88 results in Emergency Management of Infectious Diseases
67 - Smallpox
- from Part IV - Current Topics
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- By David M. Stier, Medical Epidemiologist, Medical Director, Adult Immunization and Travel Clinic, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Nikkita Patel, Research Assistant, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Olivia Bruch, Health Program Coordinator, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Karen A. Holbrook, Medical Epidemiologist, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Smallpox is caused by variola viruses, which are large, enveloped, single-stranded DNA viruses of the Poxvirus family and the Orthopoxvirus genus. Variola major strains cause three forms of disease (ordinary, flat type, and hemorrhagic), whereas variola minor strains cause a less severe form of smallpox. Vaccination with vaccinia virus, another member of the Orthopoxvirus genus, protects humans against smallpox because of the high antibody cross-neutralization between orthopoxviruses.
The Working Group for Civilian Biodefense considers smallpox a dangerous potential biological weapon because of “its case-fatality-rate of 30% or more among unvaccinated persons and the absence of specific therapy.” Of the potential ways in which smallpox could be used as a biological weapon, an aerosol release is expected to have the most severe medical and public health outcomes because of the virus's stability in aerosol form, low infectious dose, and high rate of secondary transmission. A single case of smallpox would be a public health emergency.
EPIDEMIOLOGY
Smallpox as a Biological Weapon
Smallpox has been used as a biological weapon in the distant past and has recently been a focus of bioweapons research. In the 18th century, British troops in North America gave smallpox-infected blankets to their enemies, who went on to suffer severe outbreaks. Defecting Russian scientists describe covert Russian operations during the 1970s and 1980s that focused on the development of more virulent smallpox strains and of missiles and bombs that could release smallpox.
Part IV - Current Topics
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- By Rachel L. Chin, University of California, San Francisco School of Medicine, San Francisco General Hospital, Michael S. Diamond, Washington University School of Medicine, Teri A. Reynolds, Alameda County Medical Center–Highland Campus
- Edited by Rachel L. Chin, University of California, San Francisco
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51 - Infections in Oncology Patients
- from Part III - Special Populations
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- By Erik R. Dubberke, Assistant Professor of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Multiple risk factors contribute to making infection a leading cause of morbidity and mortality in oncology patients: both neoplastic disease and treatment regimens may cause disruption of mucocutaneous barriers, altered immunity, and/or viscus obstruction. The approach to a febrile oncology patient must take into consideration the nature and stage of the underlying disease, past and present treatments, any recent instrumentation or hospitalization, and any recent antibiotic exposures.
EPIDEMIOLOGY
Solid malignancies can increase the risk of infection by various means. Obstruction of natural passages leads to inadequate drainage of body fluids, stasis, and increased risk of bacterial colonization and infection. In this setting, infections are typically due to organisms that are a part of the normal flora (e.g., upper respiratory tract flora causing postobstructive pneumonia, gastrointestinal flora causing postobstructive cholangitis). Solid malignancies can invade across tissue planes, leading to conduits between normally sterile areas and the external environment (e.g., rectovesicular fistulas). Central nervous system malignancies can lead to aspiration and subsequent respiratory tract infection by compromising the cough and/or swallow reflex. In addition to these secondary effects, necrotic tissue within a solid tumor itself can also be a nidus for infection.
Although hematologic malignancies (lymphomas, leukemias, and plasma cell dyscrasias) are rarely associated with obstruction or with the invasion of tissue planes, they are often associated with innate, cellular and/or humoral immune system dysfunction.
70 - Hantavirus
- from Part IV - Current Topics
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- By Rachel L. Chin, Editor in Chief, Professor of Emergency Medicine, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA, Deborah Colina, Michigan State University/Sparrow Hospital, Lansing, MI
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Hantaviruses belong to the enveloped viruses within the family Bunyaviridae, genus Hantavirus, and all medically important species are carried by rodents of the family Muridae. Named for the Hantaan River in Korea, hantaviruses were first isolated in 1976, though the clinical syndrome they cause came to widespread attention in the early 1950s when more than 3000 United States and United Nations Korean War forces contracted an acute febrile illness associated with renal failure and coagulopathy. Hantaviruses are also believed to have been responsible for outbreaks of hemorrhagic fevers in Russia (1913), Scandinavia (1932–1935), and Finland (1945), though they have become clinically significant in the United States only over the past 15 years.
Hantavirus infection causes two distinct clinical syndromes characterized, respectively, by renal failure or cardiovascular collapse. The so-called “Old World” hantaviruses endemic to Asia and Europe cause hemorrhagic fever with renal syndrome (HFRS), whereas the “New World” hantaviruses endemic to North America cause hantavirus cardiopulmonary syndrome (HCPS), also known as hantavirus pulmonary syndrome (HPS). Both diseases appear to be immunopathologic.
EPIDEMIOLOGY
There are 20 distinct hantavirus species, but only 11 are associated with human disease. HFRS can be caused by any of the Old World hantavirus strains including Hantaan, Seoul, Dobrava-Belgrade, and Puumala viruses. (See Figure 70.1.)
66 - Plague
- from Part IV - Current Topics
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- By David M. Stier, Medical Epidemiologist, Medical Director, Adult Immunization and Travel Clinic, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Nikkita Patel, Research Assistant, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Olivia Bruch, Health Program Coordinator, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Karen A. Holbrook, Medical Epidemiologist, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Plague is an acute bacterial infection caused by Yersinia pestis, a member of the family Enterobacteriaceae. Y. pestis is a pleomorphic, nonmotile, nonsporulating, intracellular, gram-negative bacillus that has a characteristic bipolar appearance on Wright, Giemsa, and Wayson's stains. There are three virulent biovars – antiqua, mediaevalis, and orientalis – and a fourth avirulent biovar, microtus. The orientalis biovar is thought to have originated in southern China and caused the most recent pandemic.
The Working Group for Civilian Biodefense considers plague to be a potential biological weapon because of the pathogen's availability “around the world, its capacity for its mass production and aerosol dissemination, and the difficulty in preventing such activities, high fatality rate of pneumonic plague, and potential for secondary spread of cases during an epidemic.” Of the potential ways in which Y. pestis could be used as a biological weapon, aerosol release would be most likely. This method has been successfully demonstrated to cause disease in Rhesus macaques.
EPIDEMIOLOGY
Plague as a Biological Weapon
In the 20th century, countries including the United States, the former Soviet Union, and Japan developed ways for using Y. pestis as a weapon. Creating aerosolized plague is technically challenging; however, if an intentional release of aerosolized plague were to take place, an outbreak of pneumonic plague would be likely. This would be of serious concern because of the high case-fatality rate and the potential for person-to-person transmission.
58 - Postpartum and Postabortion Infections
- from Part III - Special Populations
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- By Lisa Rahangdale, Instructor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION – INFECTIONS AND AGENTS
Infections prevalent in the postpartum and postabortion period include urinary tract and genital tract infections (including endometritis, septic pelvic thrombophlebitis, pelvic inflammatory disease, and tubo-ovarian abscess), as well as mastitis, pneumonia (as a complication of anesthesia), and wound infection. Approximately 6% of women develop infections after vaginal delivery or cesarean section, the majority (94%) after hospital discharge. The most common postpartum infections are mastitis and urinary tract infection. This chapter reviews genital tract infections, mastitis, and episiotomy site infections. See Chapters 32, 37, and 57 for discussions of pneumonia, urinary tract infections, and surgical wound infections.
Endometritis: Postpartum and Postabortion
Endometritis is infection of the uterus. This may include the lining of the uterus (endometrium), the muscular layer (myometrium), or the entire organ. Endometritis is a polymicrobial infection occurring either at the time of delivery or during operative procedures via exposure of the upper genital tract to vaginal flora. Pathogens include aerobic and anaerobic gram-positive cocci (group A beta-hemolytic Streptococcus, coagulase-positive Staphylococcus aureus, group B Streptococcus, Streptococcus pneumoniae, and Enterococcus faecalis) as well as aerobic and anaerobic gram-negative agents (Escherichia coli, Gardnerella vaginalis, and Bacteroides fragilis). Other pathogens include those associated with prior sexually transmitted infection such as Chlamydia trachomatis and Neisseria gonorrhoeae, and those associated with bacterial vaginosis such as Mycoplasma hominis and Ureaplasma urealyticum.
56 - Blood or Body Fluid Exposure Management and Postexposure Prophylaxis for Hepatitis B and HIV
- from Part III - Special Populations
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- By Roland C. Merchant, Assistant Professor of Emergency Medicine and Community Health, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, RI, Michelle E. Roland, Associate Professor of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, Positive Health Program at San Francisco General Hospital, Chief, Office of AIDS, California Department of Public Health, Sacramento, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Because the efficacy of prophylactic therapy may be highly time-dependent, the acute care management of occupational or other blood and body fluid exposures must include rapid determination of the need for prophylaxis, testing, and treatment. Attention to wound care principles and referral for social, medical, or advocacy services remain important in all cases.
EXPOSURE EPIDEMIOLOGY AND TRANSMISSION RISK
There were an estimated 78,123 visits to United States emergency departments (EDs) annually during 1998–2000 for work-related exposures to blood or body fluids. More than 90,000 females of all ages present annually for medical care after sexual assault. The frequency of ED visits for other populations and for other types of blood or body fluid exposures is not well known.
Hepatitis B
The Centers for Disease Control and Prevention (CDC) estimates that 5.6% of 20- to 59-year-olds in the United States have been infected with hepatitis B, though the prevalence and incidence has decreased over the past 20 years (see Chapter 13, Viral Hepatitis). This reduction is likely due to widespread use of the hepatitis B vaccination, universal precautions in health care settings, and educational campaigns to increase condom usage and reduce injection-needle sharing.
Although it is found in other body fluids (e.g., bile, breast milk, cerebrospinal fluid, saliva, semen, and sweat), hepatitis B is primarily transmitted through contact with blood.
65 - Botulism
- from Part IV - Current Topics
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- By David M. Stier, Medical Epidemiologist, Medical Director, Adult Immunization and Travel Clinic, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Nikkita Patel, Research Assistant, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Olivia Bruch, Health Program Coordinator, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA, Karen A. Holbrook, Medical Epidemiologist, Communicable Disease Control and Prevention Section, San Francisco Department of Public Health, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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INTRODUCTION
Botulism is a disease caused by exposure to botulinum toxin produced from Clostridium species, mainly Clostridium botulinum. Clinical forms of the disease include foodborne, inhalational, wound, infant, adult intestinal toxemia, and iatrogenic. C. botulinum is a gram-positive, strictly anaerobic, spore-forming bacillus naturally found in soil and aquatic sediments. There are seven types of the toxin based on antigenic differences, labeled A through G. Types A, B, and E (and rarely, F) are pathogenic in humans. Types C, D, and E cause illness in other mammals, birds, and fish. Botulinum toxin lacks color, odor, and taste and is the most lethal toxin known. Death is caused by doses of less than 1 μg. Antibiotics have no activity against the toxin itself.
In response to unfavorable environmental conditions (changes in pH, temperature, and water or nutrient availability), C. botulinum bacteria “sporulate.” C. botulinum spores are hardy, resistant to desiccation, heat, ultraviolet (UV) light, and alcohols, and can survive boiling for up to 4 hours; however, they are readily killed by chlorine-based disinfectants. Once spores encounter more favorable conditions, such as are found in human tissues, they “germinate,” producing growing cells that are capable of reproducing and elaborating toxin.
The Working Group for Civilian Biodefense considers botulism to be a dangerous potential biological weapon because of the pathogen's “extreme potency and lethality; its ease of production, transport, and misuse; and the need for prolonged intensive care among affected persons.”
6 - Otitis Externa
- from Part I - Systems
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- By Theresa A. Gurney, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA, Andrew H. Murr, Professor of Clinical Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, Chief of Service San Francisco General Hospital, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION – AGENTS
Otitis externa (OE) or “swimmer's ear” is a relatively common infection of the pinna and/or external auditory canal. Most episodes of OE are caused by Pseudomonas aeruginosa. Other bacterial etiologies include Staphylococcus aureus, other Staphylococcus spp., Streptococcus, Proteus, and Klebsiella.
OE can occasionally be caused by fungi, most often Aspergillus species such as Aspergillus niger, flavus, and fumigatus. Candida albicans can also cause OE.
Less commonly, a herpetic viral etiology can cause OE, or an eruption of herpetic vesicles can become secondarily infected by bacteria.
EPIDEMIOLOGY
Otitis externa occurs in both children and adults, and is often seen in months when swimming is a popular activity. This association may result from injury to the ear canal skin in the process of drying ears after swimming, which facilitates bacterial infection. Patients with chronic moisture in their ears are more susceptible to OE, and increased incidence is seen in warm, humid environments and seasons. Hearing aid wearers or frequent ear-plug users may also be at increased risk.
A history of trauma, laceration, or a recent intra-aural foreign body may be an inciting event. Overaggressive Q-tip users are frequent OE patients because of abrasion and subsequent infection of the ear canal. A careful history must be elicited in refractory cases, because although patients may have claimed that they have ceased using Q-tips, other objects such as pins, paper clips, and the ends of eyeglasses are often substituted.
54 - Fever in the Returning Traveler
- from Part III - Special Populations
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- By Derek Ward, University of California, San Francisco School of Medicine, San Francisco, CA, Alex Blau, University of California, San Francisco School of Medicine, San Francisco, CA, Matthew Lewin, Assistant Clinical Professor of Emergency Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, Expedition Doctor, American Museum of Natural History, New York, NY
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Each year millions of people travel internationally from, and visit or immigrate to, the United States. As a group, travelers are exposed to numerous infectious agents, and eliciting a travel history is crucial in any recent traveler with presenting complaints suspicious for infectious disease, because appropriate clinical management may be highly specific to the locality of exposure.
The five most commonly identified causes of systemic febrile illness in returning travelers, in order of prevalence, are malaria, dengue fever, mononucleosis (Epstein-Barr or cytomegalovirus), rickettsial infections, and enteric fever caused by Salmonella typhi or Salmonella paratyphi. Tuberculosis and leptospirosis are also common, treatable diagnoses.
EPIDEMIOLOGY
A thorough travel history begins with identification of the region of travel and includes stops made during transit, as well as other factors that may affect the risk of contracting disease:
type of travel (urban, rural, wilderness)
food and beverage consumed (unfiltered water and ice cubes, uncooked or undercooked foods, and unpeeled fruits and vegetables)
activities (camping, hiking, fishing, swimming, etc.)
hygiene practices and availability of soap and toilet facilities
exposure to animals and insects
timing of exposure
sexual contact with local population (primarily or secondarily)
prophylactic medications taken during travel
vaccination history (including childhood immunizations)
The following list of disease entities is intended to help identify exposure risk in the returning traveler. This listing is not comprehensive, and information changes frequently. Practitioners should refer to the Centers for Disease Control and Prevention (CDC) for complete and up-to-date information (http://www.cdc.gov, 1–877–394–8747).
73 - West Nile Encephalitis Virus
- from Part IV - Current Topics
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- By Michael S. Diamond, Associate Editor, Associate Professor of Medicine, Molecular Microbiology, Pathology, and Immunology Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
West Nile encephalitis virus (WNV) is a small, enveloped, mosquito-transmitted, positive-polarity RNA virus of the Flaviviridae family. This virus is closely related to other arthropod-borne viruses that cause human disease including dengue, yellow fever, and Japanese encephalitis viruses. WNV normally cycles in nature between mosquitoes and birds, but during epidemics will infect and cause disease in human, horses, and other vertebrate animals. Severe neurological disease in humans usually occurs within 1 to 2 weeks after mosquito inoculation and is more frequent in elderly and immunocompromised individuals.
EPIDEMIOLOGY
West Nile virus historically caused sporadic outbreaks of a mild febrile illness in regions of Africa, the Middle East, Asia, and Australia. However, in the 1990s, the epidemiology of infection appeared to change, with new outbreaks in parts of eastern Europe associated with higher rates of severe neurological disease. In 1999, WNV entered North America and caused seven human fatalities in the New York area, as well the deaths of a large number of birds and horses. Since then, WNV has spread to all 48 of the lower United States as well as to parts of Canada, Mexico, and the Caribbean. Because of the increased range, the number of human cases has continued to rise: In the United States between 1999 and 2007, there were more than 26,000 clinical cases of WNV, including nearly 1,000 deaths.
45 - Work-Up of Newborn Fever
- from Part II - Pediatrics
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- By Maureen McCollough, Associate Professor of Emergency Medicine and Pediatrics, Keck School of Medicine, University of Southern California; Director, Pediatric Emergency Department, Department of Pediatrics; Medical Director, Department of Emergency Medicine, Los Angeles County–USC Medical Center, Los Angeles, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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INTRODUCTION
The neonate is defined as a newborn infant younger than 4 weeks old, and fever as a temperature greater than 100.4°F or 38°C. Because clinical exam is limited and because of the high risk of serious bacterial infection in this age group, all febrile neonates must be admitted for a sepsis workup and empiric antibiotic therapy.
Neonatal infections are unique, in that transmission of organisms can occur transplacentally during gestation and can present early on or be delayed by months or longer. Vertical transmission can occur in utero or during delivery. The newborn immune system is immature, increasing the susceptibility to infection. Other disease processes such as hyaline membrane disease may complicate infectious presentations. Finally, the presentation of infectious diseases in neonates is variable, often with subtle signs and symptoms.
EPIDEMIOLOGY
Neonates who are less than 2 weeks old who present to the ED have a particularly high incidence of serious illness with 10–33% requiring hospital admission. The most common diagnoses in admitted neonates include respiratory infections, sepsis, dehydration, congenital heart disease, bowel obstruction, hypoglycemia, and seizures.
Group B Streptococcus is the most common bacterial cause of neonatal sepsis in the United States. Listeria monocytogenes, Escherichia coli, Klebsiella, enterococcus, non-group D alpha hemolytic strep, and nontypeable Haemophilus influenzae are other bacterial causes.
3 - Dental and Odontogenic Infections
- from Part I - Systems
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- By Preston C. Maxim, Associate Clinical Professor of Emergency Medicine, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION
Infections of the oral cavity are a common presenting complaint in the acute care setting and represent a diverse spectrum of disease ranging from dental caries to Ludwig's angina and retropharyngeal abscess. Odontogenic infections are generally due to normal mouth flora, specifically aerobic and anaerobic Streptococcus species, Bacteroides fragilis, and Prevotella intermedia.
EPIDEMIOLOGY
Dental infections are common in the general population, afflicting 40% of children by age 6 and 85% by age 17. The incidence approaches 100% by age 45, with approximately 50% having modest to severe periodontal disease. Comorbidities including diabetes, smoking, injection drug use, and poor oral hygiene increase the risk and severity of patients' periodontal disease. Fortunately, the incidence of secondary odontogenic infections has declined with the use of antibiotics, as has their morbidity and mortality. For example, although deep mandibular space abscesses, or Ludwig's angina, still represent 13% of the deep space infections of the neck, its mortality has declined from greater than 50% in the 1940s to approximately 5% currently.
CLINICAL FEATURES
Dentoalveolar Infections
Patients with dentoalveolar infections present to the acute care setting with a spectrum of disease ranging from caries to periapical abscesses. The persistent presence of dental plaque leads to the breakdown of the enamel and dentin layers that protect the dental pulp. Once the pulp is exposed, bacteria cause inflammation and subsequent necrosis.
10 - Deep Neck Space Infections
- from Part I - Systems
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- By Theresa A. Gurney, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA, Andrew H. Murr, Professor of Clinical Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, Chief of Service San Francisco General Hospital, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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INTRODUCTION – AGENTS
The head and neck contain a variety of fascial planes forming potential spaces for the spread of infection. If these spaces are seeded, infection may travel to vital structures such as the carotid artery, jugular vein, or mediastinum. Deep neck spaces include the submandibular, peritonsillar, parapharyngeal, retropharyngeal, and prevertebral spaces.
The majority of deep neck space infections are caused by the organisms that frequently infect or colonize the upper aerodigestive tract. These include Streptococcus and Staphylococcus species, as well as bacteria commonly found in the oral cavity such as Bacteroides species, Klebsiella, Escherichia coli, Enterobacter, Actinomyces, and Eikenella corrodens. Often these infections involve mixed flora.
EPIDEMIOLOGY
Both adults and young children can develop deep neck space infections. Teenagers and young adults present with peritonsillar space abscesses more commonly than other age groups. A recent dental infection or procedure may be a predisposing factor for a submental or submandibular space infection (see Chapter 3, Dental and Odontogenic Infections). Intravenous or subcutaneous injection of illicit substances into neck veins or tissue also predisposes to neck infections.
CLINICAL FEATURES
The clinical features of a particular deep neck space infection will reflect the anatomic characteristics of the deep neck space involved (Table 10.1). A submandibular space infection may reveal a concomitant infection of the submandibular duct. Odontogenic infections can progress to submental or sublingual infections, and therefore a through dental examination is always indicated.
7 - Sinusitis
- from Part I - Systems
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- By Theresa A. Gurney, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA, Andrew H. Murr, Professor of Clinical Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, Chief of Service San Francisco General Hospital, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION – AGENTS
Causative agents of acute bacterial sinusitis are similar to those seen in other infections of the head and neck and include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Anaerobes are less frequently encountered in acute sinusitis but play a role in chronic sinusitis. Viruses can also cause acute rhinosinusitis.
EPIDEMIOLOGY
Sinusitis is a common chronic condition for which patients seek physician attention in the United States. There are more than 25 million patient visits per year pertaining to sinus problems, including allergic rhinitis, viral upper respiratory infections, vasomotor rhinitis, bacterial rhinosinusitis, and nasal polyposis. Sinusitis occurs in patients of all ages but is more common in adults. Children with cystic fibrosis, however, are a unique population at much higher risk for sinus disease caused by atypical organisms, especially Pseudomonas.
CLINICAL FEATURES
The spectrum of acute to chronic sinusitis is mostly dependent on the duration of signs and symptoms. Acute sinusitis is defined as an infection that generally clears within 4 weeks. Chronic sinusitis is an infection that has been present for about 12 weeks despite treatment. Subacute sinusitis lasts longer than 4 weeks but less than 12 weeks. Recurrent acute sinusitis may be referred to as chronic (recurrent) sinusitis if a patient is afflicted with more than four infections in a year, each clearing completely (Tables 7.1 and 7.2).
17 - Ulcerative Sexually Transmitted Diseases
- from Part I - Systems
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- By Diane Birmbaumer, Professor of Clinical Medicine, David Geffen School of Medicine at UCLA; Associate Program Director, Department of Emergency Medicine, Harbor–UCLA Medical Center, Torrance, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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Summary
INTRODUCTION – AGENTS
Sexually transmitted infections can be divided into those that cause genital ulcers and those that do not. In North America, ulcerative sexually transmitted diseases are most commonly caused by herpes genitalis, syphilis, and, occasionally, chancroid; much rarer causes include lymphogranuloma venereum and granuloma inguinale. Definitive diagnostic tests often are not available in the acute care setting, and empiric treatment with close follow-up is often the best approach.
HERPES GENITALIS
Epidemiology
Genital herpes infection is caused by herpes simplex virus (HSV) types 1 and 2. This is by far the most common cause of ulcerating genital disease in North America: More than 50 million persons in the United States have the disease. Most U.S. cases are caused by HSV-2.
Clinical Features
Herpes genitalis can present with a broad range of symptoms. Serologic testing suggests that many infected patients are asymptomatic or have minimal symptoms. Those with an initial genital infection caused by HSV-1 tend to have milder symptoms than those infected with HSV-2. In addition, patients who already have antibodies to HSV-1 (e.g., those with a history of fever blisters) often have milder symptoms with initial HSV-2 genital infection. Symptomatic patients with genital infection caused by HSV-2 who have no prior HSV antibodies tend to present with the most severe disease. In all cases of genital herpes, recurrences may occur and are more common in patients infected with HSV-2.
48 - Pediatric Urinary Tract Infection
- from Part II - Pediatrics
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- By Laura W. Kates, Clinical Instructor of Emergency Medicine, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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- Emergency Management of Infectious Diseases
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Summary
INTRODUCTION
Urinary tract infections (UTIs) are a common problem among pediatric patients and an important cause of acute and chronic morbidity, including hypertension and renal scarring. It is often difficult to differentiate between cystitis and pyelonephritis in children.
It is estimated that 75% of children younger than 5 years old with febrile UTI have signs of pyelonephritis by renal nuclear scans. Of children with pyelonephritis, an estimated 27–64% will develop renal scarring, putting them at risk for renal insufficiency and hypertension as adults and adolescents. The risk of long-term renal damage is highest in infants and small children (<2 years old) and the diagnosis of UTI in this population can help identify patients with urinary system obstructive anomalies or vesicoureteral reflux (VUR).
EPIDEMIOLOGY
Ascending infections predominate among pediatric UTI, with Escherichia coli causing 60–80% of cases. In neonates, group B Streptococcus should be considered if mothers are colonized. Other pathogens include Proteus (more commonly in boys and children with renal stones), Klebsiella, Enterococcus, and coagulase-negative Staphylococcus.
At all ages, girls are more likely to have UTIs than boys, with 3% of girls and 1% of boys being diagnosed with UTI before puberty. The prevalence of urinary tract infection in febrile young children aged 2 months to 2 years without a clinically apparent source is approximately 3–7% (Table 48.1).
2 - Myocarditis and Pericarditis
- from Part I - Systems
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- By Jorge A. Fernandez, Assistant Professor of Clinical Emergency Medicine, Keck School of Medicine, University of Southern California; Director of Medical Student Education, Department of Emergency Medicine, Los Angeles County–USC Medical Center, Los Angeles, CA, Stuart P. Swadron, Associate Professor of Emergency Medicine, Keck School of Medicine, University of Southern California; Residency Program Director, Los Angeles County–USC Medical Center, Los Angeles, CA
- Edited by Rachel L. Chin, University of California, San Francisco
-
- Book:
- Emergency Management of Infectious Diseases
- Published online:
- 15 December 2009
- Print publication:
- 30 June 2008, pp 9-14
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Summary
INTRODUCTION
Cardiac infections are classified by the affected site: endocardium, myocardium, or pericardium. As the pathophysiology, clinical presentation, differential diagnosis, and treatment of myocarditis and pericarditis overlap significantly, these will be discussed together.
EPIDEMIOLOGY AND PATHOPHYSIOLOGY
Myocarditis is an inflammation of the myocardium; the term myopericarditis describes the frequent additional involvement of the pericardium. Pericarditis involves only the pericardium. Isolated myocarditis is often relatively asymptomatic and therefore frequently misdiagnosed. Thus, the true incidence is unknown, although autopsy studies have demonstrated occult myocarditis in up to 1% of the general population. For unclear reasons, young men more frequently develop myocarditis as well as pericarditis.
The pericardium provides a protective barrier and is composed of two layers: visceral and parietal. The visceral layer is firmly attached to the epicardium, whereas the parietal layer moves freely within the mediastinum. Approximately 20 mL of fluid is normally present within the pericardial sac. Fluid accumulation within the pericardial sac may result in cardiac tamponade if the pericardium does not have sufficient time to stretch, as compliance increases slowly over time. Thus, the rate rather than the absolute amount of fluid accumulation in the pericardial sac is the most important determinant of tamponade physiology.
Cardiac infections may spread directly from one intracardiac region to another (from endocardium toward pericardium or vice versa). Alternatively, pleural or mediastinal infections can extend into the pericardium and cause cardiac infections.
38 - Pyelonephritis in Adults
- from Part I - Systems
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- By Parveen K. Parmar, International Emergency Medicine Fellow, Division of International Health and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, Fredrick M. Abrahamian, Associate Professor of Medicine, David Geffen School of Medicine at UCLA; Director of Education Department of Emergency Medicine, Olive View–UCLA Medical Center, Los Angeles, CA
- Edited by Rachel L. Chin, University of California, San Francisco
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- Book:
- Emergency Management of Infectious Diseases
- Published online:
- 15 December 2009
- Print publication:
- 30 June 2008, pp 215-220
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Summary
INTRODUCTION
Acute pyelonephritis, an upper urinary tract infection, describes a clinical syndrome of bacteriuria associated with fever, chills, flank pain or tenderness, and lower urinary tract symptoms (e.g., frequency, urgency, dysuria). Uncomplicated infections are those in healthy, nonpregnant females aged 18–40 years, without underlying comorbidities, structural defects in urinary anatomy, or renal dysfunction. Criteria for complicated infection include extremes of age, male gender, immunosuppression (e.g., diabetes, malignancy), pregnancy, presence of a urinary catheter, an anatomic or functional abnormality, obstruction, or history of instrumentation, or the presence of an unusual or resistant organism.
EPIDEMIOLOGY
There are approximately 250,000 cases of acute pyelonephritis annually in the United States, and it is estimated that 30% of these patients are hospitalized. The prevalence of disease is greater in women than men. Men are at higher risk for pyelonephritis if they are uncircumcised, have an enlarged prostate causing urinary stasis, participate in rectal intercourse, or have undergone recent urologic instrumentation or surgery.
Other populations at risk for acute pyelonephritis include those with urinary catheters, spinal cord injury, neurogenic bladder, or fistulae involving the bladder or ureters, or who have undergone renal transplantation. Pregnant women, especially during the second trimester, are also at higher risk for pyelonephritis because of hormonally induced changes in the urinary system. Potential complications of acute pyelonephritis during pregnancy include septicemia, premature labor and low-birth-weight infants.
11 - Mumps
- from Part I - Systems
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- By Theresa A. Gurney, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco General Hospital, San Francisco, CA, Andrew H. Murr, Professor of Clinical Otolaryngology–Head and Neck Surgery, University of California, San Francisco School of Medicine, Chief of Service San Francisco General Hospital, San Francisco, CA
- Edited by Rachel L. Chin, University of California, San Francisco
-
- Book:
- Emergency Management of Infectious Diseases
- Published online:
- 15 December 2009
- Print publication:
- 30 June 2008, pp 51-52
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Summary
INTRODUCTION
Once considered a common childhood illness, mumps has dramatically declined in incidence with the widespread usage of the mumps vaccine, though there have been significant sporadic outbreaks in the United States recently. Mumps is still a common disease in countries without widespread vaccination programs.
EPIDEMIOLOGY
Mumps is an enveloped negative-sense RNA virus belonging to the Paramyxovirus family. In the United States between 2001 and 2005, only 200–300 cases of mumps were diagnosed annually. Between January and May, 2006, however, there were more than 2,500 outbreaks in 11 states. Unvaccinated individuals are particularly at risk for infection, though the majority of outbreak cases have occurred among those who have been vaccinated and have not achieved immunity.
Current recommendations are that children receive a first dose of MMR vaccine at ages 12 to 15 months and a second dose at ages 4 to 6 years. Two doses of MMR vaccine are also recommended for students attending colleges and other post–high school institutions and who do not have proof of two prior doses or other evidence of immunity.
CLINICAL FEATURES
Patients with mumps commonly present with painful, bilateral parotid swelling (Figure 11.1). They may also have fevers, dry mucous membranes, dysphagia, and trismus (Table 11.1). On questioning, the patient may describe prodromal symptoms including malaise, fevers, and a sore throat. Milking of saliva along Stenson's duct should reveal clear saliva (purulent saliva suggests a bacterial etiology).