Common Tropical Infections
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Transcript of Common Tropical Infections
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Common Tropical InfectionsCommon Tropical Infections
Siriluck Anunnatsiri, MDInfectious Disease & Tropical MedicineDepartment of MedicineKhon Kaen University
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Tropical Infections: DefinitionTropical Infections: Definition
Infectious diseases that either occur uniquely or more commonly in tropical and subtropical regions, are either more widespread in the tropics or more difficult to prevent or control.
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Tropical and Subtropical RegionsTropical and Subtropical Regions
230
350
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Common Tropical Infectious Diseases in Common Tropical Infectious Diseases in ThailandThailand
• Leptospirosis• Rickettsioses:
• Scrub typhus• Murine typhus
• Melioidosis • Enteric fever
• Typhoid fever• Paratyphoid fever
• Nontyphoidal salmonellosis
• Tuberculosis• Malaria• Dengue infection• Helminthic infection• Infective diarrhea
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LeptospirosisLeptospirosis• The most widespread zoonosis in the world• Situation in Thailand
สำ�นักระบ�ดวทิย� กรมควบคมุโรค กระทรวงส�ธ�รณสขุ
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Pathogenic Leptospira spp.
Lancet Infect Dis 2003; 3: 758
88%
7.5%
2.5%
1% each
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Saprophytic Leptospira species
Species Serovar Reference strain
Serogroup
Genomospecies 3 holland Waz Holland (P438)
Holland
L. biflexa patoc Patoc I Semaranga
L. wolbachii codice CDC
Lancet Infect Dis 2003; 3: 758
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Reservoir hosts of common leptospiral serovarReservoir hosts of common leptospiral serovar
Lancet Infect Dis 2003; 3: 758
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Risk factors for exposure to leptospiresRisk factors for exposure to leptospires
• Occupational groupsFarmers, ranchers, abattoir workers, trappers, veterinarians, loggers, sewer workers, rice-field workers, military personnel
• Recreational activitiesFreshwater swimming, canoeing, kayaking, trail biking, hunting
• Household environmentPet dogs, domesticated livestock, rainwater catchment systems, rodent infestation
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PathogenesisPathogenesisRoute of transmission:
Abrasion & cuts in skinMucous membrane/ConjunctivaIntact skin after prolong immersion in waterInhalation of aerosol/waterIngestion
Toxin production:LPSHemolysinCytotoxin
Outer envelope:Antiphagocytic component
Outer membrane protein:Interstitial nephritis
Immune complex mediated inflammation:Interstitial nephritisVasculitis
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Clinical manifestationsClinical manifestationsAnicteric leptospirosis Icteric leptospirosis
Weil’s syndrome(Incubation period 2-20 days)
Fever
Leptospiremic phase3-7 days
Immune phase0-30 days
Leptospiremic phase3-7 days
Immune phase0-30 days
Associated symptoms
MyalgiaHeadacheNausea, VomitingAbdominal painConjunctival suffusion
MeningitisUveitisRash
JaundiceHemorrhage
Acute renal failureMyocarditis
Hemorrhagic pneumonitisMeningoencephalitis
Hypotension
Leptospires present in
Blood Blood
CSF CSF
Urine Urine
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Clinical manifestationsClinical manifestations
Lancet Infect Dis 2003; 3: 758
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Laboratory diagnosisLaboratory diagnosis• Culture• Antibody detection
• Screening testMSAT, IHA, IFA, LA, ELISA, LEPTO dipstick
• Confirmation testMicroscopic agglutination test
• Antigen detection• Polymerase chain reaction (PCR)• Pathology
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TreatmentTreatment
Mild form• Doxycycline• Amoxicillin• Erythromycin
Moderate-to-severe form• Penicillin G• Doxycycline• Ceftriaxone
• Supportive & Symptomatic Treatment
• Antimicrobial therapy
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PreventionPrevention
• Protective clothing, rodent control, preventing recreation exposure
• Chemoprophylaxis• Doxycycline 200 mg once a week
• Vaccine• Animal• Human – 2 developing vaccines but no
license vaccine approval in human use
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RickettsiosesRickettsioses
Scrub typhus• Orientia tsutsugamushi• Vector: Trombiculid mite
(chigger): Leptothrombidium spp.Murine typhus
• Rickettsia typhi• Vector: Xenopsylla cheopsis
Spotted fever rickettsioses• R. helvetica, R. honei, R. felis, R.
conorii • Vectors: Ticks
www.eco-pestcontrol.com
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Distribution of scrub typhus in Asia
1979Redrawn from Harwood and James ( )
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Life cycle of murine typhus
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Pathogenesis of rickettsiosesPathogenesis of rickettsioses• Vector bites and feeds
and regurgitate bacteria into skin bite site.
• Bacteria are carried via lymphatics/small blood vessels to general circulation where they invade endothelial cells (primary target)
• Spread to contiguous endothelial cells, smooth muscle cells, and phagocytes
http://pathmicro.med.sc.edu/mayer/ricketsia.htm
• Spread via the microcirculation and invade all organ systems • Vasculitis resulting in local thrombus formation and end organ damage.
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Clinical presentationsClinical presentations
• Fever• Myalgia• Headache• Nausea/vomiting• Abdominal pain• Diarrhea• Conjunctival suffusion
/ subconjunctival hemorrhage
• Lymphadenopathy• Rash• Hepatomegaly• Splenomegaly• Jaundice• Altered
consciousness• Seizure• Hypotension
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Clinical presentationsClinical presentations
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Laboratory diagnosisLaboratory diagnosis
• Culture• Antibody detection
• Weil-Felix test: • OX-K for scrub typhus• OX-19 for murine typhus
• Latex agglutination test, dot-blot ELISA• Confirmation tests: IFA, IIP
• Polymerase chain reaction (PCR)• Pathology
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Treatment Treatment
Scrub typhus• Doxycycline• Chloramphenicol• Rifampicin• Azithromycin
Murine typhus• Doxycycline• Chloramphenicol
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MelioidosisMelioidosis• Burkholderia pseudomallei• Risk factors
• Diabetes mellitus• Thalassemia• Preexisting renal diseases• Chronic liver diseases• Immunosuppressive use
• Transmission• Direct inoculation• Inhalation• Ingestion, sexual contact (rare)
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Worldwide distribution of melioidosisWorldwide distribution of melioidosis
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Melioidosis: Clinical classificationMelioidosis: Clinical classification
• Disseminated septicemic melioidosis• Non-disseminated septicemic
melioidosis• Multifocal localized melioidosis• Localized melioidosis• Probable melioidosis• Subclinical melioidosis
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Clinical presentations of melioidosisClinical presentations of melioidosisClinical presentations
% of patients in:
Royal Darwin Hospital; n=252
Infectious Diseases Association of
Thailand; n=686
Srinagarind Hospital; n=100
Pneumonia 58 45 49
Bacteremia 46 57 59
Hepatosplenic abscess
6 9 52
Skin&soft tissue infection
17 16 23
Genitourinary tract infection
19 7 13
Bone&joint infection
4 5 27
Neurological melioidosis
4 3 NR
Pericardial effusion
1 3 NR
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Clinical presentationsClinical presentations
Lancet 2003; 361: 1720
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Laboratory diagnosisLaboratory diagnosis
• Culture – Gold standard• Antibody detection
• IHA,ELISA, immunochromatographic test, dot immunoassay, Gold-blot immunoassay
• Antigen detection• ELISA, latex agglutination, IFA
• Polymerase chain reaction
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TreatmentTreatment
• Acute phase• Ceftazidime + co-
trimoxazole• Cefoperazone/
sulbactam+ co-trimoxazole
• Imipenem/Meropenem • Co-amoxiclav
• Maintenance phase• Co-trimoxazole +
doxycycline• Co-amoxiclav• Ciprofloxacin +
azithromycin
At least 10-14 days At least 20 weeks
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Enteric feverEnteric fever• Typhoid fever
Salmonella Typhi• Paratyphoid fever
Salmonella Paratyphi A, B, and C
สำ�นักระบ�ดวทิย� กรมควบคมุโรค กระทรวงส�ธ�รณสขุ
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PathogenesisPathogenesiswww.netterimages.com
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Symptoms of enteric feverSymptoms of enteric fever
Symptoms Typhoid fever (%) Paratyphoid fever (%)Fever 89-100 92-100Headache 43-90 60-100Nausea 23-36 33-58Vomiting 24-35 22-45Abdominal cramp
8-52 29-92
Diarrhea 30-57 17-68Constipation 10-79 2-29Cough 11-36 10-68
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Signs of enteric feverSigns of enteric feverSymptoms Typhoid fever (%) Paratyphoid fever (%)
Abdominal tenderness
33-84 6-29
Splenomegaly 23-65 0-74Hepatomegaly 15-52 16-32Relative bradycardia
17-50 11-100
Rose spots 2-46 0-3Rales & rhonchi
8-84 2-87
Epitaxis 1-21 2-13Meningism 1-12 0-3
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Laboratory diagnosisLaboratory diagnosis• Culture – Gold standard: Blood, BM, duodenal string test• Antibody detection
• Widal test – poor sensitivity & specificity• Rapid serological diagnostic test
Lancet 2005; 366: 754
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Drug resistance S. Drug resistance S. Typhi 1990-2004Typhi 1990-2004
Lancet 2005; 366: 752
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TreatmentTreatment
Lancet 2005; 366: 755
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PreventionPrevention
Lancet 2005; 366: 757
• Safe water & food, personal hygiene, appropriate sanitation• Vaccination Vi polysaccharide vaccine, Ty21a vaccine, Vi conjugate vaccine
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MalariaMalaria• 4 human Plasmodium sp. pathogens
P. falciparum P. vivaxP. ovale P. malariae
• Vector: Anopheles sp.
สำ�นักระบ�ดวทิย� กรมควบคมุโรค กระทรวงส�ธ�รณสขุ
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Malaria: Life CycleMalaria: Life Cycle
http://www.cdc.gov
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Clinical outcome of malarial infectionClinical outcome of malarial infection
Nature 2002; 415: 673-679.
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Pathogenesis of P. falciparumPathogenesis of P. falciparum
Nature 2002; 415: 673-679.
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Uncomplicated malaria Uncomplicated malaria
Signs and symptoms of malaria: non-specific• Fever• Chills• Headache• Myalgia• Sore throat• Anorexia• Anemia• Hepatosplenomegaly
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WHO criteria for severe malariaWHO criteria for severe malaria• Cerebral malaria• Impaired of consciousness (GCS <11)• Severe anemia (Hct <20% or Hb <7 g/dl)• Hypoglycemia (BS <40 mg/dl)• Metabolic acidosis (HCO3 <15 mmol/L)• Acute renal failure (Cr >3 mg/dl and urine output <400 ml/day)• Acute pulmonary edema and ARDS• Shock• Abnormal bleeding• Jaundice (TB >2.5 mg/dl)• Hemoglobinuria• Hyperparasitemia ( infection rate >5%)
WHO. Trans R Soc Trop Med Hyg 2000; 94 (Suppl).
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Laboratory diagnosisLaboratory diagnosis
• Thick and thin film blood smear – Gold standard
• Antigen detection by rapid dipstick immunochromatographic assays• Histidine-rich protein-2: P. falciparum• Parasite-specific LDH: All Plasmodium spp.
• PCR technique
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Plasmodium falciparumPlasmodium falciparum
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Plasmodium vivaxPlasmodium vivax
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Plasmodium malariaePlasmodium malariae
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Plasmodium ovalePlasmodium ovale
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Antimalarial treatment: Uncomplicated Antimalarial treatment: Uncomplicated falciparum malaria or mixed infectionfalciparum malaria or mixed infection
Drugs Doses Duration (days)
Artemether (20) –lumefantrine (120)
<15 kg: 1 tab BID16-25 kg: 2 tabs BID26-35 kg: 3 tabs BID>35 kg: 4 tabs BID
3
Atovaquone (250) –proguanil (100)
20 mg/kg/day8 mg/kg/day
3
Quinine SO4 +Tetracycline orDoxycyclineClindamycin
10 mg/kg TID4 mg/kg QID2 mg/kg BID5 mg/kg TID
7
Artesunate +Mefloquine
4 mg/kg/day15 mg/kg10 mg/kg
32nd day of Rx3rd day of Rx
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Antimalarial treatment: Severe malaria or Antimalarial treatment: Severe malaria or Uncomplicated malaria with parasitemia Uncomplicated malaria with parasitemia >>4% IRBC4% IRBC
Artesunate i.v.Artesunate i.v.2.4 mg/kg at hour 0 and 12 followed by 2.4 mg/kg daily until oral medication is tolerated. Continue oral drug 2 mg/kg daily until day 7, adding 2nd agent as for quinine (below)Quinine HCl i.v.Quinine HCl i.v.20 mg/kg given over 4 hours, then 10 mg/kg every 8 hours. A second drug, e.g. doxycycline, tetramycin, or clindamycin for 7 days; or atovaquone + proguanil for 3 days, should be added when the patient can tolerate oral medication.
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Antimalarial treatment: Non-falciparum malariaAntimalarial treatment: Non-falciparum malaria
Chloroquine 600 mg base at hour 0 followed by 300 mg base at hour 6, 2nd day, and 3rd day of treatment +Primaquine (for P. vivax and P. ovale only) 0.3-0.6 mg base/kg daily for 14 days
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PreventionPrevention• Vector control
• Insecticide spraying• Larva control• Personal protection
• Insecticide-treated bednets• Insect repellents• Wearing appropriate clothing
• Antimalarial chemoprophylaxis• “Stand-by” emergency treatment
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