Infectious Disease

Conference
Team Orange
General Data
MCH
32/M
Single
Filipino
Canteen owner
Roman Catholic
Date of admission: 07/05/2018
Informant: patient
 •open wound on Right big toe
•waded in floodwater
2 weeks
PTA

• (+) undocumented fever, chills, generalized squeezing muscle aches (7/10)

• Phenylephrine + Chlorphenamine maleate + Paracetamol (Bioflu) 500 mg; Mefenamic acid 500
mg = temporary relief
• (-) cough, colds, jaundice, abdominal pain, nausea, vomiting, headache, dysuria
7 days PTA
 • Chest tightness: gradual, retrosternal, continuous, aggravated by exertion, not relieved by rest, non-radiating,
localized, 9/10
• (+) fever, chills, malaise, dizziness, diaphoresis, muscle aches, generalized weakness
2 days • (+) productive cough, whitish saliva-like sputum
• Mefenamic acid -> vomiting after
PTA

• easy fatigability upon walking 300 m

• unable to walk without assistance
• persistence of fever, malaise, muscle aches, chest tightness
• sought consult at Sampaloc hospital

1 day PTA • BP 70/50

• advised to transfer to USTH
Review of Systems
• General Survey: (+) loss of appetite, (-) change in sleep pattern, (-) weight loss
• Cutaneous: (-) jaundice, (-) nail clubbing, (-) pruritus, (-) rashes
• Eyes: (-) blurring of vision, (-) lacrimation, (-) photophobia, (-) burning sensation, (-)
itchiness, (-) redness
• Ears: (-) decreased hearing, (-) discharge, (-) tinnitus, (-) vertigo, (-) otalgia
• Nose: (-) anosmia, (-) rhinorrhea, (-) postnasal drip, (-) congestion, (-) epistaxis
• Throat and Mouth: (+) oral ulcers, (+) dental caries, (-) sore throat, (-) voice
change, (-) change in taste, (-)
• Neck: (-) neck stiffness, (-) limitation of motion
• Cardiovascular: see HPI
Review of Systems
• Pulmonary: (-) dyspnea, (+) cough, (-) colds, (-) rhinitis
• Endocrine: (-) heat/ cold intolerance, (-) polydipsia, (-) polyuria,(-) polyphagia, (-)
paresthesia
• Gastrointestinal: (-) heartburn, (-) melena, (-) hematochezia, (-) hematemesis, (-)
abdominal pain, (-) constipation, (-) diarrhea
• Genitourinary: (-) decreased urine output, (-) dysuria, (-) hematuria, (-) frequency, (-)
urgency, (-) incontinence
• Neurologic: (-) seizure, (-) paresthesia, (-) tremors, (-) dizziness
• Hematologic: (-) pallor, (-) easy fatigability, (-) gum bleeding
• Musculoskeletal: (+) back pain, (+) joint pains, (-) weakness of all extremities
Past Medical History
• (-) Hypertension • Recent antibiotic use: None
• (-) previous MI/Stroke
• • Vaccination: unrecalled
(-) previous anginal and HF
symptoms • Blood Transfusion: None
• (-) Diabetes mellitus • Previous surgeries: None
• (-) Asthma • Previous procedures: None
• (-) Thyroid disorders
• (-) Kidney disease • Previous hospitalizations: None
• (-) UTI, previous crea elevation • Allergies: None
• (-) Liver disease
• Good functional capacity
Family History
• (+) DM – Mother
• (+) Heart Disease – Maternal grandmother
• (+) Leukemia – Maternal cousin
• (+) PTB – Grandfather
• (-) Stroke
• (-) Thyroid Disease
• (-) Hematologic Disorders
• (-) Asthma
Personal and Social History
• Non-smoker
• Alcoholic beverage drinker: 2-3x per week, 3 bottles
• Denies illicit drug use
• Prefers red meat, fatty foods over fish and vegetables
• Home-cooked meals; purified drinking water
• 5 female sexual partners; (–) barrier protection
• Many rodents at home
Salient Features
Subjective Data Objective Data

● (-) HTN, DM ● GCS 15

● Previously asymptomatic ● Vital Signs
● Good functional capacity ○ BP: 103/66
● Chest tightness ○ PR: 115 bpm
● Fever and chills ○ RR 28 bpm
● Myalgia ○ T: 36 degrees Celsius
● Productive cough ○ 100% O2 Saturation
● Dizziness ● Jaundice
● Diaphoresis ● Icteric Sclerae
● Syncope ● Conjunctival Suffusion
● Hypotension ● Dynamic Precordium
● Rodents at home
● Wading in flood water
 Acute Coronary Syndrome Myocarditis/Pericarditis Acute Aortic
Dissection

● Pressure ● Excessive fatigue ● Severe, sharp

● Tightness ● Chest pain tearing pain
● Squeezing ● Unexplained ● Pulse deficit
● Heaviness sinus tachycardia ● Murmur
● Burning ● Tachypnea ● Hypotension
● Retrosternal ● Abnormal ECG ● FND
● Radiation: neck, jaw, ● Abnormal 2D Echo ● Mediastinal
Signs/Sympto arms ● Arrhythmia widening on CXR
ms ● Abnormal ECG ● Heart block
● Abnormal 2D Echo ● Heart failure
● Elevated cardiac ● Elevated cardiac
biomarkers biomarkers
 Leptospirosis Dengue Chikungunya

● Conjunctival suffusion ● High grade fever ● Fever

● Nonproductive cough ● Headache ● Severe arthralgia
● Diarrhea ● Vomiting ● Myalgia
● Nausea and vomiting ● Myalgia, arthralgia ● Malaise
● Muscle tenderness ● Rash ● Headache
● Chills ● Retroorbital pain ● Conjunctivitis
● Pharyngitis ● Nausea ● Lymphopenia
Signs/Sympto ● Hepatomegaly ● Cough ● Macular rash
ms ● Muscle rigidity ● Sore throat
● Skin rash ● Conjunctival
● Arthralgias injection
● Complications: ● Hepatomegaly
Jaundice, renal failure, ● Lymphadenopathy
ARDS, myocarditis ● Leukopenia
thrombocytopenia
Physical Exam
VITAL SIGNS • GENERAL: conscious, coherent, not in
BP: 103/66 mmHg cardiorespiratory distress, stretcher-borne,
GCS 15
PR: 115 bpm • SKIN: (+) jaundice, warm, moist skin, no
RR: 28 pallor, no active dermatoses
T: 36.0˚C • HEAD: no visible skin lesions, no masses
• EYES: (+) conjunctival suffusion, lids not
O2 sat : 100% swollen, pink palpebral conjunctiva, icteric
Ht: 165cm Wt. 74 kg sclerae, nonhyperemic bulbar conjunctivae,
pupils 2-3mm ERTL
BMI: 27
Physical Exam
• ORAL CAVITY: (+) dental caries, • EARS: non-hyperemic EAC, no
moist lips and buccal mucosa, no discharge, no tragal tenderness
lesions/masses • NOSE: no masses, no deformities, nasal
• PHARYNX: non-hyperemic non- septum midline, no rhinorrhea
exudative tonsils, non-hyperemic • NECK: supple neck, no palpable lymph
posterior pharyngeal wall nodes, thyroid gland not enlarged,
trachea midline
Physical Exam
• LUNGS: symmetrical chest • GASTROINTESTINAL: soft, flat
expansion, resonant upon percussion, abdomen, no ascites, normoactive bowel
normal breath sounds sounds, no venous hum, no friction rub,
• HEART: dynamic precordium, no tympanitic on all quadrants, no
neck vein distension, apex beat at the hepatosplenomegaly, no tenderness, no
5th LICS MCL, no heaves, no thrills, no guarding
lifts, no murmurs, distinct heart sounds • GENITO-URINARY: no CVA tenderness
• EXTREMITIES: peripheral pulses full and
equal, no bipedal edema, CRT < 2 secs
Neurological Exam
Conscious, coherent, oriented to time, person and place
GCS 15 (E4V5M6)
Cranial Nerves:
• CNI – no anosmia
• CN II – 2-3mm ERTL, isocoric
• CN III, IV, VI – EOM full and intact
• CN V – can clench teeth, no sensory deficit
• CN VII – no facial asymmetry, can smile, can frown, can puff cheeks
• CN VIII – gross hearing intact
• CN IX, X – uvula midline
• CN XI – can shrug both shoulders with resistance
• CN XII – tongue protrusion midline
Neurological Exam
Motor: Sensory:
5/5 MMT on all extremities no sensory deficits
Cerebellum: Meningeal:
(-) tremors (-) Nuchal rigidity
(-) dyskinesia (-) Kernig’s sign
(-) dysdiadochokinesia (-) Brudzinski sign
Infectious Disease History
Myopericarditis secondary
to Leptospirosis
Leptospirosis
•Leptospirasp.
–L. interrogans(pathologic) and L. biflexa(free-living)
Epidemiology
•Worldwide distribution
•Occurs most commonly in the tropics and subtropics
•Peak incidence during the summer and fall (Northern and Southern
hemispheres) and rainy seasons (tropics)
•Rodents, especially rats
–most important reservoir
•Outbreaks may result from exposure to flood waters contaminated
by urine from infected animals
Pathogenesis
1.Entry: Cuts, abraded skin, mucous membranes
- direct contact with infected urine, blood, tissue; environmental exposure
2.Proliferation and dissemination: Cross tissue barriers, disseminate to all organs
3.Incubation: Hematogenous/ Leptospiremic phase
- Leptospires can be isolated in blood
- Survival in non-immune host through:
● Binding factor H = inhibitor of complement system
● Resist ingestion and phagocytosis by neutrophils, monocytes, and macrophages
Pathogenesis
4.Host immunity: Immune / Leptospiuric phase
- appearance of antibodies coincide with the disappearance of
leptospires from blood; but persistence of organisms in various organs

•Kidney: Acute tubular damage •Lungs: Pulmonary hemorrhage

Interstitial nephritis •Thrombocytopenia:
Hypokalemia Petechiae, hemorrhages in heart, lungs,
Polyuria kidneys, adrenals, liver, muscles, etc.
•Liver: Focal necrosis Consumptive coagulopathy
Foci of inflammation
Plugging of bile canaliculi
 th
Harrison’s Principles of Internal Medicine, 19 Ed. (Fig. 208-3)
Risk Factors
● Extreme weather events: flooding
● Migration of people
● Worsening economic status
● Agricultural work
● Recreational activities: swimming
● Exposure to rodents, dogs, cats

ncbi.nlm.nih.gov
Diagnosis
Microscopic Agglutination Test (MAT)
- Gold standard
- Definitive diagnosis: four-fold increase in titer or seroconversion
Acute phase: 1:2
Convalescent phase: 1:16
- Cross-reaction: Syphilis, Lyme Disease
Myopericarditis
DEFINITION:
- Primarily a pericarditic symptom with minor myocardial
involvement.
- Used interchangeable with PERIMYOCARDITIS = primarily a
myocarditic symptom
- Evidence of pericarditis + elevation of myocardial inflammation
markers or myocardial inflammatory involvement by imaging
method but w/o wall motion abnormalities and reduced LV
function.
ETIOLOGY: MYOPERICARDITIS

- Viral infections are among the most common causes in developed

countries
- Coxsackieviruses, Adenovirus, Herpes virus, Echovirus, Influenza,
Hepatitis C, Parvovirus B19
- Can cause pericardial and myocardial inflammation via direct
cytolytic or cytotoxic effect
CLINICAL FEATURES: MYOPERICARDITIS
- Fever and leukocytosis
- Positional or pleuritic chest pain w or w/o fatigue
- Dyspnea, palpitations and decreased exercise capacity
- Heart failure symptoms
ON PHYSICAL EXAMINATION
- Normal or near normal physical examination
- Pericardial friction rub
- Signs of heart failure and volume overload
CLINICAL FEATURES: MYOPERICARDITIS
ON ECG FINDINGS:
- Diffuse ST segment elevation
- PR depression, followed by normalization of ST and PR segments
- Diffuse T wave inversions
LAB STUDIES:
- Elevation of WBC, erythrocyte sedimentation rate, C reactive
protein concentration
- Increase in serum cardiac troponin I
CLINICAL FEATURES: MYOPERICARDITIS
CHEST RADIOGRAPHY:
- Typically normal w/ minimal or small pericardial effusion and
normal ventricular function
- Enlarged cardiac silhouette (substantial pericardial effusion & left
ventricular dysfunction)
- Cephalization of the pulmonary vessels
Diagnosis
ACUTE PERICARDITIS MYOPERICARDITIS

1. Pleuritic chest pain 1. Definite diagnosis of acute

2. Pericardial friction rub pericarditis PLUS
3. ECG changes (widespread ST 2. Suggestive symptoms and ECG
segment elevation) abnormalities not documented
4. New or worsening pericardial effusion previously OR focal or diffuse
depressed LV function of uncertain
age by an imaging study
3. Absence of evidence of other cause
4. elevated cardiac enzymes , OR new
onset of focal or diffuse depressed
LV function by an imaging study, OR
abnormal imaging consistent with
myocarditis
Evaluation
•History & PE
•ECG
•Cardiac biomarkers
•CXR
•CBC, ESR, CRP
•Echocardiography
•Additional
–Cardiac magnetic resonance imaging
–Coronary angiography
–Endomyocardial biopsy
Treatment

Aspirin 650-1000 mg 3x/day 1-2 wks

Ibuprofen 600-800 mg 3x/day 1-2 wks

Indomethacin 25-50 mg 3x/day 1-2 wks

PLUS colchicine 0.5-0.6 mg 2x/day 3 months