1. Drake H. Tilley, Jr. MD MPH&TM
Top 10 ID Stuff on a Ship
Drake H. Tilley, Jr. MD MPH&TM

2. Disclaimers No financial interests to disclose.
The views expressed in this presentation are my own and do not necessarily reflect the official policy or position of the Department of the Navy, U.S. Department of Defense, or that of the U.S. Government.
There will be no endorsement of any medical product during this presentation.
Gross pictures will be shown.

3. #1 The Runny Nose
25 y/o healthy male c/o sore throat and nasal congestion x 4 days.
Things to look for on exam.
Ear effusions
Sinus tenderness
Neck adenopathy
Injected eyes
Enlarged exudative tonsils
Inflamed or exudative oral pharynx
Sputum color and character
Crackles in the lung fields
Any difficulty breathing (SOB, Cough, Dyspnea, etc….)

4. Differential
Viral URI (Adenovirus, Coronavirus, Rhinovirus, Enterovirus, HMPV)
Sinusitis (sinus pressure, nasal drainage, headache, toothache)
Otitis Media (ear pain and pressure)
Tonsillitis (sore throat, difficulty swallowing, enlarged)
Pharyngitis (sore throat)
Laryngitis (hoarse)
Bronchitis (persistent productive cough)
Pneumonia (SOB, dyspnea)
Mastoiditis (mastoid tenderness)

5. Treatment Control the snot! Don’t miss Strep Throat!
Prevents viral illnesses from becoming bacterial ones.
Use long-acting decongestants.
Use Afrin only at night to prevent rebound.
Don’t miss Strep Throat!
Treat with PCN to prevent rheumatic fever.
Clindamycin for those penicillin allergic.
When to Use Antibiotics
Cough, rhinorrhea, hoarseness, and/or oral ulcers suggest viral etiology.

6. #2 Diarrhea 22 y/o male with 24 hours of diarrhea.
Are there sick contacts?
Is there vomiting?
Is there fever?
Is there dysentery?
Is there abdominal cramping and or flatus?
Is there tenesmus?

7. Differential Norovirus Adenovirus Enterovirus Sapovirus Astrovirus
Notorious for ship outbreaks, super contagious.
Adenovirus
Enterovirus
Sapovirus
Astrovirus
Campylobacter and E. coli
Unusually comes from a food source.
Salmonella and Shigella
Usually comes from a carrier.

8. How to control an outbreak.
Make an incidence curve.
Determine if observed rate is over the baseline rate.
Plot it on a map.
Interview the “sick” and “not sick”.
Use a standardized data collection form.
Epi Info™ by the CDC
Call for back-up.
Navy Environmental Preventive Medicine Units (NEPMU’s)
Diagnosing the bug is not the most important part of an investigation.
Collect samples at the point of care.

9. How to control a norovirus outbreak.
Wash your hands!!!!
Especially after using the bathroom.
Especially before preparing food.
Alcohol gels do not kill norovirus.
Rinse your fruits and vegetables and cook your food.
70% of Norovirus outbreaks start with the cook.
Isolate the sick.
You can shed norovirus up to 2 weeks after being sick.
Clean and disinfect contaminated surfaces.
Bleach works fine.
Wash contaminated clothes and linens.

10. #3 Skin Infections 19 y/o male c/o a red swollen tender finger.
Recent hangnail or ingrown nail?
Nail biter, or recently had their nails done?
Recently punctured finger (tack, nail, thorn)?
Was the environment dirty?
Ocean or contaminated water exposure?
Animal or fish exposure to include cleaning fish tanks?
Touched any other infected area?
Blisters on mouth or genital area.
Popped a zit or boil.
Works in a garden?

11. Differential Cellulitis – warm, red, non-raised ill-defined boarders.
Erysipelas – well defined, edematous raised boarders.
Paronychia – swollen around nail bed, pus expressed.
Felon – associated puncture wound.
Herpetic Whitlow – burning, itching, clusters of blisters.
Flexor Tenosynovitis – uniform down the tendon, hurts to move finger.
Deep Space Infection – may have the 5 P’s of compartment syndrome.
Erysipeloid – animal or fish exposure, well defined, edematous raised boarders
Sporotrichosis – lymphatic spread, gardening history.
Aquarium granuloma – lymphatic spread, cold abscess, aquarium/fish exposure.
Necrotizing Fasciitis – intense pain, violate colored skin, swollen, crepitus, systemic symptoms (Fever, N/V)

18. #4 Fever and Shortness of Breath
44 y/o chief which a history of drinking excessively, reports to sick call with a fever and shortness of breath following a recent port call where he passed out drunk.
Did he vomit?
Any cough?
Chronic? Hemoptysis?
Recent influenza like illness?
Any of his friends sick?
Speed of progression of his dyspnea?
Smoking history?
Did he spend time in air-conditioned spaces?
Night sweats? Weight Loss?
PPD status and has he had any potential exposure?
Animal Exposures?

19. Differential Influenza – Like Illness (fever, muscle aches, pneumonia)
Adenovirus, Influenza, Parainfluenza, RSV, Human Metapneumovirus
Tuberculosis (chronic weight loss, fever, night sweats, cough)
Atypical pneumonia
Chlamydophila pneumoniae, Mycoplasma pneumonia, Etc.
Legionnaire’s Disease (old people who smoke in air conditioned rooms)
Community Acquired Pneumonia (Streptococcus pneumoniae)
Aspiration Pneumonia (anaerobes)

20. Diagnosis and Treatment
CXR PA and Lateral
Get the Respiratory Culture!!!
Respiratory Viral PCR Panels
Comorbidities
Alcoholism
Bronchiectasis
COPD
IVDU
Post CVA
Post-obstruction of bronchi
Post-influenza
CURB-65 (hospitalize if they have more than 1 of these)
Confusion
BUN >19
RR > 30 bpm
BP <90/60
Age >/=65
Don’t forget to vaccinate!
Influenza
Pneumococcal Vaccination

21. Diagnosis and Treatment
A good H&P will guide your antibiotic therapy.
No comorbidities, Diffuse CXR pattern – think atypicals
Use a macrolide like azithromycin or doxycycline
Comorbidities, Lobar Pneumonia – think Staph aureus, Strep pneumo, H. flu
Use a floroquinolone like levofloxacin
Did they have the potential to aspirate?
Cover anarobes – wound consider augmentin
Supper sick?
Go IV: ceftriaxone with azithromycin
Add vancomycin if you suspect resistant S. pneumoniae or MRSA.
Usually following influenza.

22. #5 Headache and Stiff Neck
23 y/o female presents with a fever, stiff neck, and a headache.
Does she have photophobia?
Is she confused?
Does she have nausea or vomiting?
Does she have a rash?
Does have meningeal signs on exam?

23. Differential Approach
Typical meningitis bugs in adults.
Meningococcal - Group B not covered in vaccine
New Meningococcal Group B Vaccines
Pneumococcal - uses steroids
H. influenzae – rare, now that everyone is vaccinated
Listeria – dairy products and deli meats
Atypical – HSV, Enterovirus, VZV, West Nile
Don’t delay treatment!
Ceftriaxone, dexamethasone, and vancomycin for empiric treatment.
LP if possible (low risk procedure).
Know how to do a Gram’s stain.

24. Prophylaxis for N. meningitides
Spread by respiratory droplets, not aerosolized.
Means prophylaxis only needed for close contacts.
Close contact is:
4 hours with the person during the week prior to illness.
Exposure to nasopharyngeal secretions (kissing, intubation, mouth to mouth resuscitation, etc.)
On a ship:
Those that work in the same confined space.
Those that are bunked in his immediate vicinity.
Those that he may have kissed or used their tooth brush, etc.
Medical personnel exposed to their respiratory secretions.
Rifampin preferred given concerns for ciprofloxacin resistance.

25. #6 Skin Rash 19 y/o with a foot rash. Does it itch?
Is it between the toes?
Is it on the soles of the feet?
Do they have to where their boots all day?
Are they using any creams? Has it been effective?
Is the rash anywhere else, such as the hands, groin or axilla?
Any systemic symptoms (fever, fatigue, headache, adenopathy, etc.)?

26. Differential Tenia pedis – Usually Tricophyton rubrum
Itches, scaly, fissures between toes
KOH prep
Erythrasma – Corynebacterium minutissimum
Demarcated brown and scaly with shedding skin.
Fluoresces coral red under Wood’s lamp.
Pitted Keratolysis – crateriform pitting over pressure bearing areas.
Dyshidrotic Eczema – itchy blisters
Intertrigo (Cutaneous Candidiasis) – itchy, with satellite lesions, macerated white skin in web spaces
Secondary Syphilis – on the soles of the feet, non-pruritic, systemic symptoms
Contact Dermatitis (irritant or allergic) – red irritated skin that is more tender than itchy, may blister.
Lichen Simplex Chronicus – Leathery thickened skin, pruritic
Psoriasis – dry, silvery, scaly, raised plaques that are non-pruritic.

35. #7 The Pecker Check 22 y/o male c/o a lesion around his anus.
Don’t ask Don’t Tell is no more!! Go ahead and ask the questions!!
Are you having unprotected sex to include anal sex?
How many partners? (sex never occurs on Navy ships)
Is it painful?
Do you have rectal pain or bleeding?
Do you have any lesions in you mouth or penis?
Do you have a drip or pain with urination?
Do you have swollen glands or a fever?

36. Differential
Genital Herpes – crops of blisters, painful ulcers, lymphadenopathy
Chancroid – very painful bleeding ulcers, ragged edge
Haemophilus ducreyi
Primary Syphilis – painless ulcer with associated lymphadenopathy
Secondary Syphilis – condyloma latum (contagious)
Lymphogranuloma Venereum
Starts as painless genital ulcer
Second stage is a lymphadenitis or proctitis (anal pain, rectal discharge, tenesmus)
Chlamydia trachomatis
Granuloma Inguinale
Painless nodules that ulcer and ooze, almost no lymphadenopathy, granulomatous boarders
Klebsiella granulomatis
HPV infection – condylomata acuminata, can lead to rectal cancer.

44. Pitfalls for Gonorrhea / Chlamydia
Not considering 3 site testing for gonorrhea and chlamydia.
Rectal and throat infection are usually asymptomatic.
You always cover chlamydia if GC positive but you don’t need to cover gonorrhea if only chlamydia positive.
You need to double cover Gonorrhea given resistance in the US.
Single dose of Ceftriaxone 250mg IM + Azithromycin 1 gram
Need to treat the partners.
Can use cefixime 400mg + azithromycin 1 gram for expedited partner therapy or EPT
Need to wait 7 days after treatment before having sex.
Forget to check for HIV.
Consider PrEP and HPV vaccination.

45. #8 Burning or Frequent Urination
23 y/o female with pain with urination.
Is it frequent?
Is there a fever?
Is there a burning sensation with urination?
Sexually active?
Is there vaginal discharge?
Do they have back or groin pain?
Is there blood in the urine?
Does you urine have an odor?

46. Pearls Don’t miss pyelonephritis! Know how to read your urinalysis.
Cystitis does not give you fever.
Know how to read your urinalysis.
Leukocyte Esterase means there are WBC present.
Nitrite Positive means bacteria are reducing nitrate to nitrite.
E. coli, Klebsiella, Proteus are nitritie positive
Pseudomonas, Enterococci, and S. saprophyticus are nitirite negative
Persistent hematuria should be worked up.
Sterile Pyuria – Think STD, TB, or Autoimmune Disease
Men rarely get UTI’s
Means that they should all be worked up further.
Hint, check the testicles and prostate.

47. Differential Causes of Urethritis \ Vaginitis
Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Trichomonas vaginalis
Diagnose with NAAT
Common Causes of UTI’s
Enterobacteriaceae (Exp: E. coli)
Staphylococcus saprophyticus
Enterococcus
Streptococcus agalactiae
Urethritis – burning urination
Cystitis – frequent urination
Vaginitis – vaginal discharge, dyspareunia
Pyelonephritis – fever, flank or inguinal pain

48. Treatment
Trimethoprim-Sulfamethxazole (TMP-SMX) is first line for uncomplicated UTI’s
Nitrofurantoin for those allergic to sulfa drugs.
Floroquinolones used if >20% of isolates in the area are TMP-SMX resistant
Fosfomycin can be used against ESBL’s but TMP-SMX is more effective.

49. #9 Pink Eye 35 y/o female sent down to the clinic for a red eye.
Is there vision loss or change?
Is there eye discharge?
Is there eye pain with movement?
Does it affect both eyes?
Is there photophobia?
Is there nasal congestion or sore throat?
History of allergies?
Exposure to chemicals, fumes, ext. (they can rub the chemicals in with their hands)
Do they where contacts?
Does she share make-up or eyedrops?
Recently had oral or unprotected sex?

50. Differential
Viral Conjunctivitis (red, itchy, bilateral, minimal serous drainage)
Usually Adenovirus
Bacterial Conjunctivitis (suppurative, unilateral)
Don’t forget about chlamydia and gonorrhea infections.
Allergic Conjunctivitis (dry, itchy eyes)
Corneal Abrasion (foreign body sensation, photophobia, h/o trauma)
Blepharitis (inflammation of the lid margin, crusting)
Hordeolum (stye)
Keratitis (eye pain, photophobia)

52. How to prevent the spread of infectious conjunctivitis.
Wash your hands with soap and water.
Alcohol sanitizers work well.
Avoid rubbing or touching your eyes.
If you do, wash you hands.
Gently rinse off eye crud several times through the day.
Avoid contact use.
Don’t share make-up, eye drops, contact solution.
Wash linens.
Yes, it’s contagious and should avoid work if possible.

53. #10 Vaccine Reactions Most all vaccines are very safe.
Risks outweigh the benefits.
Almost every vaccine is going to have soreness and mild inflation at the vaccine site and mild systemic symptoms such as fever and headache but here are the caveats you should look out for.
Don’t confuse cellulitis for a sore arm post vaccination!
The Arthus Reaction (Type III Hypersensitivity Reaction)
Don’t confuse a vagal response for an allergic reaction immediately after vaccination!

54. The super safe vaccines.
Usually means allergic reactions are 1 in a million. Systemic symptoms are mild.
Hepatitis A
Hepatitis B
HPV (Gardasil)
JE-Ixiaro
Meningococcal
IPV
Tdap
Typhoid Vi
Influenza (no you can’t catch the flu from the vaccine)

55. The Vaccines with Caveats.
Adenovirus
1 in 3 will have mild respiratory symptoms within 2 weeks.
1 in 100 with have inflammation of the GI tract or develop pneumonia.
Anthrax
Freak’in hurts. 1 in 2 will have a sore red arm.
Severe allergic reaction 1 in 100,000.
MMR
1 in 5 with fever, 1 in 20 with rash
Seizures rarely occur due to the induced fever.
1 in 40,000 will have temporarily low platelets

56. The Vaccines with Caveats
Rabies
6% receiving their booster will have hives, joint pain, and fever.
Varicella
1 in 25 will have a rash out to 1 month of the vaccination.
Also can have seizures due to induced fevers.

57. Small Pox Vaccination 1 in 175 will get myocarditis or pericarditis.
It’s a live virus, so don’t give it to anyone with immunosuppression.
Don’t give it to those with a history of eczema or atopic dermatitis.
After vaccination, avoid contact with babies and women who are pregnant or breastfeeding.
Progressive vaccinia – severe and life threatening.

58. Yellow Fever Vaccination
1 in 55,000 will have a severe allergic reaction.
1 in 125,000 will have a severe nervous system reaction.
Meningoencephalitis
Guillain-Barré
ADEM
Palsies
1 in 250,000 will have viscerotropic disease.
Multisystem organ failure leading to death.
Incidence increases with age.
Both the CNS reactions and viscerotropic disease have never been seen with the booster.

59. Yellow Fever Vaccination
2 week stay in South America
2 week stay in West Africa
Rate of catching YF
5/100,000
50/100,000
Rate of dying from YF
1/100,000
10/100,000
Sever Allergic Reaction
CNS Reaction
Viscerotropic Disease
All ages
1.8/100,000
0.8/100,000
0.4/100,000
Age > 60
1.6/100,000
1.0/100,000
Age > 70
2.3/100,000

60. The End
Questions?