results in 24 hours Not affected by BCG Minimal cross-reactivity with other mycobacteria Circumvents technical “challenges” of PPD administration, interpretation Must process in 8-30 hrs. Limited data: children < 5, immunosuppression, recent exposure ↑ False + in low prevalence* © Pros Cons *Chest 2012 Jul 1;142:55 and 10

19 When to use IGRA? Most situations where PPD is used Patients not likely to return at 48-72 hours Foreign born patients who received BCG Both TST and IGRA may be used: Foreign-born HCW who attribute + PPD to BCG Initial test negative in high risk patients “Tie breaker” in low risk patients with + test ©2012 MFMER | 3177424- 19 MMWR 2010;59(RR-5):1-25

20 ©2012 MFMER | 3220467-20 Game changer in the treatment of latent TB 900mg INH plus 900mg of Rifapentine once weekly for three months Equally effective as 9 months of daily INH ≈ $40 total Perfect situation for Directly Observed Therapy (DOT) Rifapentine is expensive: ≈ $325 for 3 month course

21 55 yr. old ♂ farmer with fever and confusion 8/2012: difficulty with concentration, spatial perception; co-workers noted distraction and trouble with word finding. Day 2: severe HA DM2, s/p bariatric surgery, hypertension Sexually active, farms and road maintenance Exam: T 38.5 0 ; drowsy; mild neck stiffness CSF: WBC 165 cells/µL(mostly lymphs) Protein 150 mg/dL; glucose 61mg/dL Gram stain: no organisms seen

22 Develops significant weakness and cog- wheeling several hours later Which one of the following tests would most likely establish the correct diagnosis? a. MRI of head with gadolinium b. CSF PCR for Herpes simplex virus c. CSF IgM for West Nile virus d. CSF serology for enterovirus

23 ©2012 MFMER | 3220467-23 4891 cases, 2293(51%) Neuro-invasive, 223 deaths; 70% from 10 states; highest number to date since 2003

24 ©2012 MFMER | 3220467-24 Unintended consequence of foreclosure

25 ©2012 MFMER | 3220467-25 WNV transmission, life cycle Hi, I’m Culex sp.

26 West Nile Virus 101 Flavivirus St Louis Encephalitis; Yellow fever; JE Acquisition: mosquito, transfusion, transplant Peak incidence: Late August, early September Incubation: 2 to 14 days 80% asymptomatic 20% WN fever; < 1% Neuro-invasive

27 When to suspect West Nile infection Mosquito season(especially August) West Nile fever is nonspecific: fever and HA Characteristic features of neuro-invasive disease Acute flaccid paralysis Parkinson-like symptoms 10% mortality with neuro-invasive disease Profound, prolonged fatigue may persist for a year JAMA 2003;290:511 and Lancet Inf. Dis 2002;2:519 Am J Trop Med Hyg 2012:87:179 Annals of Int Med 2008;149:232

28 ©2012 MFMER | 3220467-28 Diagnostic time course of West Nile Virus Serum or CSF IgM best diagnostic test IgM antibodies may persist for a year

29 ©2012 MFMER | 3220467-29 A 20 yr old female college student with a 2 day history of dysuria, urgency and frequency in the absence of fever, chills, vaginal irritation or discharge; she has had two previous UTI’s this year, most recently 3 months ago and received three days of TMP/SMX with resolution. What would you do next? a.Obtain urine for gram stain and culture b.Prescribe trimethoprim-sulfa for 3 days c.Prescribe amoxicillin for 3 days d.Prescribe nitrofurantoin 5 days e.Prescribe ciprofloxacin for 3 days

30 ©2012 MFMER | 3220467-30 When words fail……………

31 ©2012 MFMER | 3220467-31 NEJM 2012;366:1028-37 and Clin Inf Dis 2011;52(5):e103-e120

32 Key facts in UTI management E.coli increasingly resistant to TMP/SMX, FQ Avoid TMP/SMX if local resistance is ≥ 20% or used w/n last 3 months Avoid FQ if local resistance is ≥ 10% Mayo Antibiogram 2011

33 More key facts in UTI management Do not treat asymptomatic bacteriuria(AB) even with pyuria except: Pregnancy; post renal transplant Prior to urologic instrumentation Unintended consequences of AB Rx ↑ frequency of subsequent symptomatic UTI 1 Asymptomatic bacteriuria may be “protective” Alarming increase in community-acquired multidrug resistant E. coli 2 1 Clin Infect Dis 2012;55:771 2 Mayo Clin Proc 2012;87(8):753

34 Antimicrobial Cost Considerations Nitrofurantoin100 mg BID x 5 days $30-35 TMP/SMX DSBID x 3 days$9.62 1 Ciprofloxacin500 mg BID x 3 days $13 1 Fosfomycin3 gram packet once $54-60 $4 for TMP/SMX and Cipro 1

35 Bottom line in UTI management Alarming increase in antimicrobial resistance among community-acquired E. coli Treatment guidelines reflect this resistance Nitrofurantoin, TMP/SMX, Fosfomycin are top 3 choices DO NOT screen for and/or treat AB ©2011 MFMER | slide-35

36 67 yr old man with a rash Developed painless nodular, pustular rash 2 weeks ago Did not respond to several oral antibiotics and five infusions of vancomycin Swab culture: rare Pseudomonas fluorescence Treated with ciprofloxacin without improvement Examination Vital signs normal, afebrile Rash on dorsum of left forearm

37 ©2012 MFMER | 3220467-37

38 What would you do next? a. Begin anti-mycobacterial Rx b. Start trimethoprim-sulfa for suspected Nocardia c. Start antifungal Rx d. Send to Derm for biopsy

39 Most likely diagnosis? a. Squamous cell carcinoma b. Blastomycosis c. Nocardiosis d. Non-tuberculous mycobacterial infection e. Dermatophyte

40 Additional history 5 days before rash onset cleared brush, had exposure to mud, thorns; recalls many scratches, wearing short- sleeve shirt Has cattle, dogs, cats

41 ©2012 MFMER | 3220467-41 Results of biopsy/culture Lab reports growth of Trichophyton verrucosum Majocchi’s granuloma Deep folliculitis due to dermatophyte infection Can be transmitted from cows, horses to humans

42 ©2012 MFMER | 3220467-42 Trichophyton verrucosum

43 Clinical bottom line The occupational and exposure history can be critical in broadening the differential diagnosis

44 ♂ 56 year old ♂ with chronic cough, sweats 3 month history of productive cough, sweats, weight loss. No response to several AB courses PMH: MS, COPD SH: divorced, disabled miner; 50 pack year smoking history; former daily marijuana smoker, now using marijuana “chocolates.” Lives in wooded area of Michigan’s UP Recently moved into old house with obvious mold; spent several weeks using leaf blower; several local dogs ill with respiratory symptoms

45 ©2012 MFMER | 3220467-45 MBF

46 Malignancy suspected; second opinion sought Physical examination Appears cachectic(“hunter-gatherer diet”) Afebrile Many missing teeth and periodontal disease Few rales at right lung base CBC, electrolytes, etc. all normal

47 ©2012 MFMER | 3220467-47 CT chest, 2/20/2013

48 Bronchoscopy done on 2/20/13 Mucopurulent secretions noted in right lower lung. A diagnostic result was received……..

49 ©2012 MFMER | 3220467-49 Direct smear from BAL fluid

50 What is the most likely diagnosis? a. Bronchogenic CA with post-obstructive pneumonia b. Mixed aerobic/anaerobic pneumonitis c. Pulmonary blastomycosis d. Pulmonary nocardiosis

51 ©2012 MFMER | 3220467-51 Etiologic agent Blastomyces dermatitidis Natural habitat Boggy soil, wood Location River valleys: Ohio, Miss, Mo PathogenesisInhalation Blastomycosis

52 ©2012 MFMER | 3220467-52 Blastomyces dermatitidis:dimorphic fungus 52 Mycelial phase in culture Yeast phase in tissue

53 ©2012 MFMER | 3220467-53

54 ©2012 MFMER | 3220467-54 NEJM 1986;314(9):529-34 “Leave it to Beaver”

55 Looking for Blastomyces dermatitidis Several regional beaver dams were neutralized with dynamite

56 ©2012 MFMER | 3220467-56 56 SKIN BONE PROSTATE Tissue tropism of Blastomycosis Am J Med 2011;124(12):1132 Clin Inf Dis 2008;46:1801(PG) Infect Dis Clin of NA 2006;20:645 NEJM 1993;329:1231

57 ©2012 MFMER | 3220467-57 Cutaneous manifestation of disseminated Blastomycosis

58 Blastomycosis: making the diagnosis Direct smear from clinical specimen Culture Serology Previous CF test had poor sensitivity, specificity Newly approved EIA has excellent sensitivity, specificity Urine antigen: high sensitivity, poor specificity

59 Don’t forget to do your part ©2011 MFMER | slide-59

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