Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 8) ppt

Approach to the Acutely Ill Infected Febrile Patient Part 8 Inhalational Anthrax See also Chap.. 214 Inhalational anthrax, the most severe form of disease caused by Bacillus anthracis

Chapter 115 Approach to the Acutely

Ill Infected Febrile Patient

(Part 8)

Inhalational Anthrax

(See also Chap 214) Inhalational anthrax, the most severe form of disease

caused by Bacillus anthracis, had not been reported in the United States for more

than 25 years until the recent use of this organism as an agent of bioterrorism (Chap 214) Patients presented with malaise, fever, cough, nausea, drenching sweats, shortness of breath, and headache Rhinorrhea was unusual All patients had abnormal chest roentgenograms at presentation Pulmonary infiltrates, mediastinal widening, and pleural effusions were the most common findings Hemorrhagic meningitis was seen in 38% of these patients Survival was more likely when antibiotics were given during the prodromal period and if multidrug regimens were used In the absence of urgent intervention with antimicrobial

agents and supportive care, inhalational anthrax progresses rapidly to hypotension, cyanosis, and death

Avian Influenza (H5N1) Infection

(See also Chap 180) Human cases of avian influenza were first reported in Hong Kong Recent cases have occurred primarily in Southeast Asia, particularly Vietnam However, evidence of a rapidly expanding geographic distribution of the virus throughout the world is of grave concern Avian influenza should be considered in patients with severe respiratory tract illness, particularly if they have been exposed to poultry To date, human-to-human transmission is rare Patients present with high fever, an influenza-like illness, and lower respiratory tract symptoms Watery diarrhea may develop and may precede respiratory symptoms Dyspnea develops a median of 5 days after the onset of symptoms and can progress to respiratory distress syndrome, multiorgan failure, and death within 9–

10 days after the onset of illness Early antiviral treatment with neuraminidase inhibitors should be initiated along with aggressive supportive measures

Hantavirus Pulmonary Syndrome

(See also Chap 189) Hantavirus pulmonary syndrome (HPS) has been documented in the United States (primarily the southwestern states), Canada, and South America Most cases occur in rural areas and are associated with exposure

to rodents Patients present with a nonspecific viral prodrome of fever, malaise,

myalgias, nausea, vomiting, and dizziness that may progress to pulmonary edema and respiratory failure HPS causes myocardial depression and increased pulmonary vascular permeability; therefore, careful fluid resuscitation and use of pressor agents are crucial Aggressive cardiopulmonary support during the first few hours of illness can be life-saving

Conclusion

Acutely ill febrile patients with the syndromes discussed in this chapter require close observation, aggressive supportive measures, and—in most cases— admission to intensive care units The most important task of the physician is to distinguish these patients from other infected febrile patients who will not progress

to fulminant disease The alert physician must recognize the acute infectious disease emergency and then proceed with appropriate urgency

Further Readings

Beigel JH et al: Avian influenza A (H5N1) infection in humans N Engl J Med 353:1374, 2005 [PMID: 16192482]

Darouiche RO: Spinal epidural abscess N Engl J Med 355:2012, 2006

Hasham S et al: Necrotising fasciitis BMJ 330:830, 2005 [PMID: 15817551]

Idro R et al: Pathogenesis, clinical features, and neurological outcome of cerebral malaria Lancet Neurol 4:827, 2005 [PMID: 16297841]

Kyaw MH et al: Evaluation of severe infection and survival after splenectomy Am J Med 119:276.e1, 2006

Nguyen HB et al: Severe sepsis and septic shock: Review of the literature and emergency department management guidelines Ann Emerg Med 48:28, 2006

Osborn MK, Steinberg JP: Subdural empyema and other suppurative complications of paranasal sinusitis Lancet Infect Dis 7:62, 2007

Stephens DS et al: Epidemic meningitis, meningococcaemia, and Neisseria

meningitidis Lancet 369:2196, 2007

van de Beek D et al: Community-acquired bacterial meningitis in adults N Engl J Med 354:44, 2006

Wills BA et al: Comparison of three fluid solutions for resuscitation in dengue shock syndrome N Engl J Med 353:877, 2005 [PMID: 16135832]

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