Category Archives: Infections

Zika Virus Infection – Global Threat for 2016 – Microcephaly and Guillian Barre Syndrome

Zika virus (ZIKV) is a flavivirus related to yellow fever, dengue, West Nile, and Japanese encephalitis viruses.

CDC site for Zika alerts

ZIKV has been isolated from Ae. africanus, Ae. apicoargenteus, Ae. luteocephalus, Ae. aegypti, Ae vitattus, and Ae. furcifer mosquitoes

Zika virus was first discovered in 1947 in the Zika Forest, Uganda, when a Rhesus monkey, placed in a cage to study Yellow Fever developed a febrile illness that was transmitted by innoculation into mice. The Zika Virus was discovered.

In 1948, Zika virus was found in the Aedes Africanus mosquito in the Zika Forest.

In 1968, the virus was found in humans in Nigeria causing a febrile illness. Also in 1971-1975 as well.

Later the virus was found to cause illness in various other parts of Africa and asia, including India, Malaysia, Philippines, and Vietnam.

Then the virus was found to exist in the Aedes aegyptii mosquito.

The Yap island infection in 2007 was the first time infection had spread outside of Asia and Africa.

The disease went on to French Polynesia in 2013  and the Cook islands and new Caledonia in 2014

Clusters of infection started to appear in Brazil in 2014 and 2015. This is because of the mosquito vectors that spread the disease can travel to these areas.

Zirka (ZIKV) virsu causes a self-limited infection in the form of an exanthematous- type rash, low grade fevers, conjunctivitis, and arthralgias. Guillain-Barre syndrome has been associated with this infection (an ascending paralysis). there is much confusion between ZikV and Dengue infection .

(Zika Virus) ZrkV now joins Chikungunya (CIKV) and Dengue Virus (DENV) as global health threats!

 

Zika virus is believed to be transmitted to humans by infected mosquitoes and has been isolated from Aedes africanus, Aedes luteocephalus, and Aedes aegypti

Until the YAP island/Micronesia outbreak, no transmission of Zika virus had been reported outside of Africa and Asia (2007) in which an outbreak of illness characterized by rash, conjunctivitis, subjective fever, arthralgia, and arthritis occurred on YAP island. Reverse-transcriptase–polymerase-chain-reaction assay determined the source to be Zika virus.  Dengue, chikungunya, o’nyongnyong, Ross River, Barmah Forest, and Sindbis viruses were all NEGATIVE in this study.

The Federated States of Micronesia is an archipelago nation located northeast of Papua New Guinea. Yap State is the westernmost of the four states of the country. In Yap cases were defined by fhaving generalized macular or papular rash, arthritis or arthralgia, or nonpurulent conjunctivitis. Acute phase studies were taken 10 days after symptoms and convalescent titers were taken at Day 14. In this Zika virus outbreak, approximately three quarters of Yap residents were infected with Zika virus, and we estimated that more than 900 people had illness attributable to Zika virus infection. It was a mild illness. It appeared that  Aedes hensilli was a vector of Zika virus transmission in Yap. More than 73% of Yap islanders were found to have had infection after the age of 3.

The attack rates of Zika virus disease detected by surveillance were higher among females than males and among older persons than younger persons.  These discrepancies may be because of differences in health care–seeking behavior for this relatively mild illness.

In the NEJM article regarding the Zika infection on Yap: “The accessibility of air travel and the abundance of mosquito vectors of flavivirus in the Pacific region raise concern for the spread of Zika virus to other islands in Oceania and even to the Americas.” This was in 2007. Also they ended the article with : “The emergence of Zika virus as an important human pathogen on Yap in 2007 underscores the ease with which exotic pathogens are transported between continents and the need for clinical vigilance and strong epidemiologic and laboratory surveillance systems to detect the spread of infectious diseases”

So as a summary, ZikV, ChickV, and DenV cause an exanthemotous illness with a generalized rash and fever and all three spread by the same Aedes mosquito species. It is hard to distinguish between the illnesses. The effect of the concurrent outbreaks caused by these three different arboviruses is unknown.

Fever and arthralgias are more common in Dengue and ChikV infections whereas Guillan Barre episodes are more associated with Zika infection.

The first well-documented report of human ZIKV disease was in 1964 when Simpson described his own occupationally acquired ZIKV illness at age 28 (27). It began with mild headache. The next day, a maculopapular rash covered his face, neck, trunk, and upper arms, and spread to his palms and soles. Transient fever, malaise, and back pain developed. By the evening of the second day of illness he was afebrile, the rash was fading, and he felt better. By day three, he felt well and had only the rash, which disappeared over the next 2 days. ZIKV was isolated from serum collected while he was febrile.  . Other manifestations included anorexia, diarrhea, constipation, abdominal pain, and dizziness.  Yap Island infection was characterized by rash, conjunctivitis, and arthralgia.

Diagnostic tests for ZIKV infection include PCR tests on acute-phase serum samples, which detect viral RNA, and other tests to detect specific antibody against ZIKV in serum. An ELISA has been developed at the Arboviral Diagnostic and Reference Laboratory of the Centers for Disease Control and Prevention (Atlanta, GA, USA) to detect immunoglobulin (Ig) M to ZIKV. IgM was detectable as early as 3 days after onset of illness.  In the samples from Yap Island, cross-reactive results in sera from convalescent-phase patients occurred more frequently among patients with evidence of previous flavivirus infections than among those with apparent primary ZIKV infections . Cross-reactivity was more frequently noted with dengue virus than with yellow fever, Japanese encephalitis, Murray Valley encephalitis, or West Nile viruses.  Zika Virus Outside Africa <Link

ZIKV illness to date has been mild and self-limited, but before West Nile virus caused large outbreaks of neuro-invasive disease in Romania and in North America, it was also considered to be a relatively innocuous pathogen.

In the early 2015, records of patients presenting a “dengue-like syndrome” appeared in the public health service in the city of Natal (05°47’42”S 35°12’32”O), state of Rio Grande do Norte, Brazil. A physician specialist in infectious disease evaluated the patients and the clinical signs and symptoms and laboratory findings indicated a non-DENV and non-Chikungunya virus (CHIKV) infection. Symptoms included arthralgia, oedema of extremities, mild fever, maculopapular rashes frequently pruritic, headaches, retroorbital pain, no purulent conjunctivitis, vertigo, myalgia and digestive disorder. http://www.ncbi.nlm.nih.gov/pmc/articles/PFirst report of autochthonous transmission of Zika virus in Brazil

Zika Rash from "First report of autochthonous transmission of Zika virus in Brazil" article
Zika Rash from “First report of autochthonous transmission of Zika virus in Brazil” article.

In Brazil’s caese:  The most commonly reported symptoms were maculopapular rash (100%)  and pain, with pain lasting 2-15 days. Headaches, myalgias, and retro-orbital pain was common, and joint pains included the hands , ankle, elbow , knee, wrist, and foot.  Periarticular swelling occurred, fever (around 39ºC),  and submandibular or cervical lymphadenopathy in some. Most had normal levels of leukocytes and neutrophils and platelets were normal in all of them.

As of January 23 – the CDC recommends that pregnant women not travel to  Brazil, Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, Venezuela and Puerto Rico. Zika has been found in Bolivia, Brazil., COlombia, Ecuador, French Guiana, Guyana, Suriname, Venezuela, and Paraguay. In the Caribbean, Barbados, Guadeloupe, Haiti, Martinique, and Saint Martin have Zika Virus present. Also Mexico, Puerto Rico, Honduras, Panama, and Guatemala have Zika virus present as well.

Microcephaly has been linked to this infection as a result of infection during pregnancy. Obviously microcephaly results in developmental delay (Mental Retardation.)

In this Dec. 23, 2015 photo, Solange Ferreira bathes her son Jose Wesley in a bucket at their house in Poco Fundo, Pernambuco state, Brazil. Ferreira says her son enjoys being in the water, she places him in the bucket several times a day to calm him. (AP Photo/Felipe Dana)
In this Dec. 23, 2015 photo, Solange Ferreira bathes her son Jose Wesley in a bucket at their house in Poco Fundo, Pernambuco state, Brazil. Ferreira says her son enjoys being in the water, she places him in the bucket several times a day to calm him. (AP Photo/Felipe Dana)

In El Salvador, cases of a demyelinating condition called Guillian Barre syndrome has occurred in association with the Zika infection.

El Salvador has recommended a Two year halt on pregnancies and Jamaica recommends a 6-12 month wait for women to become pregnant. Obviously, these recommendations will be challenging to follow.

For those who get pregnant in high risk areas, ultrasound and amniocentesis ( a needle is used to collect amniotic fluid for analysis) is performed and tested for Zika virus. If positive, options are discussed.

Prevention of the disease if travel is a necessity includes wearing long sleeved shirts and pants, using insect repellents that have DEET, Picardin, oil of lemon eucalyptus (OLE), or IR3535. DEET can be used on infants 2 months or older and pregnant women can safely use EPA-registered insect repellents.

 

 

CDC Zika website

Possible link between Zika virus and birth defects

Zika virus: a new global threat for 2016

Outbreak of Exanthematous Illness Associated with Zika, Chikungunya, and Dengue Viruses, Salvador, Brazil

Zika Virus Outbreak on Yap Island, Federated States of Micronesia NEJM

Zika virus outside Africa.

Comparing dengue and chikungunya emergence and endemic transmission in A. aegypti and A. albopictus

Zika virus – following the path of dengue and chikungunya

First report of autochthonous transmission of Zika virus in Brazil.

First report of autochthonous transmission of Zika virus in Brazil

Factors responsible for the emergence of arboviruses; strategies, challenges and limitations for their control.

Factors responsible for the emergence of arboviruses – strategies, challenges and limitations for their control.

Emerging arboviruses in the Pacific

Zika Virus in an American Recreational Traveler

Zika Virus in an American Recreational Traveler

zika rash back
zika rash – back

Symptomatic management with supportive care is indicated for acute cases. Prevention is achieved by vector control and insect bite precautions. Aedes spp. is adapted for indoor and daytime biting in urban areas. They are known to breed in aquatic environments such as small puddles, open water storage containers, and plants that hold water between the leaves and stems. Insect bite precautions (during early morning and late afternoon peak biting times) and vector control should be tailored to known epidemiology.

Outbreak of Exanthematous Illness Associated with Zika, Chikungunya, and Dengue Viruses, Salvador, Brazil

Zika Virus Outbreak in Bahia Brazil

This report illustrates the potential for explosive simultaneous outbreaks of ZIKV, CHIKV, and DENV in the Western Hemisphere and the increasing public health effects of Aedes spp. mosquitoes as vectors. The apparent increase in reports of Guillain-Barré syndrome during the outbreak deserves further investigation to elucidate whether this syndrome is associated with ZIKV infection.

Identification of ZIKV, CHIKV and DENV as etiologic agents of acute exanthematous illness suggests that these 3 Aedes spp. mosquito-transmitted viruses were co-circulating in Salvador and highlights the challenge in clinically differentiating these infections during outbreaks.  In Brazil,  that ZIKV sequences obtained belonged to the Asian lineage and showed 99% identity with a sequence from a ZIKV isolate from French Polynesia (KJ776791) .

Reported cases of indeterminate acute exanthematous illness and suspected dengue fever in Salvador, Brazil, by date of medical care, February 15−June 25, 2015
Reported cases of indeterminate acute exanthematous
illness and suspected dengue fever in Salvador, Brazil, by date of
medical care, February 15−June 25, 2015

Immunological Surveys of Arbovirus Infections in Southeast Asia

The Global Ecology and Epidemiology of West Nile Virus

Potential Sexual Transmission of Zika Virus

Potential for Zika virus transmission through blood tranfusion in French Polynesia

Evidence of perinatal transmission of Zika virus

Two cases of Zika fever imported from French Polynesia to Japan

Detection of Zika Virus in Urine

Complete Coding Sequence of Zika Virus from a French Polynesia outbreak 2013

A diagnostic polymerase chain reaction assay for Zika virus

Zika virus infection complicated by Guillain-Barré syndrome

Zika virus a previously slow pandemic spreads rapidly through the Americas

Zika and transfusion medicien

Zika virus in Brazil and the danger of infestation by Aedes mosquitoes

Febrile Illness with Skin Rashes

Viral exanthems

 

Update: January 20, 2016

Hawaii baby born with small head had prior Zika infection   A child born in the past few weeks in Hawaii had microcephaly ( a small head) and the mother had lived in Brazil in 2015. Both were positive for prior Zika infection. Currently,  cases in Brazil increased to 3,500, and 46 babies have died. The CDC gave recommendations not to travel to Brazil if pregnant or if wishing to get pregnant due to concerns over Zika Virus:

CDC issues interim travel guidance related to Zika virus for 14 Countries and Territories in Central and South America and the Caribbean

CDC has issued a travel alert (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing: Brazil, Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, Venezuela, and the Commonwealth of Puerto Rico.  

This alert follows reports in Brazil of microcephaly and other poor pregnancy outcomes in babies of mothers who were infected with Zika virus while pregnant. However, additional studies are needed to further characterize this relationship. More studies are planned to learn more about the risks of Zika virus infection during pregnancy.

Until more is known, and out of an abundance of caution, CDC recommends special precautions for pregnant women and women trying to become pregnant:

As a reiteration, Zika virus is a flavivirus that is related to Japanese encephalitis virus, West Nile, Dengue, and yellow fever. It originated in the Zika Forest in Uganda and was first found in 1947 in a rhesus monkey.

As of February 1, 2016 the virus has spread in Africa, Southeast Asia, the pacific Islands, and the Americas.

Zika is likely to spread to the United States since the mosquito vector, Aedes, an aggressive daytime biter, is present in the US as well. Obviously international travelers will promulgate the spread of the disease.

The symptoms of infection are fever, rash, muscle and joint pains with conjunctivitis (pink eye) primarily, but there is associations with microcephaly and Guillian Barre syndrome (GBS) as well.  GBS is a neurological syndrome of weakness and paralysis.

Brazil has had 4000 cases of microcephaly in 2015 which i 20 times higher than the year before with evidence of viral infection in the mother’s of these patients.

Infections have been found in travelers in Hawaii, Florida, Illinois, and Texas. All were international travelers.

The primary goal to thwart continued spread and infection is vector control. Physical removal of standing water and adding fish to areas with water so as to eat larvae are part of a solution, Insecticides are beneficial as well. Also being tried is the release of sterile male mosquitoes.

The Pan American Health Organization (PAHO) has been issuing updates for increased surveillance for Zika, including immunological effects of the virus as well as congenital effects from infection.

Travel advisories are in effect from the CDC primarily for pregnant women in which they suggest postponing travel if  pregnant if one is travelling to Zika-affected areas.

There are licensed vaccines for yellow fever, Japanese encephalitis, and dengue fever currently, but non e for Zika. NIH and Brazilian agencies are currently working on this.

80 % of Zika infections are asymptomatic and most are self-limited. It is hard to test for the virus due to cross-reactivity with other flaviviruses. The CDC is able to test amniotic fluid and serum  for the virus currently.

NEJM Zika in the US NEJM article re: zika in the US

microcephaly alert in Brazil

Interim Guidelines for Pregnant Women During a Zika Virus Outbreak — United States, 2016 _ MMWR  – Guidelines from CDC for pregnant women 2016

CDC Guidelines for ZIKA 2016

Ebola epidemic – JAMA 2014  Ebola epidemic in 2014

WHO Ebola final report July 2015

Clinical resources Ebola

Zika Virus: An Emerging Health Threat

<Blog from NIH – video

Zika Virus: An Emerging Health Threat

Notes from NIH blog:

According to the researchers’ calculations, about 200 million Americans—more than 60 percent of the population—reside in areas of the United States that might be conducive to the spread of Zika virus during warmer months through biting mosquitoes, including areas along the East and West Coasts and much of the Midwest. In addition, another 22.7 million people live in humid, subtropical parts of the country that might support the spread of Zika virus all year round, including southern Texas and Florida. Already, there are reports of local spread of the virus within Puerto Rico and of travelers returning to the U.S. with the Zika infection.

In November, health authorities in French Polynesia also reported an unusual increase of central nervous system malformations in fetuses and infants that seemed to coincide with the Zika outbreak there. And, last week, came news reports of the first child born in the U.S. with microcephaly possibly linked to Zika. The child’s mother had lived in Brazil during her pregnancy before moving to Oahu, Hawaii [5]. As an additional concern, there are reports in French Polynesia and Brazil of a possible connection between Zika infection and Guillain-Barré syndrome, a mysterious condition in which the immune system attacks part of the peripheral nervous system [1]

Zika virus infection can be spread by yellow fever mosquitoes (Aedes aegypti), and experimental evidence suggests the virus also can be transmitted by Asian tiger mosquitoes (Aedes albopictus).Aedes mosquitoes—already known for transmitting other viral illnesses, such as dengue and chikungunya—have a wide and expanding global distribution, including in the United States.

zika-virus-americas-association-with-microcephaly-rapid-risk-assessment

The global distribution of the arbovirus vectors Aedes aegypti and Ae. albopictus

Zika and blood transfusions

The global compendium of Aedes aegypti and Ae. albopictus occurrence

Zika Virus in the Americas — Yet Another Arbovirus Threat

CDC teleconference Januray 2016 re ZIKA

 

 

 

 

 

 

 

 

 

Insane Medicine – Travelers to the Caribbean or South America – beware of Chikugunya virus!

  • Insane Medicine - Chikungunya virus is spread by mosquitos
    Chikungunya virus is spread by mosquitos

    Insane Medicine - Specifically, the Aedes mosquito spreads this virus.
    Insane Medicine – Specifically, the Aedes mosquito spreads this virus.
  • Chikungunya is making headlines again as a million cases have occurred this year. We covered Chikungunya virus in a prior article http://www.insanemedicine.com/?p=69 in insanemedicine.com.
  • As a refresher, Chikungunya virus is an arbovirus endemic to Wet Africa that produces fever and arthritis in multiple locations. It is spread by the Aedes mosquito to humans, with primates as reservoirs. Aedes aegypti is one vector, that is present in the U.S. Southeast and lives in urban areas, frequenting small puddles of water. Aedes albopictus (Asian Tiger mosquito) is the other vector, and it spreads yellow fever, west nile, japanese encephalitis virus, and eastern equine encephalitis virus as well. It is found in the southeastern and mid-atlantic states areas.
  • A person who gets Chikungunya fever from the bite of one of these mosquitos develops fevers of three to five days duration and about two to five days after this, the patient develops polyarthralgias (arthritis pains) in the hands, wrists, and ankles most commonly. This arthritis can cause sever pain that lasts days to months. Rash also occurs about three days after onset of illness and is small and flat in nature.  In severe cases, death can result. Respiratory failure, encephalitis (brain infection), hepatitis, renal failure,  myocarditis (heart inflammation) have been associated with severe infection.
Chikungunya
Chikungunya
Insane Medicine - Nothing is too small for a mosquito
Insane Medicine – Nothing is too small for a mosquito.

The following is a link to updated information on the Chikungunya virus (Pan American conference) http://www.paho.org/hq/index.php?option=com_topics&view=article&id=343&Itemid=40931&lang=en

https://www.flickr.com/photos/pahowho/sets/72157645069134907/  < Pictures of infected victims.

Insane Medicine - Chikungunya fever skin rash
Insane Medicine – Chikungunya fever skin rash
  • What is so special about this tropical infection in the United  States? First, There is no immunity to this disease in the Americas, so it can spread rapidly.  Secondly, 1.03 million people have contracted the disease, with 155 dying, especially in Martinique and Guadeloupe. There have been 11 cases in Florida.
  • The economic impact of this disease are  significant with many having chronic arthritis, unable to walk due to the pain. 20-30 % have chronic rheumatological symptoms. This results in disability and missed work.
  • There is no specific treatment or cure. There is no vaccine available as of 2014.
Insane Medicine  distribution of Chikungunya virus
Insane Medicine distribution of Chikungunya virus
Map of Caribbean where the Chikungunya is located
Map of Caribbean where the Chikungunya is located.
  • The best treatment for this disease is prevention, through the use of insect repellent and extermination of mosquitoes by removing their  breeding grounds (areas of standing water) and through the use of insecticide.
  • There have been 11 cases of Chikunguya virus in the U.S., and 1900 cases  or so that have been imported to the U.S. through traveling.  This number will probably rise over the next year.
  • If you are traveling to South America or the Caribbean, be certain to carry insect repellent.
  • More information can be found at the CDC website : http://www.cdc.gov/chikungunya/
  • CDC reportable diseases website: http://wwwn.cdc.gov/nndss/
I survived
I survived

keepcalminsectrepellent
keepcalminsectrepellent
chikungunya drinkschikungunya drinks
chikungunya drinks

 

 

Insane Medicine – Your dishtowels have Salmonella and stool-related bacteria growing in them!!

Insane Medicine - Dirty dish towels and even 'clean' ones have tons of bacteria in them!
Insane Medicine – Dirty dish towels and even ‘clean’ ones have tons of bacteria in them!
Salmonella has been found with coliform bacteria to survive on dish towels even after washing and drying.
Salmonella has been found with coliform bacteria to survive on dish towels even after washing and drying.
  • Bacteria have been found to survive and grow on your dish towels, which can then cross-contaminate your food and give you illness!!
  • E. Coli and coliform bacteria, all from our gut (poop) have been demonstrated to grow on dish towels. The bacteria were cultured on special plates and their numbers decreased with frequent towel washing, but they could still survive the cleaning and drying process, thereby giving them the chance to contaminate other foods or your hands when you dry them in the towel.
  • Salmonella likewise can do similar as E. coli. In one study, it was found in 14% of all dishtowels surveyed in several cities!!
  • The moisture and food particles that remain on the towels with use allow the perfect environment for the growth of these bacteria.
  • Also found were Campylobacter on towel that had been used when a person did not wash their hands sufficiently after handling chicken.  E. coli 0157:H7 and numerous other bacteria have been cultured on kitchen/dishwasher towels.
  • What should you do? It was found that bleaching the towel could decrease bacterial counts. Using a 4000mg/L bleach solution for two minutes was effective in decreasing the bacteria. http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Documents/Chlorine_Dilution_Tool2.xlsx < Calculator for bleach concentration.
  • Other options include frequent replacement of your dish towels. So remember – your dish towels may be your enemy in the realm of cleanliness as they carry many bad bacteria on them when they are not cleaned appropriately.
  • http://www.foodprotection.org/files/food-protection-trends/Sep-Oct-14-Gerba.pdf  < –Study showing contamination of dish towels with bacteria!!

Insane Medicine – Get your Influenza vaccine!!!

  • Get your Influenza vaccination!! The strains covered by the vaccine are based on circulating strains in the southern hemisphere from the prior year. It is effective in 50-80% of young adults if the match is close between the vaccine components and the circulating strain, but even if not, there is a reduced risk of death from influenza.
  • Older people have less response to the vaccine.
  • The intranasal vaccination is a weakened live preparation sprayed in the nose of patients age 2 to 49. Pregnant patients cannot get this one. This works better than the inactivated vaccine if you are less than 6 years old, whereas the opposite it true in adults. The shot works better for adults.
  • The elderly, especially those older than 65, do not respond as well to the regular vaccination. There is a Fluzone High-Dose vaccination that has four times as much antigen in it and is more effective in preventing influenza.
  • The vaccination decreases the risk of cardiovascular events in patients with heart problems, and it prevents risk even more in those who recently had a heart attack.
  • All pregnant patients need to be vaccinated – this protects the mother, and the antibodies protect the baby  for six months after delivery! It takes two weeks for the vaccine to be fully effective inpatients.  Remember that pregnant patients must not get the live vaccine.
  • If you have an egg allergy, you can get the FluBlok vaccination.
  • Vaccination should be done from October until May.
  • Side effects for the injection form of the vaccine include aches at the injection site and a small risk of a nerve condition called Guillian-Barre syndrome. The live nasal mist can cause nasal congestion and a sore throat. Patients who get this vaccine shed live virus for a few days after and should not be near people who have poor immune systems from problems such as chemotherapy.
  • Either way, the influenza vaccine SAVES LIVES!!

Insane Medicine – Ebola threats continue to rise

ebola virus infections

Insane Medicine -Reported ebola cases - they continue to rise and unreported cases are definitely increasing as well!
Insane Medicine -Reported ebola cases – they continue to rise and unreported cases are definitely increasing as well!
  • Are US hospitals prepared for Ebola? Not really. The entire process of protecting health care workers has been in a state of flux. The CDC itself has been changing the rules of engagement for healthcare providers in terms of the protective mechanisms that need to be applied in the event of an Ebola patient’s arrival.
  • Most Emergency Departments would need to shut down after the arrival of such a patient due to decontamination needs. As was seen in Texas, even with protocols the disease still is able to spread to healthcare workers. It seems logical that patient with risk factors in the US for Ebola should be transported immediately to centralized facilities capable of handling such biohazards. They should bypass smaller ED’s and free-standing ED’s., where staff have little or no training in biohazard protection. In the US, there are probably less than 15 dedicated isolation centers for hazardous infections, Emory having two of them.
  • The disease continues to increase in the number it has infected. There is no current accepted treatment for it. The graphs above show the large numbers infected and the continued rise in affected individuals. As expected, some of those with the disease will travel abroad…
  • There are many gaps in the current data for infections, the total number being vastly under-reported. The fall in the number of infections in some areas may be due to overwhelmed facilities turning away Ebola victims, many of whom go on to die elsewhere. Those people fall through the cracks of epidemiological surveys. Many patients may not be seeking medical care because they live far away or the facilities are full. They die at home and are buried.
  • Many patients in Africa do not get tested for the disease but have symptoms of it. There are not enough resources to test in many areas. In Liberia, only 22% of the cases were confirmed by testing.
  • The worst case scenario per the CDC is that 1.4 million people may be infected in Africa by January 20. Currently, the number of cases is doubling every three to four weeks and is continuing. The key to containment will be control measures to prevent spread in theses areas, including safe burial practices.
  • In the US, the presence of a single infected patient who flew into Texas demonstrates the degree of risk and magnitude of strain on resources that occurs. Tracking hundreds of contacts on planes and casual contacts is very difficult and costly.

Links to Ebola related reports are as follows:

http://www.sciencemag.org/site/extra/ebola/  < Science Magazine special collection.

http://maimunamajumder.wordpress.com/2014/10/09/ebola-new-updated-charts-14/  <– statistical data from MIT

http://healthmap.org/ebola/#projection  < Ebola infection data model of number of infections.

 

  • Currently, two vaccines are being developed in trials for Ebola. NewLink genetics (NLNK) has a vaccine in trials now that uses the Ebola surface protein in a weakened version  of vesicular stomatitis virus (a virus that attacks farm animals). GlaxoSmithKline is developing and testing another Ebola vaccine, in which genes for a surface protein from two different strains of Ebola have been stitched into a chimpanzee adenovirus. Hopefully one of these systems will be effective.

Insane Medicine – Parasites – Cyclospora in food

Insane Medicine - Cyclospora - a cause of food poisoning that results in diarrhea illness
Insane Medicine – Cyclospora – a cause of food poisoning that results in diarrhea illness
  • We don’t think much of parasites in the United States as a source of illness because they seem like such tropical diseases, however, there are quite a few problems caused by parasites here, some that are transported to us, especially on food. Recently, in Texas, an infection caused by a protozoan, Cyclospora cayetanensis resulted in diarrhea-type illness in Texas. The culprit was cilantro imported from Peubla, Texas!
  • Cyclospora has been an occasional culprit of gastrointestinal infections in the United States. it is not endemic, but rather is tropical or sub-tropical in it’s origins.
  • It is a single celled organisms that is spread from fecally contaminated food and water.
  • Food products that have been found to carry Cyclospora in past outbreaks include snow peas, raspberries, and basil. No frozen products have been associated with outbreaks. It can occur at any time of the year but mostly in spring and summer months.
  • Symptoms of infection develop in a week, resulting in abdominal bloating and cramps, with primarily diarrhea, less often, there may be vomiting. Infected people can lose a lot of weight. Symptoms may last weeks to months with diarrhea alternating with constipation even.
  • It is diagnosed by examining stool for the parasite specifically. There is no blood test for this. Its’s treatment is with a sulfa- based antibiotic (trimethoprim-sulfamethoxazole).
  • Cyclospora is not killed by routine disinfection and sanitation measures, but it is best to wash fruit off thoroughly.
  • Do you have this infection? Unlikely, but in a group setting of infection, especially with the symptoms listed above, it is something to consider.

http://www.cdc.gov/parasites/cyclosporiasis/publications.html  <— Link to prior outbreaks of Cyclospora in the United States.

Insane Medicine - Cyclosporiasis life cycle - from CDC
Insane Medicine – Cyclosporiasis life cycle – from CDC

Insane Medicine – Chikungunya Virus Gone viral – The arthritis virus in the Caribbean!

Insane Medicine -Chikungunya  Virus
Chikungunya Virus at elcetron microscope magnification levels.



Aedes mosquito on human

 

  • Chikungunya Virus was first found inTanzania in 1952. It is an RNA virus of the alphavirus genus and the Togaviridae family.
  • It is primarily found in Western Africa, similiar to where ebola is currently found this year. It is endemic in West Africa, but in 2103, it was found in the Caribbean, including St. Martin and Puerto Rico. Two mosquitos,  Aedes aegypti and Aedes albopictus (African tiger mosquito) are the mosquito vectors for the disease. The Aedes albopictus mosquito can carry Yellow fever and Dengue fever as well as Chikungya.
  • The virus causes crippling arthralgias  and fever. The illness can result in a rash. It lasts for several months, with the arthritis pain being prolonged and severe. Hence, the name Chikungunya, which in Tanzania means ”stooped over.’
  • The initial fever lasts 7-10 days and there may be swelling if the fingers and toes. In severe cases, a person can get an inflamed heart muscle, known as myocarditis and kidney failure.
  • Similar viruses include O’nyong-Onong (Central Africa), Baima-Ross River virus, Semili Virus, Mayaro virus (South America), and the Sindbis group virus. All of them cause severe arthritis.
  • Treatment – supportive care only, Fluids and pain management are cornerstone to treatment. There is no vaccine currently available. The best treatment is prevention – prevent mosquito bites by wearing  long clothes and lots of bug spray! If you are traveling to the Carribbean, be certain to wear bug spray to prevent infection.

http://www.cdc.gov/chikungunya/geo/index.html

 

Toenail problems? New solutions for fungal nails!

Onychomycosis
Onychomycosis – yellowed, thickened nails
  • Onychomycosis – refers to nail infections by fungus, including yeasts and molds.  Toenail onychomycosis is most commonly due to dermatophytes, a type of fungus (i.e. Trichophyton rubrum and T. mentagrophytes)
  • Risk factors for the problem include swimming,   athlete’s foot, diabetes, genetics, and living with family members who have the disease.
  • Besides being unsightly, the nails can be difficult to cut and also can increase the risk of bacterial infection. Pain can be an issue as well, as nails can become sensitive to pressure.
  • Yeasts, like Candida Albicans, can also cause some cases of nail fungus, especially on the hands. People who immerse their hands in water a lot are at risk.
  • Some fungal infections can discolor the nail black –  (dematiaceous fungi  – pigment-producing molds)
  • As a result of these infections, the nails get thickened, discolored,  with crazy shapes and debris under the nail.
  • Two recent approved topical therapies that appear to have excellent effectiveness have come to the market.
  • Kerydin (Tavaborole) topical solution can be applied to the nail daily for 48 weeks. No nail removal is required and the solution is not absorbed to any degree by the body. About a third had significant improvement without adverse reactions to any large degree. It is expensive (~400$)
  • Efinaconazole (Jublia) topical solution is another new arrival to treat the standard nail infections caused by T. Rubrum/T. Mentagrophytes. It is a topical triazole that blocks the fungus from producing it’s cell membrane. Applied at a drop a day to the affected nail for 52 weeks,  40% had mycological cure with minimal side effects, but at a cost of $450 a month.
  • Oral treatments that are mainstay include  Terbinafine (Lamisil) daily for 12 weeks and itraconazole daily for three months. Their effectiveness is about 30%-40% with more side effects.
  • Alternative therapies with some possible efficacy include applying Vicks Vapor rub (a mixture of menthol, eucalyptus oil, camphor, and thymol) to the nails every day for up to a year. This has worked well for quite a few people.
  • Tea tree oil is another alternative topical therapy with unproven results.
  • Still, oral therapies are still the best options as of yet. Oral Lamisil (terbinafine) cures 40% to 60% of patients…compared to less than 9% for Penlac (ciclopirox) and 11% for clotrimazole 1% topical solutions (less effective topical agents also on the market).
  • Key preventative measures include wearing flip-flops around a shared shower or pool, wash and dry feet thoroughly every day , do not clip your nails too low to the base, and avoid nail polish.

Ebola Virus

Ebola Virus Infection

Ebola virus_virion
Ebola virus_virion magnified under electron microscope
  • Ebola has continued to spread in West Africa, infecting over 4500 people through September 2014, with 2300 deaths. The average mortality rate has been 70% with this infection.
  • This epidemic is the Zaire Ebola virus. There are several other sub-types of Ebola. It is an RNA virus of the filovirus family. It’s reservoir is the fruit bat and is spread among humans by direct contact with body fluid or the consumption of infected food or plants contaminated with bat droppings.
  • This epidemic started in Guinea in march.
  • Humans, apes, certain mammals, and potentially rodents can get Ebola.
  • There is no specific treatment as of yet, various interventions have been tried, but the main treatment is isolation of the individual, intravenous fluids, hydration, management of electrolyte issues, and prevent co-infection from bacteria.
  • Ebola life cycle
    Ebola life cycle

    According to a CDC prediction tool recently released, if current conditions persist, the cases will double every 20 days up to 20,000 infected by early November. This can be prevented by isolating at least 70% of the infected patients in specialty Ebola units. The more delay there is in obtaining this critical isolation and treatment number, the more likely infection rates will increase.

  • The CDC still predicts that the epidemic will end even if counter-measures are delayed, it will just result in more deaths.
  • Ebola virus infection isolation and treatment is needed to decrease spread.
    Ebola virus infection isolation and treatment is needed to decrease spread.

     

  • Many health care providers have lost their lives in Africa treating the sick, including researchers, nurses, and doctors. Fear of the disease and customary burial practices have increased the transmission rate and death rates. There are fewer and fewer doctors and nurses available to help stem the infection.

 



Enterovirus EV-D68 Marches on!

  • As more states report clusters of severe cold-like illnesses, some of which have been linked to EV-D68, it seems apparent that cases and locations of the illness will keep mounting.
  • There is no vaccination or antibiotic to treat a virus, and just because you have a cough, nasal congestion, or signs of an upper respiratory illness, it does not mean that you have the EV-D68. Don’t get in a panic, even if you do.
  • Treatment plans if you get cold-like symptoms : see your doctor/ER if you feel short of breath or have severe symptoms. Avoid close contact and wash your hands frequently. Take in plenty of liquids. Tylenol and ibuprofen for fevers and aches.
  • Doctors will basically assess you in the Emergency Department for possible other diseases such as pneumonia, bronchitis, or worsening asthma. Bacteria are treatable, but most viral infections require only supportive care. Doctors will assure your hydration status, administer nebulizers for bronchospasm, and use imaging such as a chest xray to look for pneumonia.
  • Severe symptoms such as dehydration and persistent vomiting, low oxygen saturation in your blood stream requiring oxygen, or another severe diagnosis may necessitate admission to a hospital.
  • As many children have never had exposure to this infection, immunity will be low, hence, more severe presentations.
  • Don’t forget to get your Flu vaccine this year!

I have a cold