1

AP112 Pathologic Diagnosis of Infectious

Diseases: New Strategies and Challenges

Course DirectorSherif R. Zaki, M.D., Ph.D.

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Course Objectives

• Differentiate between infectious and non-infectious processes

• Design syndromic approach to diagnosis of infectious diseases

• Compare histopathologic, special stains, immunohistochemical testing and molecular methods and make a rational decision on which methods to use in your practice

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Course Objectives• Decide which criteria/tests

(histopathology, special stains, IHC, etc) are applicable to achieve specific diagnoses

• Determine if testing can be performed in your laboratory vs. specialty laboratory

• Discuss clinical history, pathologic examination and epidemiologic analysis that might prompt consideration of a bioterrorism event or of an emerging disease

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Agenda

• Sherif Zaki, M.D., Ph.D. 1:35-2:15Chief, Infectious Disease Pathology Centers for Disease Control and PreventionRole of Pathology in Studies of Emerging Infectious Diseases and Other Health Threats

• Margie A. Scott, M.D. 2:15-3:00Chief, Pathology & Laboratory Medicine ServiceCentral Arkansas Veterans Healthcare SystemMicrobiology and Molecular Applications for the Modern Laboratory

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Agenda

• A. Brian West MD, FRCPath . 3:30-4:15Department of PathologyNew York University Medical CenterGastrointestinal Infections: a systematic approach to diagnosis

• Wun-Ju Shieh, M.D., M.P.H., Ph.D. 4:15-5:00Staff Pathologist, Infectious Disease Pathology Centers for Disease Control and PreventionPathologic Diagnosis of Encephalitis

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Role of Pathology in Studies of

Emerging Infectious Diseases and Other Public Health Threats

Sherif R. Zaki, M.D., Ph.D.Chief, Infectious Disease Pathology Activity

National Center for Infectious DiseasesCenters for Disease Control and Prevention

© College of American Pathologists 2004. Materials are used with the permission of

Sherif R. Zaki, MD, PhD.

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Factors in the Emergence of Infectious Diseases• Human demographics and behavior• Technology and Industry• Economic development and land use• International travel and commerce• Microbial adaptation and change• Breakdown of public health measures• Deliberate disseminationFrom Institute of Medicine, 1992

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Infectious Disease Pathology and Public Health• Pathologists among first health care workers

to encounter infectious disease outbreaks• Pathologists are in excellent position to

discover emerging infectious diseases• Collaborative research

– Epidemiologists– Clinicians– Veterinarians– Microbiologists

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Infectious Disease Pathology and Public Health• Many examples of recent emerging

infectious diseases diagnosed through autopsies

• Autopsy is increasingly being viewed as an effective surveillance tool– Pathologic specimens can serve as

sentinel indicators of emerging pathogens

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Recent Global Challenges to Public Health (CDC)

• 93 - Hantavirus Pulmonary Syndrome – U.S.• 94 - Plague/leptospirosis – India• 95 - Leptospirosis – Nicaragua• 95-01 -VHFs (Ebola, Lassa, RVF) – Africa, Asia• 96 - Typhus – Burundi• 97 - H5N1 Influenza – Hong Kong• 98-99 - Enterovirus 71 - Malaysia, Taiwan• 98 - Plague – Ecuador• 99 - Nipah virus – Malaysia, Singapore• 99-04 -West Nile virus – U.S.• 00 - Rift Valley – Kenya, Saudi Arabia, Yemen• 01 - Anthrax – U.S.• 03 - SARS – Global• 03 - Monkeypox – U.S.• 03-04 - Pediatric Influenza Deaths – U.S.• 02-04 – Emerging viral infections in transplant recipients – U.S.

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Syndromic Approach to Diagnosis of Emerging Infectious Diseases

• Hemorrhagic Fevers – Hantavirus, Lassa, Malaria,Anthrax

• Cutaneous Rash – Monkeypox, Rickettsialpox• Pneumonia – SARS, influenza• Encephalitis – WNV, Nipah• Transplant (Immunosuppressed) – WNV, LCM,

Rabies

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Syndromic Approach to Diagnosis of Emerging Infectious Diseases

• Histopathologic pattern• Laboratory approach

– Culture– Serology– EM– IHC– Molecular

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15

Tissues

VascularBone

Musculo-Skeletal

Eyes, SkinEyesSkin

Donor

Organs

HeartLungsLiver

PancreasKidney

Organ and Tissue Recovery

Screening and Testing

16Iwamoto M, et al. Transmission of West Nile Virus from an organ donor to four transplant recipients. NEJM, 2003; 348(22):2196-2203.Cushing MM, et al. Fatal West Nile virus encephalitis in a renal transplant recipient. AJCP, 2004; 121:26-31.

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Investigation of Rabies Infections in Organ Donor and Transplant Recipients –

Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR, 2004; 53(26):586-589.

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Investigation of Rabies Infections in Organ Donor and Transplant Recipients –

Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR, 2004; 53(26):586-589.

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Investigation of Rabies Infections in Organ Donor and Transplant

Recipients – Alabama, Arkansas, Oklahoma, and Texas, 2004.

MMWR, 2004; 53(26):586-589.

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Investigation of Rabies Infections in Organ Donor and Transplant Recipients –

Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR, 2004; 53(26):586-589.

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Case Histories• On Dec 8, 2003, CDC contacted by WI

DOH– Two organ transplant recipients died– Another organ transplant recipient with

seizure– All from same donor

• Organ procurement organization contacted, all stored tissues quarantined

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EM of Cytopathic Agentin Vero E6 Cells

Mouse Brain

LCM IHC

24Kidney recipient #1

25Kidney recipient #2: skin

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Liver recipient

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LCMV- liver transplant Lassa fever- liver

Imported Lassa fever – New Jersey. MMWR, 2004; In Press.

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Clinical History

• 38 yo male from NJ• Traveled to West Africa frequently• 08/21/04 – high fever, chills, severe

sore throat, diarrhea, and back pain• 08/23/04 – boarded flight from Sierra

Leone to Newark, connecting at Gatwick Airport

• 08/24/04 – arrived in Newark, was hospitalized, and died

Geographic Distribution

of Arenaviruses

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Airplane Seating PlanRow 19 A B C D E F J K L Row 19

Row 20 A B C D E F J K L Row 20

Row 21 A B C D E F J K L Row 21

Row 22 A B C D E F J K L Row 22

Row 23 A B C D E F J K L Row 23

Red – Index case

Green – contacted and healthy

Blue – not contacted

Imported Lassa fever – New Jersey. MMWR, 2004; In Press.

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•36 yo male 3rd mate on MS Overseas Marilyn

•Made port in West Africa (Sierra Leone, and Nigeria)

•08/23/04 – high fever, chills, severe sore throat, and myalgia

•08/31/04 – died onboard, body frozen in meat locker, and ship quarantined off of Texas coast

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33

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Dengue

Imported Dengue – United States, 1997 and 1998. MMWR, 2000; 49:248-53.

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Yellow Fever

Fatal Yellow Fever in a traveler returning from Venezuela, 1999. MMWR, 2000; 49:303-05.

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May 1993

On presentation

3 days later3 days later

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38

39

40

41

42

122

3

7

23

12

3

1

5

21

3

1 11 11112

3

12

1112

1122

12

32

12

4

1

3

112

12

1 112

6

43 3

111

32

4

6

4

223

1 1

33

8

6

3

6

23

11 122

12

32

1 11 1

1

34

7

5

1

2

3

1

4

1

1

23

1 111

121 11

1

1111

1

11

1

21

2

1 3

2

242

2

1 1

22

1

1

1

2

1

12

1

112

12

1

1

21

0

2

4

6

8

10

12

14

J M S J M S J M S J M S J M S J M S J M S J M S J M S J M S J

Month and Year of Onset

Num

ber o

f Cas

es

Alive Dead

Hantavirus Pulmonary Syndrome Cases by OutcomeUnited States, as of January 15, 2003

*Thirty-two additional cases (nineteen deceased) with onset before 1993 not shown.

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

N=333*

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44Zaki SR, et al. Leptospirosis associated with an outbreak of acute febrile illness and pulmonary hemorrhage, Nicaragua 1995: Lancet, 1996; 347:535-36.

test

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Zaki SR, et al. Leptospirosis associated with an outbreak of acute febrile illness and pulmonary hemorrhage, Nicaragua 1995: Lancet, 1996; 347:535-36.

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Rainfall Data 1994 - 1998, Springfield, IL

Jan Feb Mar Apr May Jun Jul0

2

4

6

8

10

12

Month

Prec

ipita

tion

(inch

es) 1998 Precipitation (inches) 1994-1997 Mean Precip. (inches)

Illinois triathlon

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Springfield Triathlon Participants (n=875)

nvestigation - telephone survey, case control study,it i ti ti i t l i ti ti l b t

49Guarner J, et al. Leptospirosis mimicking acute cholecystitis among athletes participating in a triathalon. Human Path., 2001; 32(7):750-52.

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Recognition: Palm Beach County, Florida• 63 yo male photo editor

employed by American Media, Inc.

• Onset 9/30/01: fever, fatigue, sweats, altered mental status

• Admitted to hospital 10/2

• CDC notification 10/3

Sa

sS

Alachua

BakerBay

Bradford

Brevard

Broward

Calhoun

Charlotte

Citrus

Clay

Collier

Columbia

Dade

De Soto

Dixie

Duval

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Hol mes

Indian River

Jackson

Jefferson

Lafayette

Lake

Lee

Leon

Levy

Liberty

Madison

Manatee

Marion

Martin

Monroe

NassauOkaloosa

Okeechobee

Orange

Osceola

PalmBeach

Pasco

Polk

Putnam

St Johns

St Lucie

nta Rosa

Sarasota

SeminoleSumter

SuwanneeTaylor

Union

Volusia

Wakulla

WaltonWashington

Alachua

BakerBay

Bradford

Brevard

Broward

Calhoun

Charlotte

Citrus

Clay

Collier

Columbia

Dade

De Soto

Dixie

Duval

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Hol mes

Indian River

Jackson

Jefferson

Lafayette

Lake

Lee

Leon

Levy

Liberty

Madison

Manatee

Marion

Martin

Monroe

NassauOkaloosa

Okeechobee

Orange

Osceola

Pal mBeach

Pasco

Polk

Putnam

St Johns

St Lucie

Sarasota

SeminoleSumter

SuwanneeTaylor

Union

Volusia

Wakulla

WaltonWashington

Santa RosaEscambia

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InhalationalAnthrax

CSF Gram Stain

Chest CT

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Guarner J, et al. Pathology and pathogenesis of bioterrorism-related inhalational anthrax. AJP, 2003;163(2):701-9.

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Inhalational Anthrax: Florida 2001

Guarner J, et al. Pathology and pathogenesis of bioterrorism-related inhalational anthrax. AJP, 2003;163(2):701-9.

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Guarner J, et al. Pathology and pathogenesis of bioterrorism-related inhalational anthrax. AJP, 2003;163(2):701-9.

55Guarner J, et al. Pathology and pathogenesis of bioterrorism-related inhalational anthrax. AJP, 2003;163(2):701-9.

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Shieh W-J, et al. The critical role of pathology in the investigation of bioterrorism-related cutaneous anthrax. AJP, 2003;121:26-31.

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Index Case in New York City

• Oct 1st: Seen by Infectious Disease MD and reports handling “threat” letter at work

• Oct 3rd: Bacterial cultures of wound and Sept 25th letter test (-) for B.

anthracis• Oct 8th: Patient re-contacts DOH after

hearing of Florida anthrax case• Oct 9-11:Developed contingency plans with

NBC

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Friday, October 12, 2001

• 12 AM: CDC reports (-) PCR on biopsy• 3 AM: CDC reports IHC + on biopsy• 6 AM: NYCDOH’s EOC activated• 9 AM: NBC informed. Start epi

investigation• 12 PM: Press conference at NBC• 3 PM: Open antibiotic distribution clinic

Index Case in New York City

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Shieh W-J, et al. The critical role of pathology in the investigation of bioterrorism-related cutaneous anthrax. AJP, 2003;121:26-31.

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When it rainsit pours….

• By the evening of October 12th, 3 additional highly suspect cutaneous cases were reported (all associated with major media outlets)

• As each case confirmed by IHC, multidisciplinary teams mobilized for on-site investigations and response

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1. Palm Beach County – 10/3

3. Washington, DC – 10/15

2. New York City – 10/124. Trenton, NJ – 10/17

Epidemiologic Investigations of Cases

5. Oxford, CT – 11/20

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Hamilton, NJPostal Facility

Morgan, NYCPostal Facility

West Palm, FLPostal Facility

Oct. 9 Envelopes

Sept. 18Envelopes

AMI

NBC

ABC

NY Post

CBS

State Dept, VA Mail Processing

Facility

Brentwood, DCPostal Facility

Daschle Office

Leahy Office

Hospital Worker, NYC

Elderly Woman, CT

Bookkeeper, NJ?

?

?

Cases of anthrax associated with paths of mailed envelopes and intended target sites.

Cutaneous case

Inhalational case

Intended target

Known path of mailed envelopes

Recovery site of implicated envelope

? *

Presumed or intendedpath of mailed envelopes

Mail Carrier, NJ

?

? Uncertain path of contaminated mail

Blue = Sept 18 envelopesGreen = Oct 9 envelopesOrange = Undetermined exposure to envelopes

**

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Spider Bite

(brown recluse)

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68

69

70

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Prarie Dog (tongue)

Guarner J, et al. Pathology of monkeypox in prarie dogs: clues into transmission and pathogenesis. EID, 2004; 10(3):426-31.

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Guangdong Province,

China

A

A

Hotel MHong Kong

B

J

H

Hospital 2Hong Kong

A

H

J

B

4 other Hong Kong Hospitals

C DE

Hospital 3 Hong Kong

Hospital 1 HK

Hospital 4 Hong Kong

2 family members

C D E

34 HCWs

HCW

B Germany

Bangkok

Singapore

United States

I

IL§

M§

Vietnam

K † IrelandK †

37 HCWs

HCW

0 HCWs

28 HCWs

156 close contacts of HCWs

and patients

FG †

Canada

G †F

4 family members 10 HCWs

37 close contacts

99 HCWs (includes 17 medical students)

4 HCWs*

3 HCWs

HCW

HCW

2 family members

Unknown number

close contacts

2 close contacts

* Health-care workers; † All guests except G and K stayed on the 9th floor of the hotel. Guest G stayed on the 14th floor, and Guest K stayed on the 11th floor; § Guests L and M (spouses) were not at Hotel M during the same time as index Guest A but were at thehotel during the same times as Guests G, H, and I, who were ill during this period.

Chain of transmission among guests at Hotel M—Hong Kong, 2003

Data as of 3/28/03

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Ksiazek TG, et al. A novel coronavirus

associated with Severe Acute Respiratory Syndrome.

NEJM, 2003; 348(20):1953-66.

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Zaki SR, et al. Measles. In: Pathology of Infectious Diseases. Eds.

Appleton and Lange, Stamford, CT, 1997;125-136.

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78

79

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Ksiazek TG, et al. A novel coronavirus associated with Severe Acute Respiratory Syndrome.

NEJM, 2003; 348(20):1953-66.

SARS Coronavirus Isolate

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Coronavirus-infected cell in

Bronchial Alveolar Lavage (BAL) of SARS

Patient

Ksiazek TG, et al. A novel coronavirus associated with Severe Acute Respiratory Syndrome.

NEJM, 2003; 348(20):1953-66.

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Shieh W-J, et al. Immunohistochemical, in situ hybridization, and ultrastructurallocalization of SARS-associated coronavirus in lung of a fatal case of severe acute respiratory syndrome in Taiwan. Hum Path, 2004; (submitted).

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Shieh W-J, et al. Immunohistochemical, in situ hybridization, and ultrastructurallocalization of SARS-associated coronavirus in lung of a fatal case of severe acute respiratory syndrome in Taiwan. Hum Path, 2004; (submitted).

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SARS-CoV in Intraalveolar Fibrin

Shieh W-J, et al. Immunohistochemical, in situ hybridization, and ultrastructural localization of SARS-associated coronavirus in lung of a fatal case of severe acute respiratory syndrome in Taiwan. Hum Path, 2004; (submitted).

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Hamster SARS Model

Anjeannette R, et al. SARS Coronavirus infection of Golden Syrian hamsters. J Virol, 2004; (in press).

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2003-04 Influenza Season• Early onset

– Early reports of pediatric deaths• Increased media attention• H3N2 predominant strain• Mismatch of vaccine and circulating

strain• CDC requested reporting of influenza-

associated deaths

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Domestic Influenza Activity – Pediatric Impact

0

1

2

3

4

5

6

7

8

9

10/11

/2003

10/18

/2003

10/25

/2003

11/1/

2003

11/8/

2003

11/15

/2003

11/22

/2003

11/29

/2003

12/6/

2003

12/13

/2003

12/20

/2003

12/27

/2003

1/3/20

041/1

0/200

41/1

7/200

41/2

4/200

41/3

1/200

42/7

/2004

Date of Death

Num

ber o

f Dea

ths

Influenza A (H3N2) Fujian-like

N = 135 deaths from 38 states

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Signs and Symptoms (n=135)

11%14%30%37%48%59%77%Percentage

Vomiting40 Seizures19 Diarrhea15

Runny nose/congestion50 Difficulty breathing65

Sign/symptom# children

Cough80 Fever/ feverishness104

Children experienced > one symptomChildren experienced > one symptom

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90

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Influenza

Guarner J, et al. Immunohistochemical and in situ hybridization studiesof influenza A virus infection in human lungs. AJCP, 2000; 114:227-33.

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Laboratory confirmation*(n=135)

• 41 (30%) Viral culture• 82 (61%) Rapid tests

– 35 (43%) were confirmed by a second method • 23 (17%) Direct Fluorescent antibody• 18 (13%) IHC staining**• 4 (3%) PCR

* Some children were tested by > 1 method* Some children were tested by > 1 method** 6 diagnosed by IHC alone** 6 diagnosed by IHC alone

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Pandemic Influenza: The Ever Present Threat

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Direct Interspecies Transmission of Avian Viruses to Humans Exposed to Infected Poultry

• 1997: 18 cases of human respiratory illness caused by HP avian H5N1; 6 deaths – Hong Kong

• 1998/9: 8 cases of human respiratory illness caused by H9N2; no deaths –China, HK

• 2003: 2 additional HP H5N1 cases in humans; 1 death – China, HK

• 2003: >80 cases of infection by HP H7N7 avian viruses; 1 death - ND

• 2004: 28 cases of human respiratory illness by HP H5N1 avian viruses; 20 deaths – Vietnam and Thailand

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Summary

• Era of increased awareness of emerging and reemerging diseases

• Fundamental principle is recognition of these diseases

• Importance of multidisciplinary approach• Importance of syndromic approach• Importance of traditional laboratory and

contemporary methods• Frontline role of pathology

– Recognition of emerging infectious diseases– Guiding epidemiologic investigations– BT investigations