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Slide 1JSOMTC, SWMG(A)
Bacterial InfectionsPFN: SOMCML03
Hours: 2.5
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of “Bacterial Infections”
Condition: Given a lecture in a classroom environment
Standard: Receive a minimum score of 75% on the written exam IAW course standards
Slide 3JSOMTC, SWMG(A)
References
Pathophysiology for the Health Professions, 4th Edition
Merck Manual, 19th Edition
Current Medical Diagnosis & Treatment,
51st Edition
Special Operations Forces Medical Handbook, 2nd Edition
Sanford’s Guide to Antimicrobial Therapy, 44th Edition
2
Slide 4JSOMTC, SWMG(A)
Reason
The regions that SOF personnel deploy to are among the most disease‐ridden places on the planet. Preventative measures combined with maintaining a high index of suspicion will result in more combat ready forces on the battlefield accomplishing the mission.
Slide 5JSOMTC, SWMG(A)
Agenda
Identify Group A B‐hemolytic Streptococcusand the diseases it can cause
Communicate the etiology, signs and symptoms, the Jones Criteria, diagnostic tests, and management of rheumatic fever
Communicate the etiology, signs and symptoms, diagnostic tests, and management of bacterial meningitis
Slide 6JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of anthrax, to include: pneumonic, G.I., and cutaneous forms
Communicate the etiology, signs and symptoms, diagnostic tests, and management of brucellosis
3
Slide 7JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of tularemia
Communicate the etiology, signs and symptoms, diagnostic tests, and management of typhoid
Communicate the etiology, signs and symptoms, diagnostic tests, and management of cholera
Slide 8JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of plague
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the four kinds of tetanus, to include: generalized, neonatal, local, and cephalic tetanus
Slide 9JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Clostridium perfringensinfections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Bartonella bacterial diseases, to include: Cat Scratch Disease, Trench Fever, and Oroya Fever
4
Slide 10JSOMTC, SWMG(A)
Identify Group A Beta‐hemolytic Streptococcus and the Diseases it
Can Cause
Slide 11JSOMTC, SWMG(A)
A Look at Gram‐positive Cocci
Slide 12JSOMTC, SWMG(A)
Streptococcal Infections
Group A Beta‐hemolytic Streptococcus‐GABS
Streptococcal pharyngitis
Impetigo
Necrotizing fasciitis
Indirect sequelae
Scarlet fever
Rheumatic fever
Glomerulonephritis
5
Slide 13JSOMTC, SWMG(A)
Strep Pharyngitis
Slide 14JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, the Jones Criteria, Diagnostic Tests, and Management of Rheumatic
Fever
Slide 15JSOMTC, SWMG(A)
Rheumatic Fever
Acute inflammatory complication of GABS infection
Characterized by:
Chorea (involuntary writhing movements)
Carditis
Arthritis
6
Slide 16JSOMTC, SWMG(A)
Rheumatic Fever
Acute Rheumatic Fever (ARF) ‐ Typically occurs approximately 19 days after untreated streptococcal pharyngitis
Slide 17JSOMTC, SWMG(A)
Rheumatic Fever
Etiology ‐ GABS
Slide 18JSOMTC, SWMG(A)
Rheumatic Fever
Group A Beta‐hemolytic strep
7
Slide 19JSOMTC, SWMG(A)
Subjective: Symptoms
Fever, malaise, wt. loss
Migratory arthralgias (polyarthritis)
Rash, erythema marginatum
Sub Q nodules (involving extensor surfaces)
Chorea
Carditis: palpitations, chest pain, SOB, lethargy, fatigue
Rheumatic Fever
Slide 20JSOMTC, SWMG(A)
Rheumatic Fever
History
Have you had a sore throat in the last few weeks?
Have you taken your temperature or do you feel hot?
Have you felt sick for a long time?
Slide 21JSOMTC, SWMG(A)
Objective: Signs
Fever (102 F)
Rash (erythema marginatum)
Short, abrupt, non‐purposeful movements (often disappear during sleep)
Grimacing
Bibasilar rales, aortic insufficiency or mitral regurgition murmurs, S3 gallop
Rheumatic Fever
8
Slide 22JSOMTC, SWMG(A)
Rheumatic Fever
Erythema Marginatum
Slide 23JSOMTC, SWMG(A)
Rheumatic Fever
Laboratory findings
ESR >120 mm/h
WBC 12,000 – 20,000
ECG – prolonged PR interval
CXR may show cardiomegaly
ASO titer
Slide 24JSOMTC, SWMG(A)
Diagnosis requires the following:
Two major criteria or
One major and two minor criteria
Jones Criteria (Rheumatic Fever)
9
Slide 25JSOMTC, SWMG(A)
Major criteria
Polyarthritis
Chorea
Carditis
Erythema Migrans
Sub Q nodules
Evidence of recent GABS (+ culture)
Minor criteria
Arthralgia
Fever
Elevated ESR
Prolonged PR interval
Jones Criteria (Rheumatic Fever)
Slide 26JSOMTC, SWMG(A)
Rheumatic Fever
Differential diagnosis
Polyarthritis:
• Gonococcal arthritis
• Subacute bacterial endocarditis
• Lyme disease
• Reiter’s syndrome
Carditis:
• Viral myocarditis
• Pericarditis
Slide 27JSOMTC, SWMG(A)
Management
New recommendation (2012) by Infectious Disease Society of America to only treat pharyngitis patients with a positive test for GABS
Rapid Strep to become part of MES
Primary: Benzathine Penicillin or oral PCN VK
Alternate: Clindamycin or Azithromycin
ASA or NSAID
Rheumatic Fever
10
Slide 28JSOMTC, SWMG(A)
Patient education
Relapsing condition
• Prophylaxis treatment before procedures
Bedrest until afebrile
Diet regular
Medications: expect tinnitus with high dose aspirin
Rheumatic Fever
Slide 29JSOMTC, SWMG(A)
Rheumatic Fever
Complication of untreated strep throat
Presentation: young patient (5 – 20 y/o)
Most common clinical manifestations
Poly arthritis (painful migratory arthritis)
Chorea (spastic involuntary movements)
Carditis (rubs/murmurs/gallop)
Jones criteria used for diagnosis
Slide 30JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Bacterial Meningitis
11
Slide 31JSOMTC, SWMG(A)
Caused byGram‐negative Aerobic Cocci
Slide 32JSOMTC, SWMG(A)
Meningococcal Meningitis(Neisseria Meningitidis)
Slide 33JSOMTC, SWMG(A)
Meningococcal Meningitis
Types
Neisseria meningiditis ‐ most common etiology for large, periodic epidemics
Strep. pneumoniae ‐ most often cause of community acquired infection
H. influenza ‐ decreased incidence with childhood vaccination programs
12
Slide 34JSOMTC, SWMG(A)
Meningococcal Meningitis
Characteristics
High fever, headache, and stiff neck
Infection has rapid onset / progression
Prompt diagnosis and treatment critical towards reduction of morbidity
Slide 35JSOMTC, SWMG(A)
Slide 36JSOMTC, SWMG(A)
Meningococcal Meningitis
Symptoms
Initial
• High fever
• Headache
• Stiff neck
•Malaise
• Photophobia
• Arthralgias/myalgias
Advanced
• Delirium
• Nausea / vomiting
• Skin rash
• Dizziness
• Seizures
• Coma
13
Slide 37JSOMTC, SWMG(A)
Meningococcal Meningitis
History
How fast did your symptoms progress?
Have you been exposed to others who have been ill or had meningitis?
Have you had meningitis in the past?
Does it hurt to bend your neck or touch your chin to your chest?
Vaccinations against meningitis?
Travel to “meningitis belt”?
Recently done “The Haj”?
Slide 38JSOMTC, SWMG(A)
Meningococcal Meningitis
Objective: Signs
Fever to 104oF or 40oC
Cervical meningismus
Prostration
Toxic appearance
Slide 39JSOMTC, SWMG(A)
Meningococcal Meningitis
Hemorrhagic petechial skin lesions
Possible papilledema due to increased ICP
Eponyms / classic signs
Meningeal signs
Brudzinsky sign
Kernig’s sign
14
Slide 40JSOMTC, SWMG(A)
Slide 41JSOMTC, SWMG(A)
Meningococcal Meningitis Brudzinsky ‐ flexion of head / neck onto chest causes increase of pain of nuchal or spinal regions / patient will tend to flex the leg / knee
Kernig's ‐ extension of leg / knee with patient in supine position – this movement is limited by spasm of hamstring which also causes pain
Slide 42JSOMTC, SWMG(A)
Lab: WBC Count ‐ Leukocytosis
15
Slide 43JSOMTC, SWMG(A)
Lab: Gram‐negative Cocci
Slide 44JSOMTC, SWMG(A)
Meningococcal Meningitis
CSF analysis
Bacterial form ‐ elev WBC (over 10000) PML* predom., decreased glucose, increased protein
Viral form ‐ WBC decreased (below 1000 ), less than 50% PML’s, nl glucose, nl protein
Slide 45JSOMTC, SWMG(A)
Meningococcal Meningitis
Assessment ‐ DDX
Rickettsial infection
Dengue
Leptospirosis
Cerebral malaria
Malignancy
Severe viral or bacterial sepsis
Subdural/epidural hematoma
Stroke
Toxin (e.g., drugs, ETOH, etc.)
16
Slide 46JSOMTC, SWMG(A)
Meningococcal Meningitis
Plan (Empiric Treatment)
Availability of certain procedures may be limited in the field
Begin antibiotics as soon as possible
Empiric choices: penicillin or ampicillin
Ceftriaxone (Rocephin) or cefotaxime (3rd generation cephalosporin)
Plus vancomycin in adults to cover possibility of penicillin resistant Strep. pneumoniae
Slide 47JSOMTC, SWMG(A)
Meningococcal Meningitis
Plan (cont.)
Evacuate immediately
Airway support/oxygen (intubate as needed)
Fluid hydration with IV NS or LR
Control fever with Tylenol
Consider steroids (Decadron)
Respiratory isolation x 24h
Intimate contacts: prophylaxis
Slide 48JSOMTC, SWMG(A)
Meningococcal Meningitis
Prevention
Isolation
Medications
• Ciprofloxacin 500mg PO single dose
• Ceftriaxone 250 mg IM single dose
Vaccine
Elimination of carrier
17
Slide 49JSOMTC, SWMG(A)
Meningococcal Meningitis
Treatment
High index of suspicion
High fever, headache, stiff neck
Rapid progression of symptoms (hours)
Administration of broad‐spectrum antibiotics should not await the results of diagnostic tests
Slide 50JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of the Three Forms of Anthrax
Slide 51JSOMTC, SWMG(A)
Caused by Gram‐positive Bacilli
18
Slide 52JSOMTC, SWMG(A)
Anthrax
Slide 53JSOMTC, SWMG(A)
Anthrax
Characteristics
Acute bacterial (spore‐forming bacillus) infection
Transmission
• Break in skin / mucus membrane
• Inhalation (pneumonic form)
• Ingestion
Inhalation form uniformly fatal w/o treatment
Cutaneous form approx 10% fatal w/o treatment
Slide 54JSOMTC, SWMG(A)
Anthrax
Subjective (Symptoms)
Cutaneous• Pruritic papule
• Ulcer
• Vesicle / pustule
• Painless eschar
• Non‐blanching petechiae
19
Slide 55JSOMTC, SWMG(A)
Anthrax
Slide 56JSOMTC, SWMG(A)
Anthrax
Slide 57JSOMTC, SWMG(A)
Anthrax
20
Slide 58JSOMTC, SWMG(A)
Anthrax
Subjective (continued)
Pulmonary (bio‐weapon)
• Fever
• URI‐like cough and chest discomfort
• 36‐48 h after infection, stridor; respiratory distress
• Shock and death
Slide 59JSOMTC, SWMG(A)
Anthrax
History
Is anybody else in your unit sick with the same symptoms?
Have you handled animal carcasses or local products made from hide or wool?
Did you have a rash that turned into a painless sore?
Slide 60JSOMTC, SWMG(A)
Anthrax
Objective (Signs)
Inspection: papule with vesicles forms an ulcer; non‐tender ulcer with black eschar
• Rapid respiratory rate, neck and chest edema
Auscultation: rhonchi or rales; hypotension
Palpation: regional adenopathy
Percussion: localized dullness (pulmonary)
21
Slide 61JSOMTC, SWMG(A)
Anthrax
Lab / x‐ray
Gram stain ‐ gram positive rods / boxcar shape
Blood culture
Sputum culture
X‐ray: mediastinal widening and lymph node enlargements
Slide 62JSOMTC, SWMG(A)
Anthrax
Lab / X‐ray
Slide 63JSOMTC, SWMG(A)
Anthrax
DDx
Staphylococcal boil
Orf
Scrub typhus
Spider bite
Tularemia
Influenza
22
Slide 64JSOMTC, SWMG(A)
Anthrax
Plan (Treatment)
Cutaneous‐ 80% self‐limiting
• Ciprofloxacin 500 mg PO bid x 60d or
• Doxycycline 100 mg PO bid x 60d
Pulmonary‐Begin antibiotics as soon as possible:
• Ciprofloxacin 400mg IV q12h x 7‐10d
Prophylaxis – Empiric (presumed exposure)
• Ciprofloxacin 500 mg po bid x 60d or
• Doxycycline 100 mg PO bid x 60d
• Both reduced to 30d for vaccinated personnel
Slide 65JSOMTC, SWMG(A)
Anthrax
Considerations
Inhalation form = poor prognosis even with appropriate therapy
Cutaneous form = almost always responds to timely antimicrobial therapy
Slide 66JSOMTC, SWMG(A)
Anthrax
Highly infectious disease of animals
Spores resist destruction and remain viable in soil for decades
Several forms of transmission
Cutaneous is the most common (occupational)
Pulmonary anthrax is often fatal (Bio‐weapon)
Ciprofloxacin (Doxy is alternate)
Vaccine is available*
23
Slide 67JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Brucellosis
Slide 68JSOMTC, SWMG(A)
Brucellosis (Malta or Undulant Fever)
Slide 69JSOMTC, SWMG(A)
Brucellosis
Subjective (Symptoms)
Fever– prolonged, unpredictable
Relative bradycardia
Flu‐like symptoms
Profuse malodorous sweating
Chronic (wks‐months): fever, wt. loss, arthralgias, myalgias
24
Slide 70JSOMTC, SWMG(A)
Brucellosis
History
Have you had any raw milk or cheese?
Have you come in contact with cattle, goats, buffalo, camels, reindeer, caribou, yaks, coyotes, deer or swine?
Do any of your joints hurt?
Slide 71JSOMTC, SWMG(A)
Objective (Signs)
Temperatures to 104o F
Palpation: generalized adenopathy
Chronic: hepatomegaly; splenomegaly
Brucellosis
Slide 72JSOMTC, SWMG(A)
Brucellosis
Assessment
Travel history, animal exposure, and consuming unpasteurized milk products
DDX
Enteric fever
TB (non pulmonary)
Non‐falciparummalaria
25
Slide 73JSOMTC, SWMG(A)
Brucellosis
Plan (Treatment)
Primary: doxycycline with gentamicin (danger of renal insufficiency)
Alternate: doxycycline and rifampin
High incidence of relapse with single agent
Slide 74JSOMTC, SWMG(A)
Brucellosis
Patient education
Avoid untreated milk; boil milk first
Avoid doxycycline in children who are < 8, excessive sun light exposure
Take doxy with food to avoid nausea
Do not take doxy with high‐calcium food*
Do not lay down for less than 1 hr after taking**
Slide 75JSOMTC, SWMG(A)
Brucellosis
Systemic febrile illness
Fever, headache, chills and body aches
Positive history of exposure to infected animals or animal products (raw milk)
Combination therapy
26
Slide 76JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Tularemia
Slide 77JSOMTC, SWMG(A)
Tularemia
Acute disease with several forms
Transmitted by ticks and deer flies or contact with infected animal (skinning rabbits)
Characterized by local ulcerative lesion and regional lymphadenopathy
The pneumonic form is potential bio‐weapon
Slide 78JSOMTC, SWMG(A)
Subjective (Symptoms)
Fever
Nausea and vomiting
Severe prostration
Tularemia
27
Slide 79JSOMTC, SWMG(A)
Tularemia
History
Have you recently had a tick exposure?
Have you been hunting and skinned/dressed/ate any small wild animals?
How long have you felt feverish? (Can last 1 month)
Slide 80JSOMTC, SWMG(A)
Tularemia
Objective (Signs)
Inspection: Fever to 104o F; relative bradycardia; papule; exudative pharyngitis; conjunctivitis; eyelid edema
Rash: Maculopapular, ulcer
Auscultate: Rales
Palpate: Swollen localized lymphadenopathy
Slide 81JSOMTC, SWMG(A)
Tularemia
Oculoglandular
Ulcer of Tularemia
28
Slide 82JSOMTC, SWMG(A)
Tularemia
Cervical lymphadenitis
Slide 83JSOMTC, SWMG(A)
DDX
Meningococcal infection
Rickettsial infection
Cat‐scratch disease
Syphilis
Lymphogranuloma
Plague
Anthrax
Tularemia
Slide 84JSOMTC, SWMG(A)
Plan (Treatment)
Primary: streptomycin / gentamicin
Alternative(s): doxycycline / ciprofloxacin
Tularemia
29
Slide 85JSOMTC, SWMG(A)
Francisella tularensis is a small non‐sporulating, aerobic bacillus that can enter the body by ingestion, inoculation, inhalation, or contamination
A history of exposure to rabbits or ticks
Localized ulcer and swollen lymph nodes
Pneumonic form is potential bio‐weapon
Tularemia
Slide 86JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Typhoid
Slide 87JSOMTC, SWMG(A)
Typhoid Fever
30
Slide 88JSOMTC, SWMG(A)
Typhoid Fever
Typhoid fever – Salmonella typhi
Illness common in developing countries with poor sanitation
Incubation 1‐3 weeks after exposure
Slide 89JSOMTC, SWMG(A)
Typhoid Fever
Subjective (Symptoms)
Flu‐like symptoms
Rash – transient rose‐colored (rose spots)
Constipation / diarrhea (pea soup)
Abdominal discomfort (intestinal perforation)
Slide 90JSOMTC, SWMG(A)
History
How long have you felt feverish?
Have you noticed any red to pink spots on your abdomen or chest?
Have you recently traveled in a developing country?
What do you BMs look like*?
Typhoid Fever
31
Slide 91JSOMTC, SWMG(A)
Typhoid Fever
Objective (Signs)
Stepladder temperatures
Relative bradycardia
Rose spots (2‐3 mm) pink to red papules on chest / abdomen that fade with pressure
Abdominal distension
Bloody diarrhea
Splenomegaly / hepatomegaly
Slide 92JSOMTC, SWMG(A)
Typhoid Fever
Rose Spots
Slide 93JSOMTC, SWMG(A)
Typhoid Fever
Laboratory
WBC count is lowered
Fecal leukocytes
Anemia
32
Slide 94JSOMTC, SWMG(A)
Typhoid Fever
DDX
Non‐typhoidal salmonella
TB
Hepatitis
Leptospirosis
Malaria
Amebic liver abscess
Brucellosis
Slide 95JSOMTC, SWMG(A)
Plan (Treatment)
Primary: ciprofloxacin
• Avoid in pre‐pubertal children
Alternative: ceftriaxone (Rocephin)
• Azithromicin
Steroids for delirium or shock (dexamethasone)
Typhoid Fever
Slide 96JSOMTC, SWMG(A)
Patient education
Use tepid baths to bring down temperature
Vigorous oral rehydration
Avoid laxatives, salicylates
Immunize
Preventive medicine
Typhoid Fever
33
Slide 97JSOMTC, SWMG(A)
Typhoid Fever
Step‐ladder fever, prostration, rose‐colored rash, and abdominal pain
Transmitted in feces of asymptomatic carriers or the urine / stool of those with active disease
Diarrhea with bleeding (positive Guaiac test)
Vaccine is available
Slide 98JSOMTC, SWMG(A)
Typhoid Fever
Typhoid Mary (1869‐1938)
Asymptomatic carrier
Cook in NYC
Associated with 53 cases of Typhoid, including 3 deaths
Changed name to continue cooking
Quarantined last 23 years of her life and died of pneumonia there
Slide 99JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Cholera
34
Slide 100JSOMTC, SWMG(A)
Cholera
Slide 101JSOMTC, SWMG(A)
Cholera
Acute infection
Vibrio cholerae
Involving the entire small bowel
Profuse watery diarrhea, vomiting, muscular cramps
Dehydration, oliguria, and collapse
Possible death w/o rehydration
Slide 102JSOMTC, SWMG(A)
Cholera
Symptoms and signs
Incubation 1‐3 days
Can be mild to fulminant diarrhea
Rice‐water stools
Vomiting
Hypovolemia
Oliguria and anuria
Circulatory collapse
35
Slide 103JSOMTC, SWMG(A)
DX
Confirmed ‐ isolation of Vibrio cholerae
DDX:
Shigellosis dysentary
Typhoid fever
Amebic dysentary
Pseudomembranous colitis
Cholera
Slide 104JSOMTC, SWMG(A)
Treatment Correct hypovolemia
•Oral Rehydration Solution (ORS)
• Intravenous (LR)
Medications:• Cipro
• Doxy
• Tmp‐smx (e.g., Bactrim or Septra)
• Erythro
Cholera
Slide 105JSOMTC, SWMG(A)
Profuse watery diarrhea ‐ (rice water), 1L/h
Potential for epidemics – spread by contamination of water and food
Aggressive rehydration therapy (primary treatment)
Antibiotics
Vaccines not very effective, and generally not recommended
Cholera
36
Slide 106JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of the Three Forms of Plague
Slide 107JSOMTC, SWMG(A)
Plague
Slide 108JSOMTC, SWMG(A)
Plague Bubonic Plague, Pestis, Black Death
A highly fatal illness – transmitted by a bite from a rodent flea or by contact with infected wild rodents
The bubonic form (95% of cases)
The pneumonic form and septicemic form are rapidly toxic and nearly always fatal*
Plague
37
Slide 109JSOMTC, SWMG(A)
Causative organism ‐ Yersinia pestis, Gram‐negative rod
Reservoir ‐ primarily wild rodents (rats, chipmunks, and some other mammals)
Vector ‐ infected flea
Pneumonic plague vector ‐ man to man via infected droplets from pulmonary lesions of Yersinia pestis
Endemic to all continents, except Australia
Plague
Slide 110JSOMTC, SWMG(A)
Plague
Bubonic
Pneumonic
Septicemia
Slide 111JSOMTC, SWMG(A)
Bubonic plague
Most common form
> 50% mortality in untreated patients, < 5% mortality in treated patients
Incubation period ‐ varies from hours to 12 days, but usually 2‐5 days
Plague
38
Slide 112JSOMTC, SWMG(A)
Pneumonic plague
Incubation period 2 to 3 days
Untreated patients die within 48 hours of symptoms
Immediate treatment
Plague
Slide 113JSOMTC, SWMG(A)
Septicemic plague
Usually occurs with bubonic plague
May be fatal before the manifestations of bubonic plague occur
Incubation period ‐ a few hours to days
Plague
Slide 114JSOMTC, SWMG(A)
History
Do you have tender lymph nodes?
Can you see or recall a flea bite near the bubo?
Have you been handling rodents lately?
How long have symptoms been present?
Plague
39
Slide 115JSOMTC, SWMG(A)
Plague
Signs and symptoms
High fever with sudden onset
Chills
Severe headache
Tachycardia
Slide 116JSOMTC, SWMG(A)
Bubonic Plague
Bubonic plague
Enlarged lymph nodes (buboes)
• Extremely tender
• Inguinal, axillary nodes most common
Meningeal signs may be seen
Slide 117JSOMTC, SWMG(A)
Plague
Bubonic Plague
40
Slide 118JSOMTC, SWMG(A)
Septicemic plague
Secondary to bubonic or pneumonic plague
Abdominal pain
Nausea and vomiting
Signs of bleeding‐ purpura or DIC
Hypertension
Shock
Plague
Slide 119JSOMTC, SWMG(A)
Plague
Septicemic Plague
Slide 120JSOMTC, SWMG(A)
Pneumonic plague
Dyspnea
Painless cough
Hemoptysis
Untreated, fatal within 48 hours
Plague
41
Slide 121JSOMTC, SWMG(A)
Plague
Pneumonic Plague
Slide 122JSOMTC, SWMG(A)
Laboratory
Gram’s stain of bubo or sputum
•Gram‐negative coccobacillus with a bipolar (safety pin) appearance
CXR: diffuse pneumonitis
• Increased markings throughout lung fields
Plague
Slide 123JSOMTC, SWMG(A)
Plague
Bipolar or “safety pin” appearance
42
Slide 124JSOMTC, SWMG(A)
Plague Dx
Based on recovery of the organisms from blood, bubo, sputum, or lymph
DDX:
Tularemia
Rickettsial infection
Acute lymphadenitis
Dengue
Typhus
Hantavirus
Slide 125JSOMTC, SWMG(A)
Plague
Plan
Treatment:
• Primary: gentamicin IV (adjust to kidney function)
• Alternative: doxycycline
• Note: if meningitis develops, use ciprofloxacin or choramphenicol
Patient education: Plague is a quarantinabledisease subject to World Health Organization regulations (report to higher!)
Slide 126JSOMTC, SWMG(A)
Plague
Antibiotic management
Start immediately if suspected
DOC ‐ gentamycin 2mg/kg IV loading dose then 1.7mg/kg q8h
• Streptomycin 30 mg/kg q.d. IM or IV in 2 divided doses for 10 days
• Doxycycline 100 mg bid PO or IV
• Tetracycline 25mg/kg day in 4 divided doses for 7 to 10 days
•Will not be tested on dosing!
43
Slide 127JSOMTC, SWMG(A)
Plague
Prevention
Rodent and flea control
Vaccine• No vaccine currently in US
Post‐exposure prophylaxis: Doxycycline
Do not perform I&D of suppurative nodes
Slide 128JSOMTC, SWMG(A)
Plague
Sudden onset high fever
History positive contact with rodents / fleas
Buboes
Vaccine only known to be effective against bubonic form
Potential bioweapon
Quarantine
Slide 129JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of the Four Kinds of Tetanus
44
Slide 130JSOMTC, SWMG(A)
Caused By Anaerobic, Spore‐forming, Gram‐positive Bacilli
Slide 131JSOMTC, SWMG(A)
Tetanus
Caused by the toxin produce by Clostridium tetani bacteria (spores in the soil)
Causes acute central nervous system intoxication introduced into the body:
Open wounds, burns, frostbite, needles
Unclean cutting/dressing of the umbilical cord
Crush injuries
Incubation: varies
Slide 132JSOMTC, SWMG(A)
Tetanus
Signs and symptoms
Neonatal cases: weakness, irritability, trouble nursing, unable to suck
Trismus (lockjaw)
Painful muscle spasms (to mild stimuli)
45
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Tetanus
50% of all cases are neonatal
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Tetanus
History
Have you received a tetanus immunization?
• If so, when was the last one?
Have you recently had a potentially contaminated wound?
Does loud noise/laughing/people touching you/gusts of air trigger painful muscle spasms?
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Objective (Signs)
Fever
Tetanic muscle spasms (stimulus induced)
Trismus (lockjaw)
Opisthotonos (arched back spasm)
Respiratory muscle spasm
Tetanus
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Tetanus
Opisthotonos (arched back spasm)
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Tetanus
Trismus (lockjaw)
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Tetanus
DX
Diagnosis based on history and physical findings; Gram stain will show drumstick‐looking bacilli
DDX
Meningoencephalitis
Strychnine poisoning
Hypocalcemia tetany
Generalized seizures
Rabies
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Tetanus
Plan (Treatment)
Maintain airway
Tetanus (human) immune globulin (TIG)
Tetanus immunization (Td vs. TD vs. DTP)
Narcotic analgesia
Diazepam
Antibiotics
Debridement
Evacuate to hospital ‐ bedrest
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Tetanus
Patient education
Bedrest in a non‐stimulating environment
Sedation to keep the patient calm
Maintain current tetanus immunization
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Tetanus
Disease is caused by the toxin; not the bacteria
Neonatal cases > 50% , umbilical stump
Lockjaw , and painful muscle spasms
Control spasms with anti‐toxin (TIG)
Supportive care
Prevention – vaccine
Recovery from tetanus illness does not confer (give) immunity
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management of Clostridium Perfringens Infections
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Clostridial Wound Infections
Clinical manifestations
Clostridial cellulitis ‐ invades already dead tissue
Clostridial myositis ‐ intermediate stage
Myonecrosis (gas gangrene) ‐ rapidly fatal
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Clostridial Wound Infections
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Clostridial Wound Infections
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Clostridial Wound Infections
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Clostridial Wound Infections
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Clostridial Wound Infections
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Clostridial Wound Infections
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Clostridial Wound Infections
DX
Gram stain
Tx
HBO*
Surgery
ABX
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The Etiology, Signs and Symptoms, Diagnostic Tests, and Management of Bartonella Bacterial Diseases
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Caused byGram‐negative Bacilli
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Bartonella Infections
Cat‐scratch disease (or fever)
Trench fever
Oroya fever
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Cat‐scratch Fever
A bacterial disease caused by Bartonella henselae
From a scratch or bite by a cat or kitten
Causes lymphadenitis and variable fever > 101o F
Infection self‐resolves in 2‐6 months
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Disease is found in all parts of the world
Infected animals do not become sick
Papule at inoculation site
Lymph glands nearby become swollen/tender
Low fever, headache, anorexia
Cat‐scratch Fever
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Cat‐scratch Fever
History
Do you have any swollen or sore lymph nodes?
History of cat contact in 90% of cases
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Objective (Signs)
Variable fever: >101o F is accompanied by crusted papule or pustule at inoculation site
Later: tender, fluctuant, regional lymphadenopathy develops, (3 mo)
12% have splenomegaly
Cat‐scratch Fever
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Cat‐scratch Disease
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Cat‐scratch Disease
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DDX
Cutaneous plague
Tularemia
Cat‐scratch Fever
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Cat‐scratch Fever
Plan (Treatment)
Azithromycin ‐ 500 mg PO day 01, then 250 mg PO days 2‐5
Doxy is alternate ‐ 100 mg PO bid x 5 days
Analgesics
Warm soaks and heating pads on sore areas
Relieve pain in fluctuant lymph node with needle aspiration, avoid incision and drainage
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Trench Fever
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Trench Fever
Headache
Fever: episodic fever (relapses up to 10 years)
Severe back / leg pains
Transient rash (maculopapular)
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Trench Fever
History
Have you been around anyone with lice or poor body hygiene?
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Trench Fever
Objective (Signs)
Fever (up to 105oF) lasting 4‐5 days, recurs in paroxysms for 3‐6 weeks
Pain and tenderness, especially in shins
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Trench Fever
DDX
Various chronic febrile illnesses of the tropics: malaria, tuberculosis, brucellosis
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Treatment
Doxycycline 100 mg po bid x 15 days
Aspirin prn
Trench Fever
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Oroya Fever (Bartonellosis)
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Oroya Fever
Historical
Disease confirmed in 1885 by medical student named Daniel Carrion
He injected himself with blood from a verruga peruana lesion…and subsequently died
The disease was then sometimes referred to as “Carrions Disease”
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Oroya Fever
Subjective (Symptoms)
Fever, which can persist up to 6 weeks
Pallor; weakness; chills; muscle / joint pain
Raised skin lesions
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History
Have you traveled in the past month to Peru, Ecuador or Colombia?
Oroya Fever
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Objective (Signs)
Fever (up to 105o F)
Severe anemia
Skin lesions, verruga peruana
Oroya Fever
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Oroya Fever
Verruga Peruana
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Oroya Fever
DDX
Kaposi’s sarcoma (KS)
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Oroya Fever
Plan (Treatment)
Oroya fever: doxycycline
Verruga peruana: rifampin
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Bartonellosis
Cat‐scratch disease – lymphadenopathy, fever
Trench fever – prolonged or recurrent fever
Oroya fever – acute febrile hemolytic anemia, skin lesions
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Terminal Learning Objective
Action: Communicate knowledge of “Bacterial Infections”
Condition: Given a lecture in a classroom environment
Standard: Receive a minimum score of 75% on the written exam IAW course standards
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Agenda
Identify Group A B‐Hemolytic Streptococcusand the diseases it can cause
Communicate the etiology, signs and symptoms, the Jones Criteria, diagnostic tests, and management of rheumatic fever
Communicate the etiology, signs and symptoms, diagnostic tests, and management of bacterial meningitis
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of anthrax, to include: pneumonic, G.I., and cutaneous forms
Communicate the etiology, signs and symptoms, diagnostic tests, and management of brucellosis
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of tularemia
Communicate the etiology, signs and symptoms, diagnostic tests, and management of typhoid
Communicate the etiology, signs and symptoms, diagnostic tests, and management of cholera
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of plague
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the four kinds of tetanus, to include: generalized, neonatal, local, and cephalic tetanus
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Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Clostridium perfringensinfections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Bartonella bacterial diseases, to include: Cat Scratch Disease, Trench Fever, and Oroya Fever
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Reason
The regions that SOF personnel deploy to are among the most disease ridden‐places on the planet. Preventative measures combined with maintaining a high index of suspicion will result in more combat ready forces on the battlefield accomplishing the mission.
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Break