RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in irinn

Emerging Infectious Diseases and Eosinophilia

Class
Course
Code
Title
Lecturer
Date

IC2
Tropical Medicine
TM
Dr
Ciaran Bannan
18th September 2015

Case 1
60 year old man
2 month history of headache, weakness,
fatigue and vomiting
Seen by a number of health care providers
and treated for migraine and sinusitis with
little relief
Bloods done by GP revealed low sodium

Case 1
Referred to ED Moderate distress
Mild neck stiffness and fever
Subtle hearing loss

Non smoker
Occasional alcohol
HIV and Mantoux negative
Travel to Canada west coast including Vancouver
Island

Case 1
Lumbar puncture
Opening pressure of 40mmHg
WCC 66 (50:50 ratio)
Elevated protein
Low glucose
CSF gram stain negative

Any additional tests you would ask for?

Diagnosis
From Google
Cryptococcal meningitis with C gattii
Affects immunocompetent hosts
Treatment:
Amphotericin B and Flucytosine
Serial LPs to reduce intracranial pressure

Teaching Tips
Buzz words in questions
I say Tick bite in Connemara with bulls eye rash
You say

Teaching Tips
Buzz words in questions
I say Tick bite in Connemara with bulls eye rash
You say
Lyme Disease

Teaching Tips
Buzz words in questions
I say Cat and Cervical adenopathy
You say

Teaching Tips
Buzz words in questions
I say Cat and Cervical adenopathy
You say
Bartonella infection (Cat scratch disease)
Toxoplasmosis

Teaching Tips
Buzz words in questions
I say Worsening asthma, ESR >100, Leukotriene
antagonist and eosinophilia

You say

Teaching Tips
Buzz words in questions
I say Worsening asthma, ESR >100, Leukotriene
antagonist and eosinophilia

You say
Churg-Strauss syndrome

Case 2
38 year old man
Traveled to Saint-Martin on honeymoon
7 days

No significant past history

Attended for travel vaccines
Lots of mosquito bites
No illicit drugs / risky behaviour
Presents with fever and joint pains on return

Case 2

Febrile 38.8 degrees

Headache, GCS 15/15
Conjunctivitis
Muscle and joint pains
Non-specific maculopapular rash
Severe symmetrical bilateral arthritis and
synovitis involving upper and lower limbs
FBC reveals lymphopenia

Case 2
What would you consider in the differential?

Differential

Dengue
Leptospirosis
Malaria
Influenza
Rickettsia
Measles, Rubella, Parvovirus, Enterovirus
Post infection arthritis
Rheumatologic conditions

Chikungunya
Arbovirus
Arthropod-borne virus

To walk bent over

Similar to dengue
Same mosquito (Aedes)

Persistent or recurring polyarthralgias

No specific treatment
No vaccine available

Case 3
60 year old man
Presents acutely unwell
1 week history of
Fever
Cough
Sputum
SOB

Case 3

Acutely unwell
Febrile 38.3 degrees
Hypoxic, Tachycardia, RR > 30
Bloods
Raised WCC (Neutrophils)
Raised inflammatory markers

CXR
Recent travel to Saudi Arabia

Differential
Community acquired pneumonia
Influenza

Abnormalities on Chest Imaging of the Patient.

MERS-CoV
Middle East Respiratory Syndrome
Coronavirus
Similar to SARS (Mortality rate 10%)
No vaccine or specific treatment
Supportive management only
Transmission linked to camels
Household contact risk approximately 5%
Mortality rate 30%

Case 4

42 year old engineer

Recently returned from Liberia (10 months ago)
Fever 39 degrees
Headache
Muscle pain
Vomiting and diarrhoea
Melena
Muscle pain
Unable to give coherent history

Case 4
How would you manage this patient?

Case 4
HPSC website
The Management of Viral Haemorrhagic Fever
in Ireland
Senior staff
Fill out a VHF Clinical risk assessment form
Risk stratify

Bloods exclude malaria

Isolation

Ebola

Filovirus
First recognised 1976 in the DRC
Fruit bat as reservoir
Spread human-to-human by:
Blood
Secretions
Bodily Fluids

Mortality rates 50-90%

Case 5
Irish female is transferred from a Greek
Hospital following ICU admission in Athens
with a pneumonia
Ventilated for past week
Evacuated by air ambulance
Sputum and blood cultures reveals:
Klebsiella pneumoniae

Lab rings you in a panic

Antibiotic

Susceptiblity

Penicillins

Resistant

Cephalosporins

Resistant

Carbapenems

Resistant

Quinolones

Resistant

Aztreonam

Resistant

Co-trimoxazole

Resistant

Aminoglycosides

Resistant

Super-resistant bugs
Relying on old toxic agents
Colistin
Polymixin B

Few therapeutic options

Easily spread amongst institutions
MRSA, VRSA, Resistant gonorrhoea, etc, etc
Few new antibiotics in pipeline
Major global concern

Case 6

28 year old back packer

Yosemite national park
Signature tent cabins in Curry Village
3 weeks after:
Flu like illness
Fever
Increasing respiratory rate
Admitted to hospital

Case 6

Progressive deterioration
Respiratory failure
Required ECMO
Renal failure
Required dialysis
Eventually full recovery

Case 6
What would you consider?

Hantavirus

Newly discovered Bunyavirus

Respiratory and renal failure
Carried asymptomatically by mice
Shed in urine, saliva and faeces
Secretions dry on dust particle
Particles get swept up in the air infecting
humans (Survives externally for up to 48hrs)
Confined places

Case 7
46 year old Irish business man
Cruise to Jamacia
1 week after return develops headache, neck
stiffness, and vomiting
No PMHx, Multiple sexual partners
Low grade fever and stiff neck
LP - WCC 300, 60% eosinophils, normal
glucose, Protein of 150. Negative gram stain

Most likely cause

Trepenoma Pallidum
Mycobacterium tuberculosis
Coccidioides immitis
Angiostrongylus cantonensis
Lymphoma

Angiostrongylus cantonensis

Rat lungworm
Accidental ingestion of larva
Undercooked snails
Food contaminated by rats
Eosinophilic meningitis

*** Not coming up in your finals ***

Eosinophil-associated diseases

Allergic diseases
Infectious diseases
Malignancy
Diseases with specific organism involvement
Immunologic reactions
Hypoadrenalism

Thorough history and physical .

Common causes

Toxocara dog or cat faeces (children)

Trichinella Undercooked meat, esp pork
Schistosomiasis, Hookworm, etc
Stool and urine studies for ova and parasites
Strongyloidiasis Serology

Tropical Infections commonly associated

with eosinophilia

Brugia malayi
Loiasis
Mansonella perstans
Onchocerca volvulus
Strongyloidiasis
Often treat empirically - Ivermectin

Toxocariasis
Wuchereria bancrofti

Occasionally associated

Angiostrongylus
Ascaris
Cysticerosis
Dracunculiasis
Echinococcus
Fascioliasis
Gnathostomiasis

Hookworm
Paragonimiasis
Schistosomiasis
Trichinella
Trichuris

Non-tropical causes

Aspergillosis
Atopy
Cancer / Leukaemia / Lymphoma
Churg-Strauss Syndrome
Coccidiomycosis
HIV and HTLV-1 infection
Hyper-eosinophilic syndrome
Pemphigoid / Pemphigus
Polyarteritis nodosa

Not associated

Amoebiasis
Arboviral infections
Brucellosis
Enteric fever
Giardia duodenalis
Leishmaniasis
Leprosy
Malaria
Trypanosomiasis