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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > Tetanus, Brucellosis, Melioidosis, Bartonella, Anthrax > Flashcards

Tetanus, Brucellosis, Melioidosis, Bartonella, Anthrax Flashcards

1
Q

What is tetanus?

A

Clostridium tetani - gram positive anaerobe

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2
Q

2 toxins released by tetanus

A

Tetansopasmin - enters nerves and CNS (inhibits GABA) -> spasms

Tetanolysin

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3
Q

What is cause of death in tetanus?

A

Autonomic or respiratory involvement

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4
Q

Who gets neonatal tetanus

A

Babies of non-immune mothers

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5
Q

Tetanus Ix? dx? In ICU they should all get?

A

Clinical diagnosis
Tetanus Ig
Wound debridement
Metronidazole
benzos

May need rx of autonomic sx eg Labetalol for HTN / Atropine for bradys
May need paralysis
-Should all get magnesium

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6
Q

Tetanus control

A

Vaccines

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7
Q

Brucellae are? How do you get infected? Key at risk group?

A

gram negative coccobacilli
-Brucella melitensis

Consuming milk / unpasteurised cheese from affected animals

-Farmers/vets at high risk as aerosol infection from the placenta is very infectious

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8
Q

Brucellosis sx?

A

Has relapsing and remitting fever over several months
Often cough and low mood / anorexis

Key feature is focal MSK typically vertebrae, hip or knee

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9
Q

Brucellosis bloods

A

lymphopenia and thrombocytopenia
Often mild rises LFTs

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10
Q

Brucellosis rx without bone / localising disease? with bone/localising?
if kids?

A

Doxy + gent
Doxy+gent+rifampin - if bone/localising

Young kids / pregnant - co-trimox + rifampin

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11
Q

Neurobrucellosis rx

A

Doxy+rifampin+ceftriaxone

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12
Q

Brucellosis control

A

Pasteurize milk / cheese
Can vaccinate animal herds
Slaughter herds which have any positive tests (need to financially compensate)

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13
Q

What causes melioidosis? Found where? Pathogenesis

A

Gram negative bacilli - Burkholderia pseudomallei
Rice paddys in south east asia

Innoculation of contaminated soil/water

cause multiple abscesses or remain latent for years

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14
Q

melioidosis dx? rx?

A

Culture/gram stain blood/pus
Now has lateral flow assay / other RDTs

Requires expensive Abx
-ceftazidime or a carbapenem
-followed by prolonged co-trimox [doxy/co-amox options]

-Mortality remains 20% despite this rx

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15
Q

Malodorous sweat =

A

brucellosis

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16
Q

brucellosis ix?

A

Rose-bengal agglutination test

PCR / serology - best but less good in relapse

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17
Q

Brucellosis most common bug?

A

Brucella melitensis - Goats/sheep reservoir
[Brucella abortus second most]

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18
Q

What global region has highest rates of brucella

A

Mongolia > Middle east

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19
Q

Leading cause of laboratory transmitted infection worldwide

A

Brucella (especially Brucella melitensis)

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20
Q

Presents with:
Night sweats, weight loss
Constipation
Back pain
Key Dx? Other key Sx?

A

Brucella

[Extensive sweating
Back pain]

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21
Q

Brucella vertebrae features Vs TB
Age? sex? where? multiple vertebrae? abscess? type of lesion?

A
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22
Q

Brucella in kids presents different in what way?

A

<15 - often presents with peripheral arthritis
Spondylitis very rare

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23
Q

Which deficiency does Brucella cause worse Sx? who does this affect?

A

Iron deficiency - More common in women

Severe thrombocytopenia
Arthritis
Clinical severity

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24
Q

Blood finding in severe brucella =

A

Thrombocytopenia

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25
Q

Brucellosis bug

A

Brucella melitensis

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26
Q

When do you get outbreaks of melioidosis? Method of inoculation

A

Rainy seasons
-lives in water and soil

Usually percutaneous
-Can be respiratory / GI

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27
Q

Risk factors for severe burkholderia pseudomallei?

A

Most people who get melioidosis are ASx

diabetes
excessive alcohol use
chronic renal/lung disease
[All associated with neutrophil dysfunction]

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28
Q

Most common manifestation of melioidosis?

A

Pneumonia most 50%
Skin [ulcers/abscesses] 13%
GU 12%
No focus 11%
[visceral Abscess/bone/joint]

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29
Q

Chonic melioid resembles?

A

TB - often upper lobe cavitary lesion
Fever
Wt loss
Cough (hemoptysis)

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30
Q

Most common location for visceral melioidosis abscess

A

Prostate

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31
Q

Scratched by cat - has this lesion
then develops painful lymphadenopathy =

A

Bartonella Henselae - cat scratch disease

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32
Q

Cause of this neuroretinitis

A

Bartonella Henselae - Macular star

Some patients develop a star shaped macular exudate
(“macular star”).

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33
Q

Vector for carrions disease? cause?

A

Lutzomya. verrucarum
Bartonella bacilliformis

34
Q

What is this lesion on the back of a calf? Geography

A

Mular lesions (carrions disease - Bartonella bacilliformis )

Peru, equador, columbia

35
Q

Bartonella type of bacteria? stain?

A

Gram negative bacilli - giemsa stain
Grows at 27 degrees

36
Q

Anaemia, Hepatomegaly, fever, Cardiac murmur, Jaundice, Visit jungle in peru

A

Bartonella Baciliformis (carions disease)

37
Q

Why anaemia in Bartonella Baciliformis infection?

A

Infect RBCs

38
Q

Bartonella endocarditis Rx

A

Doxy + gent

39
Q

Oroya fever Rx

A

Bartonella Bacilliformis

Cipro + ceftriaxone if severe

Co-amox if <14

40
Q

Chronic Bartonella bacilliforms causes multiple eruptions rx?

A

Azithromycin

41
Q

Anthrax bug

A

Bacillus anthracis
- Encapsulated gram-positive rods

42
Q

Different forms of anthrax, associated mortality?

A

Skin - 1% mortality
GI - 50% mortality
Pulmonary - inhalation = dead
Meningitis -> dead
IV - in IVDU forms a black eschlar

43
Q

=? history?

A

Papule which ulcerates -> dark eschar
-> oedema -> tender proximal lymphadenopathy

PAINLESS at the site of lesion - look at oedema surrounding

44
Q

Compare anthrax and spider bite

A

Anthrax - painless lesion + oedema with painful lymph node

Loxosceles - Painful lesion without oedema

45
Q

Uncooked meat -> oral pharyngeal ulcerations + significant cervical lymphadenopathy
Gastroenteritis + bloody diarrhoea

A

GI anthrax

46
Q

pt develops rapid appearance of pulm sepsis
Hemorrhagic mediastinitis (pleuritis or myocarditis)
No pneumonia (increased Mediastinal ganglia).
Then develops stridor.

A

Pulm anthrax

47
Q

IVDU with apparent Bacillus cereus bacteraemia ….
Gram-positive in chains

A

Anthrax

48
Q

Anthrax Ix

A

Gram stain - blood, CSF, skin lesion (eschar), or oropharyngeal ulcer

PCR / other serology

49
Q

cutaenous Anthrax Rx

A

Penicillin
Or Cipro

50
Q

Anthrax post-exposure prophylaxis

A

Cipro for 60 days
Anthrax vaccine over 4 weeks (3 doses)

51
Q

3 main species of Bartonella and 1 things they cause each

A

Bartonella henselae - cat scratch CSD, BA, peliosis hepatis, endocarditis, bacteremia, neuroretinitis

Bartonella bacilliformis - Carrion’s disease

B Quintana - BA, endocarditis, trench fever, chronic bacteremia

52
Q

Which bartonella seen in HIV commonly

A

Bacillary angiomatosis (B hensalae/quintana)

53
Q

Bartonella henselae Rx If visceral involvemetn

A

Doxy + rifampicin/gent if visceral

Azithro for CSD

54
Q

GI/inhalation anthrax rx

A

cipro + linezolid [+antitoxin]
[If ANY possibility of meningitis - meropenem too]

then 2 months of cipro/doxy as post exposure

55
Q

CNS anthrax Rx

A

cipro + linezolid + mero [+antitoxin]
[Gram positive smash linez/mero]

then 2 months of cipro/doxy as post exposure

56
Q

49M poor controlled t2dm ->amputation 1 week ago
Breathing difficulty. Not eating. Difficulty
swallowing. Spasms = ? name 2 ddx?

A

Tetanus

Strychnine poisoning
HypoCa
Neuroleptic malignant syndrome
rabies
Epilepsy

57
Q

What is trismus? Risus sardonicus? Opisthotonus?

A

Trismus - lock jaw
Risus sardonicus - spasmed smile
Opisthotonus - extensive spasm -> arched back

58
Q

Diagnosis of tetanus

A
  1. Trismus (inability to open the mouth)
    or
  2. Risus sardonicus (sustained spasm of the facial
    muscles)
    or
  3. Painful muscular contractions.

CLINICAL not via tests

59
Q

Injury to face
* Lower cranial nerve muscles
* Facial palsy/stiffness
* Trismus
* Pharyngeal spasms
* Laryngeal spasms, dysphagia, neckstiffness
* Paresis of IX/X/III

A

Cephalic tetanus

60
Q

Wound on limb
then spasms of muscles around wound
* Pain
* Weakness
* Increased deep tendon
reflexes

A

Localised tetanus

61
Q

Tetanus Rx name 5 parts

A

Minimise stimuli - light/sound
Benzodiazepines IV
Magnesium
Ventilate
Surgical debridement
Metronidazole
Tetanus Ig (Human vs equine antitoxin are equal)
Autonomic sx rx - eg labetalol / clonidine

62
Q

Management of autonomic dysfunction in tetanus

A

Hypertension - Labetaol (short-acting)

Suppression of catecholamine release- clonidine/morphine

62
Q

Management of autonomic dysfunction in tetanus

A

Hypertension - Labetaol (short-acting)

Suppression of catecholamine release- clonidine/morphine

63
Q

Do you need a tetanus vaccine if you’ve already had tetanus?

A

YES
There is no naturally-acquired immunity to tetanus. Immunity
It can only be acquired only by active or passive immunisation.
3 doses -> boosters every 10 years

64
Q

7d baby
Born at full term now refusing to feed.
Fever, breath holding, clenched hands, facial muscle spasm, arching back. Umbilical cord necrosis.
dx?
prevention?

A

Neonatal tetanus

Vaccination of mothers
clean delivery practice

65
Q

types of tetanus

A

localised, neonatal, cephalic
generalized present in (80%)

66
Q

Define neonatal tetanus elimination

A

<1 per 1000 live births in every district each year

67
Q

South/SE Asia - Without local evidence of snakebite
sleeping on floor Nocturnal onset of chest discomfort, breathlessness, abdominal pain=? Key Sx?

A

Elapid - c krait (Bungarus) bites

“early morning paralysis”

68
Q

2 main snake families

A

Viperidae - short thick bodies and tails. Long retractable fangs
-vipers, adders, pit-vipers, moccasins, rattlesnakes

Elapidae - Long thin bodies, short ‘fixed’ fangs
- cobras, kraits, mambas, coral snakes, Oceanian venomous snakes, sea-snakes

69
Q

What is this called in snake bite

A

Cyto-toxicity: local swelling, bruising, blistering, necrosis

70
Q

Snake bite then this =? Test with?

A

Haemato-toxicity
(vipers, Oceanian elapids, a few colubrids)

WBC20 test

71
Q

snake bite then - unable to protrude tongue + ptosis

A

Neuro toxicity
Elapids (and some vipers)

72
Q

How do you check true ptosis

A

patient is asked to “look up at my finger”
Note raised eyebrows and puckered forehead from contraction of frontalis muscle, hooded pupils, and associated divergent gaze and dilated pupils

73
Q

Bitten by snake -> hypovolaemic shock = which snake

A

Viper

74
Q

Myocardial toxicity = what type of snake

A

Vipers (including European adder)

75
Q

Generalised myotoxicity (rhabdomyolysis) = which snake?

A

Elapids - especially sea snakes

76
Q

How often do you get ‘dry’ bites with snakes

A

About 50% - doesn’t actually inject venom

77
Q

Pre-hospital Rx snakebite - name 3 aspects

A

Reassure the victim
* Immobilise whole body, especially bitten limb
* Remove tight rings, bracelets, anklets
* Apply pressure-pad-immobilisation
* Transport rapidly but safely and passively to medical care (recovery position)

pressure pads -> compresses veins / lymphatics

78
Q

Snake bite in hospital -> give antivenom. What are some considerations?

A

1- administer antivenom intravenously
2- pre-treat with sub-cutaneous adrenaline (epinephrine)
3- monitor patient closely for signs of early antivenom
reaction over next 4 h
4- observe response to antivenom (improved signs, restored
blood coagulability, or consider repeat dose)
5 - Tetanus booster

79
Q

Name 3 indications for antivenom

A

Shock

Spontaneous systemic bleeding +/-

Incoagulable blood (+ve 20WBCT, INR>1.3)

Neurotoxicity

Black urine (haemoglobin or myoglobin)

Rapidly-progressive local swelling (especially bites on digits)

80
Q

Snakebite -> given antivenom and returns a week later like this? rx?

A

late serum-sickness type reactions

Develop 5-15 days post-antivenom – Treat with histamine H1 blockers (e.g. chlorphenamine) or prednisolone

81
Q

Melioid appearance

A

Gram -ve rod

Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt (26 decks)

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