Background Information:
Combination antiretroviral therapy (cART) reduces HIV-associated morbidities and mortalities but cannot cure infection. Recent literature has suggested that early initiation of cART with primary infection can lead to “functional cure” for HIV infected patients with suppressed viremia and delayed progression to clinical symptoms.
Pertinent Study Design and Conclusions:
- Researchers studied 14 patients whose treatment with combination antiretrovirals began soon after exposure to HIV. The patients' viral loads became undetectable within roughly 3 months, and treatment was interrupted after about 3 years.
- The patients were found to have very low viral loads and stable CD4-cell counts after several years without therapy. The researchers estimate that about 15% of those treated early could achieve similar results.
Bottom Line:
Have a high suspicion of acute anti-retroviral syndrome in the ED (fever, rash, pharyngitis, lymphadenopathy) and test properly (viral load NOT ELISA) to identify patients who may benefit from early, rapid initiation of cART.
University of Maryland Section of Global Emergency Health
Author: Emilie J. B. Calvello, MD, MPH
General Information:
14 cases of lower respiratory infection caused by a new coronavirus (not the original SARS virus, but with a similar picture) occurred in the past year. Mortality rate of this virus is >50%.
Area of the world affected:
Relevance to the US physician:
Bottom Line:
Consider this infection in patients with a lower respiratory tract infection who have traveled to or had contact with someone who traveled to the above regions in the past 10 days.
ASK ABOUT RECENT TRAVELS IN PATIENTS PRESENTING WITH SYMPTOMS OF SEVERE LOWER RESPIRATORY TRACT INFECTION!
University of Maryland Section of Global Emergency Health
Author: Veronica Pei MD, MPH
Case Presentation: A 31 yo Hispanic male presents to your emergency department with extensive facial abrasions and contusions from an assault 7-8 days ago, c/o difficulty swallowing for 1-2 days. He was seen at that time in a nearby emergency department for his abrasions and contusions.
Upon examination, you find him to be irritable and restless, diaphoretic, tachycardic, and with mild neck stiffness. Over the course of his stay in the ED, he develops generalized muscle rigidity, severe neck stiffness and opisthotonic posturing.
Clinical Question: What is the diagnosis? And what went wrong?
Answer: This is an early presentation of generalized tetanus.
Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only nine randomized trials reported in the literature over the past 30 years. The goals of treatment include:
. At risk populations:
o Elderly patients are substantially less likely than young individuals to have adequate immunity against tetanus.
o Immigrants from Mexico had a 67% non-protective anti-tetanus antibody (ATA) level.
o In a pilot study 86% of Korean immigrants did not have protective ATA levels
o Emergency physicians were less likely to adhere to the tetanus guidelines when admitting patients to the hospital.
· Halting the toxin production: wound management and antimicrobial therapy
o Metronidazole 500mg IV q 6-8 hrs or Penicillin-G 2-4M units IV q4-6 hrs for 7-10 days
· Neutralization of the unbound toxin
o Human Tetanus Immunoglobulin (HTIG): A dose of 3000 to 6000 units intramuscularly should be given ASAP
o Since tetanus is one of the few bacterial diseases that does NOT confer immunity following recovery from acute illness, all patients with tetanus should receive FULL active immunization immediately upon diagnosis
· Treatment of generalized tetanus: this is best performed in the ICU and includes:
o Early and aggressive airway management
o Control of muscle spasms
o Management of dysautonomia
o General supportive management
Bottom Line:
o EP’s consistently under-immunize for tetanus, especially in elderly and immigrant populations, who have a much higher risk of under-immunization.
o Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.
o Emergency physicians must comply with immunization guidelines for injured patients to assure adequate protection from both tetanus and diphtheria.
University of Maryland Section of Global Emergency Health
Author: Terry Mulligan DO, MPH
-A genetic autosomal recessive blood disorders that result from a defect in either the alpha (α) or Beta (β) globin chain in the hemoglobin molecule.
-Most common in people from a Mediterranean origin.
-Three types depending on the affected globin chain, α, β, or Delta (δ)
-Presents as hemolytic anemia with hepato-splenomegaly.
-Can present as mild anemia and may be misdiagnosed as iron deficiency anemia.
-Diagnosis is made through studies such as bone marrow examination, hemoglobin electrophoresis, and iron studies.
-The disease can cause hemochromatosis, which may be worsened by repeated blood transfusions.
-Hemochromatosis damages multiple organs including the Liver, spleen, endocrine glands and the heart causing cardiomyopathy and consequently heart failure.
-Severe thalassemia usually requires blood transfusion on regular basis (first measure effective in prolonging life)
-Treatment of trait cases is symptomatic with analgesics, anti-inflammatory (steroids or NSAIDs)
-The introduction of chelating agents capable of removing excessive iron from the body has dramatically increased life expectancy.
-Deferasirox (Exjade) was approved by the FDA in January 2013 for treatment of chronic iron overload caused by nontransfusion-dependent thalassemia.
Background Information:
Ever wonder what you would do if you were the first on scene after the earthquake in Haiti or in the Superdome as Hurricaine Katrina survivors started to arrive? How could you save the most lives? As is typical of emergency medicine, blood and gore tend to get the most attention, but if you want to save lives you have to think about what is the greatest life threat. In a large-scale disaster, it turns out, lack of water and abundance of feces kill the most the fastest and need to be addressed first.
The Sphere Project Handbook:
-one of the core documents of humanitarian response
-outlines what should be done to save the most lives in the first days, weeks, and months of a disaster.
-available free online (see reference below)
Pertinent Conclusions: (need-to-know recommendations for the first few days)
-Water: 15L/person/day (any quality--sanitize as per our previous pearl)
-Latrines: max 20 people/latrine, <50m from dwellings, >30m from water sources
-What kind?
-First 2-3 days: demarcated defecation area
-days-2 months: trench latrines (shallow trenches to defecate in)
Other hygeine:
-Solid waste disposal: one 100L refuse container/10 households, emptied at least 2x/week
-Dead bodies: dispose of according to local custom. Generally not an immediate source of infection
-Shelter: >3.5 sq. meters/person of covered floor space
Bottom LIne:
People's need for water and defecation will not stop in a disaster and too little water and too much excrement are the greatest immediate life threats to disaster survivors. Plan to deal with these early to save the most lives.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
Japanese Encephalitis
- The most common disease producing enzymopathy in humans
- Affects 400 million people worldwide
- Highest prevalence is among persons of African, Asian, and Mediterranean descent
- Patients can be asymptomatic but may present with symptoms of acute hemolytic anemia, which may be precipitated by certain medications (Oxidative medications) or foods (some types of beans)
- Avoid oxidative drugs (consult your PharmD when your patient has G6PDd)
- Diagnosis: Measure the actual enzyme activity of G6PD rather than the amount of the enzyme. A more practical test is the presence of Indirect hyperbilirubinemia, but it is non specific
- Treatment consists of oxygen and bed rest in minor cases. However, severe cases may require PRBC transfusion
Just a quick clarification to last week's melioidosis pearl:
An astute reader noted the typo: "The patient should also be covered for melioidosis, and infection caused by Burkholderia pseudomallei." The sentence should read "...meliodosis, an infection caused by Burkholderia pseudomallei."
Just to clarify, melioidosis is caused by the bacteria Burkholderia pseudomallei.
Many apologies for any confusion this might have caused.
Thanks for reading!
Andi Tenner, MD, MPH
Background Information:
Active tuberculosis (TB) develops in 5-10% of individuals who become infected with M. tuberculosis, typically after a latency period of 6-18 months (but sometimes decades later). Compliance with the 9 month self-supervised isoniazid (INH) regimen has been porr with completion rates <60%. Until recently, daily rifampin for 4-6 months has been the only alternative when the bacterium is resistant or INH cannot be used.
Pertinent Study Design and Conclusions:
Bottom LIne:
A substantially shorter course of therapy with INH-RPT is now the recommended treatment for latent TB.
University of Maryland Section of Global Emergency Health
Author: Emilie J. B. Calvello, MD, MPH
Case Presentation:
A 43 year old diabetic woman presents with dyspnea and a dry cough. Her vital signs are: BP 84/42, HR 135 RR 37 T 38.5. Lobar consolidation is seen on chest xray. She decompensates and is intubated, a central line is placed, and IV fluids are started. Her husband reports that they had just returned from a vacation in Thailand one week earlier.
Clinical Question:
Does the recent travel change your choice of empiric antibiotics?
Answer:
The patient should also be covered for melioidosis, and infection caused by Burkholderia pseudomallei.
Bottom Line:
Patients presenting with severe infections and recent travel to an endemic area should receive emperic antibiotics with ceftazidime or a carbapenem until another source is identified.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD, MPH
A 38 year old man is brought in by ambulance for a seizure. His medical history is not known. On exam he is post-ictal and otherwise has a non-focal neurologic exam. He has an abrasion above the right eye, a small tongue laceration, and was incontinent of urine. A head CT was done and is shown below. What was the cause of this man's seizure?
1301231959_neurocysticercosis.jpg (109 Kb)
More than 1.2 billion people are infected with at least one species.
Most helminth infections are contracted by ingesting the eggs, except strongyloides and hookworm whose larvae penetrate bare skin when it is contact with the soil.
The roundworm (Ascaris lumbricoides) life cycle involves migration through the lung tissue which can cause pneumonitis. Patients can present with interstitial infiltrates, wheeze, and blood tinged sputum. Ascaris than migrates to the intestines where it can cause partial small bowel obstruction. In pediatric patients, the appendix may be invaded causing gangrene with symptoms indistinguishable from appendicitis. In adults, the worms can invade the biliary tract and cause biliary disease or pancreatitis. Fever causes this helminth to migrate and it can emerge from the nasopharynx or the anus.
Whipworms (Trichuris trichiura) present as colitis or symptoms similar to inflammatory bowel disease. Chronic illness can involve anemia and clubbing. In severe cases, trichuris can cause dysentery and rectal prolapse.
Hookworms (Necator americanus or Ancylostoma duodenale) also have a pulmonary phase, but with milder symptoms than Ascaris. Eventually hookworms cause iron deficiency anemia and malnutrition. They can be a primary cause of anemia in pregnancy in endemic areas.
Threadworm (Strongyloides stercoralis) can cause a wide spectrum of disease presentations. The infection can start with a rash, larva currens. The infection may be subclinical or may invade the lung, intestinal wall, or the nervous system. Eventually hyperinfection may develop which is a very large increase in worm burden and then the infection becomes disseminated.
Toxocara canis or toxocara cati have affected approximately 14% of the US population. These helminthes reproduce in dogs or cats, and human infection is not part of the normal life cycle. Most infections are subclinical but it can produce a mild pneumonitis that is very similar to asthma. There can be pain and inflammation as the helminthes travel through organs such as the liver or lung and is called visceral larva migrans. The helminth may also move through the eye and optic never causing an ocular form of the disease, ocular larva migrans.
Pinworms (Enterobius vermicularis) are the cause of most common helminth infection in US and can present with anal pruritus leading to trouble sleeping. When an infection is identified, everyone in the household should be treated, regardless of symptoms.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD, MPH
General Information:
-Leptospirosis is a tropical infectious disease that is also endemic in the US. (Estimated 16% seroprevalence in inner city Baltimore!)
-The spirochete is spread through animal urine and can survive in water or soil for weeks.
-Risk factors: rural exposure to animal urine (farming, adventure sports) or urban exposure to rat urine.
-Infection is acquired through breaks in the skin or mucus membranes
-Outbreaks are often seen following rain or floods.
Clinical Presentation:
-Non-specific febrile illness (usually not diagnosed in these cases)
-If untreated, 5-10% progress to jaundice, renal failure, thrombocytopenia, hemorrhage, and respiratory failure.
Diagnosis:
- Primarily based on clinical presentation and history
- Paired serum sent to CDC (the acute serum sample should be drawn in the ED)
Treatment:
- Doxycycline, Ceftriaxone and Penicillin are all effective
Bottom Line:
Consider and treat for Leptospirosis in patients with possible exposure animal urine (especially after a flood) who present in extremis with renal failure, jaundice, and thrombocytopenia.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
Bottom Line: A mild increase in blood parasite count after initiation of treatment is not uncommon. Marked increases should indicated treatment failure and the treatment drug should be changed to another class.
University of Maryland Section for Global Emergency Health
Author: Emilie J.B. Calvello, MD, MPH
1212252349_Malaria_Pearl_Visual_EJBC_copy.pdf (1,967 Kb)
· A parasitic disease transmitted by the bite of the 'Glossina' insect (tsetse fly.)
· The disease is most prevalent in rural areas of Africa. Untreated, it is usually fatal. Infection with the genus Trypanosoma brucei gambiense may lead to chronic asymptomatic illness.
· Travelers to endemic areas in Africa are risk becoming infected.
· Symptoms resemble a viral illness; headaches, fever, weakness, pain in the joints, and stiffness. The parasite is able to crosses the blood-brain barrier and causes neurological symptoms, mainly psychiatric disorders, seizures, coma and ultimately death.
· Diagnosis is by serological tests (Card Agglutination Trypanosomiasis Test or CATT). Confirmation of infection requires the performance of parasitological tests to demonstrate the presence of trypanosomes in the patient.
· Treatment: four drugs are registered for the treatment of HAT: pentamidine, suramin, melarsoprol and eflornithine.
Background:
Dengue is the most rapidly expanding mosquito-borne virus with an increasing incidence and geographical area. It is most commonly found in the tropics, but there are occasional outbreaks in other places, including Texas and Hawaii.
Clinical:
Three Phases:
1. The febrile phase lasts 2-7 dyas and is similar to other viral syndromes, often with high fever and nausea/vomiting. Petechiae may also be present which can be induced by the application of a tourniquet.
2. The critical phase occurs after defervescence and lasts only 24-48 hours. IT is marked by increased capillary permeability and can lead to severe pulmonary edema, shock, and multisystem organ failure.
3. The recovery phase is marked by hemodynamic improvement. Some patients have a rash described as "isles of white in a sea of red."
Some patients will develop bradycardia. Most patients have a self-limited form of the illness that is not severe, and consists of symptoms seen in the febrile phase. The patients that develop severe dengue can have markers in the febrile phase that are associated with organ dysfunction, GI bleeding, and increased capillary permeability. Other concerning symptoms early are abdominal tenderness and persistent vomiting.
Treatment:
Treatment is supportive, mostly consisting of IV fluids, which is very effective when started early in the patient's illness. For more information and maps of endemic areas check out the CDC or WHO websites: http://www.cdc.gov/travel/notices/in-the-news/dengue-tropical-sub-tropical.htm or http://www.who.int/denguecontrol/en/
University of Maryland Section for Global Emergency Health
Author: Jenny Saltzberg
General Information:
• Millions of people around the world (including our patients who travel and victims of disasters like Hurricane Sandy) are exposed to non-potable water.
• How to treat contaminated water:
♦ Filter cloudy water through a clean cloth or allow to settle prior to treatment
♦ The safest method is boiling water vigorously for 1 minute (or, at least 3 minutes at altitudes >6,000ft)
♦ Chemical disinfection is not as effective but, if boiling is not possible, use either:
• 2 drops of unscented bleach (5.52% Cl) per quart/liter of water. (Unknown strength? Add 10 drops per quart/liter.)
-Or-
• 5 drops of tincture of 2% iodine per quart/liter.
- If the water is cloudy or cold, double the chlorine or iodine.
- Notes: Pregnant women or people with thyroid conditions should not use iodine
♦ UV decontamination can be accomplished by leaving clear bottles of water in direct sun for >6 hours or special equipment, but requires clear water
• Boiling, Chlorine/Iodine, and UV will kill viruses, bacteria, and Giardia
• Only Boiling kills Cryptosporidium
Bottom Line:
• If bottled water is available, use it.
• If not, boil your water.
• In order to treat for a wide variety of pathogens, it is best to combine available methods.
University of Maryland Section for Global Emergency Health
Author: Andi Tenner
University of Maryland Section for Global Emergency Health
Author: Emilie J.B. Calvello, MD, MPH
· Explosions can cause a complex series of injuries, which may include subtle or delayed findings. Repeated evaluations, such as serial abdominal exams, may be required.
· Blast injuries are divided into 4 categories:
o Primary blast injuries: Injury from blast wave over-pressure. Found in gas filled structures (ear, lung, hollow organs)
o Secondary blast injuries: Injury from thrown objects (primarily penetrating trauma, but may blunt)
o Tertiary blast injuries: Injuries from patient being thrown by blast wave (blunt trauma)
o Miscellaneous (quaternary) blast injuries: Injuries from other causes, such as burns, crush injuries, rhabdomyolysis, and toxic chemicals.
· The most common primary blast injury is tympanic membrane rupture.
University of Maryland Section for Global Emergency Health
Author: Jon Mark Hirshon
University of Maryland Section for Global Emergency Health
Author: Andi Tenner
