Hantavirus and More 1 2/21/2014 Objectives Hantavirus Plague - - PDF document

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Hantavirus and More 1 2/21/2014 Objectives Hantavirus Plague - - PDF document

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2/21/2014 Emerging and Re-emerging infections from the North American Wild Sukhjit S. Takhar, MD Brigham and Women s Hospital Harvard Medical School Hantavirus and More 1 2/21/2014 Objectives Hantavirus Plague Rocky

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Emerging and Re-emerging infections from the North American Wild

Sukhjit S. Takhar, MD Brigham and Women’s Hospital Harvard Medical School

Hantavirus and More

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Objectives

  • Hantavirus
  • Plague
  • Rocky Mountain Spotted Fever
  • Rabies

Would you rather have?

  • Hantavirus
  • Plague
  • Rocky Mountain Spotted Fever
  • Rabies
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48 year old male 3 days of influenza-like symptoms Shortness of breath Back country hiking and camping 7 days ago in Yosemite

Hantavirus Pulmonary Syndrome

Sin Nombre virus

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Hantavirus

  • Severe hemorrhagic fever with renal

syndrome

  • Hantavirus pulmonary syndrome

Hantavirus in Yosemite

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Hantavirus in the US

  • 1993

– 24 patients with severe pneumonia – 75% case fatality rate

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Hantavirus

  • Parasites of rodents and insectivores
  • Reservoir of Hantavirus (SNV): Deer

Mouse

– Cotton and rice rats (south east)

Transmission

  • Breath air contaminated with virus

– Rodent urine – Rodent droppings – (contaminated food, bites, etc…)

  • Incubation period: 1 to 6 weeks
  • HPS does not have person to person

transmission

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Clinical Case Definition

  • Febrile illness with interstitial edema

(ARDS) in a previously healthy individual

– Fever, headaches, muscle aches – Pulmonary edema

Clinical Manifestations

  • 1. Fevers, chills, myalgia, headaches
  • 2. Pulmonary vascular permeability
  • 3. Shock
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Laboratory Abnormalities

  • Hemo-concentration
  • Leukocytosis

– Bandemia – Atypical lymphocytes

  • Thrombocytopenia

Diagnosis

  • Rural rodent exposure?

– Influenza like illness? – Shortness of breath?

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Treatment

  • Supportive care
  • Antibiotics until confirmatory testing
  • Analgesics and antipyretics

Could it be?

  • Zoonosis from rats?

– Plague?

  • Tick Borne?

– Tularemia?

  • Infectious pneumonia
  • Sepsis
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Plague

Yersinia pestis

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History of Plague

  • Black death
  • Late Middle Ages ~1347-1350

– 75 million – 200 million deaths – Killed 1/3 of the human population

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Pathogenesis

  • An Infection of Rodents and Fleas

– Fleas feed on bacteremic hosts (often a rodent) – Feed on other rodents and transmit the disease

Transmission

  • Bite from an infected flea (or rarely other

animals)

  • Direct contact with contaminated tissues
  • Rarely, inhalation of respiratory section
  • Short Incubation (1-6 days)
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Clinical Manifestations

  • Bubonic Plague
  • Septicemic Plague
  • Pneumonic Plague

Oregon case

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Bubonic Plague

  • Fevers, chills, weakness
  • Regional Lymphadenitis (Buboes)
  • Often the first stage of the disease

Treatment

  • Fatal cases are associated with delays in

diagnosis and treatment

– Aminoglyocoside – Fluoroquinolones – Tetracyclines

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Plague

  • Report to state health department
  • Consider bioterrorism
  • Antibiotic prophylaxis

Plague in Yosemite

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Could it be?

  • Anthrax?
  • Tularemia?
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Rocky Mountain Spotted Fever

Rickettsia rickettsii

Rocky Mountain Spotted Fever

  • Vector: Hard Ticks (dog ticks)
  • Incubation period (2 – 14 days)
  • Untreated mortality: 20-87%
  • Needs to be attached for at least 4-6 hours
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Rocky Mountain Spotted Fever

  • North Carolina
  • Oklahoma
  • Arkansas
  • Tennessee
  • Missouri
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Risk Factors

  • Exposure to the tick vector

– Exposure to dogs – Wooded area – Peaks in summer months

Clinical Presentation

“A febrile disease, characterized clinically by a continuous moderately high fever, and a profuse or purpuric eruption in the skin, first appearing on the ankles, wrists, and forehead, but rapidly spreading to all parts

  • f body.”
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RMSF

  • Clinical Triad: Fever, Rash, and Headache

is only present 3% early in disease

  • Consider the disease with fever and

headache

  • Rash appears 2-5 days after onset of fever
  • Innoculation eschar is rare

Diagnosis

  • History
  • Physical Examination
  • Epidemiological Data
  • Then laboratory confirmation
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Tick Removal

  • Fine-tipped tweezers to grasp tick
  • Pull upward
  • Clean wound
  • Do not use nail polish, petroleum jelly, or

heat

Treatment

  • Treated Mortality 5%
  • Tetracyclines and Chloramphenicol

– Doxycycline in Children is ok for this!

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Other things to think about…

  • Meningiococcemia
  • Tick Borne Rickettsial disease

– Anaplasmosis – Erlichiosis

  • Other Tick Borne Diseases

– Tularemia?

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Rabies

Rhabdovirdae

Rabies

  • Epidemiology of human rabies reflects

local animal rabies

  • Developing countries: Dogs
  • United States: Bats and rabid wild animals
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Rabies

  • Neurotropic viral infection transmitted from

a bite of an infected animal

  • Travels to CNS
  • Acute, progressive encephalomyleitis
  • Incubation 1-3 months (days – years)
  • Highest case fatality ratio of any infectious

disease if untreated

Rabies

  • 92% of reported cases of rabies in 2010

were in wild animals

  • Wild carnivores and Bats

– Racoons 36.5% – Skunks 23.5% – Bats 23.2% – Foxes 7.2%

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Rabies

  • Bites, scratches, or mucous membrane

exposures to bat

  • Clustering of human cases with bat

exposures have never been reported

Wound Management

  • Clean the wound

– Soapy water – Betadine

  • Protective effect of wound care may be as

important as vaccination

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Postexposure Prophylaxis

  • Rabies Immunogloblin (RIG) + Rabies

Vaccination

  • 2010 CDC Guidelines

– Reduced (4-dose) regimen – Improved from the Semple Vaccine

  • (Daily injections of 5-10 ml) into abdominal wall)

Rabies

  • Survival from clinical rabies is extremely

rare

  • Consider rabies in patients with

progressive encephalitis

  • Avoid wildlife
  • Prompt PEP
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Selected References

  • Rhee, D. K., Clark, R. P., Blair, R. J., Katz, J. T., & Loscalzo, J. (2012). Breathtaking
  • Journey. New England Journal of Medicine, 367(5), 452-457.
  • Hantavirus, C. D. C. (2012). Atlanta, GA: US Department of Health and Human

Services, CDC; 2012.

  • Perry, Robert D., and Jacqueline D. Fetherston. "Yersinia pestis--etiologic agent of

plague." Clinical microbiology reviews 10.1 (1997): 35-66.

  • Chapman, Alice S., et al. "Diagnosis and management of tickborne rickettsial

diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals." MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports/Centers for Disease Control 55.RR-4 (2006): 1.

  • Dantas-Torres, Filipe. "Rocky Mountain spotted fever." The Lancet infectious

diseases 7.11 (2007): 724-732.

  • Shah, Usha, et al. "Trial of human diploid cell rabies vaccine in human volunteers."

British medical journal 1.6016 (1976): 997-997.

  • Willoughby Jr, Rodney E., et al. "Survival after treatment of rabies with induction of

coma." New England Journal of Medicine 352.24 (2005): 2508-2514.

  • Rupprecht, Charles E., and Robert V. Gibbons. "Prophylaxis against rabies." New

England Journal of Medicine 351.25 (2004): 2626-2635.