Infections without bordersdn3g20un7godm.cloudfront.net/2011/AM11SA/152.pdf · 2011-11-16 · bioterrorism-related anthrax, United States, epidemiologic findings. Emerg Infect Dis

Infections without borders

2011 ASCP Annual Meeting

Jeannette Guarner, MD

Department of Pathology and Laboratory Medicine

Emory University

� Conflicts: none

� Disclosures:

� Paid by The Emory Clinic

� Worked at CDC 1997-2007, now guest researcher

� Brought up in Mexico, thus funny accent


� Husband, at Emory University, Chair of Global Health

� Images, own and from CDC: � http://phil.cdc.gov/phil/home.asp

� http://www.terrorismcentral.com/Library/WMD/Bio/plague/LabProtocols.html

Objectives

� Identify the epidemiology, clinical and pathologic presentation and microbiologic aspects of anthrax, plague, mycobacteria, SARS coronavirus, and 2009 H1N1 influenza virus.

�Recognize these diseases and consult with the appropriate health care entities.


appropriate health care entities.

�Assess if their area/ hospital preparedness plan includes these infectious agents.

�Structure:� Scenarios/ cases

QUESTION: A CSF sent from the Emergency Department

shows the following on the Gram stain. What is the best

description for the structures present inside the red circle?

1. Gram-positive cocci

2. Gram-negative bacilli

3. Gram-positive bacilli

4. Gram-negative cocci

2011 ASCP Annual Meeting1 2 3 4

0% 0%0%0%

4. Gram-negative cocci

Gram stain

Crystal violet

Fixation

Iodine

(mordant)

Alcohol

(decolorization)

Safranin

(counterstain)


QUESTION: What organisms should be considered in the

differential diagnosis of this case based on the Gram stain?

1. Streptococcus

pneumoniae,

Staphylococcus aureus

2. Bacillus spp., Listeria

monocytogenes, and


0% 0%0%0%

monocytogenes, and

Corynebacterium spp.

3. Neisseria meningitidis,

Haemophilus influenzae

4. Pseudomonas spp.,

Escherichia coli., and

Salmonella spp.

Chart review

�The specimen belongs to a 63 year old man that

presented with fever, vomiting and confusion.

�Past medical history: 4 days of fever, myalgias, and

malaise. He had not had a sore throat or any other

upper respiratory symptoms.


upper respiratory symptoms.

�He had been trekking in the North Carolina

mountains the week before his symptoms started.

�Physical exam: No nuchal rigidity. Chest

examination revealed bibasilar ronchi.

�The chest X-Ray

showed a widened

mediastinum


QUESTION: In this patient with the gram-positive bacillus in

his CSF, what is the most likely cause of a widened

mediastinum?

1. Ruptured esophagus

2. Metastases to mediastinal

lymph nodes

3. Inhalational anthrax


0% 0%0%0%

3. Inhalational anthrax

4. Aortic aneurysm

Bacillus anthracis in the laboratory

� Bacillus anthracis should grow within six to eight hours.

� Colonies show a “medusa head” appearance or have comma shaped projections

� Colonies are sticky when picked up


� Colonies are sticky when picked up

� The organisms are gram-positive, spore forming, catalase positive and non-motile.

� The capsule can be highlighted using India ink

QUESTION: To which one of the following agencies does the

hospital where the patient is being treated needs to

immediately report that there is a suspect anthrax case?

1. State Public Health

Department

2. Local Federal Bureau of

Investigation (FBI)


0% 0%0%0%

Investigation (FBI)

3. Department of Homeland

Security

4. Centers for Disease Control

and Prevention (CDC)

Hospital course

�The patient was empirically treated with intravenous

cefotaxime and vancomycin.

�Within hours after admission, the patient had a

generalized grand mal seizure and was intubated

and high dose steroids were added.


and high dose steroids were added.

�On the second hospital day, hypotension and acute

renal failure developed. He continued to be

unconscious during the hospitalization.

�On the third hospital day, he developed refractory

hypotension, had a cardiac arrest and died.

QUESTION: Should an autopsy be performed?

1. Yes, because the cause

of death is unknown.

2. Yes, because this death

was a possible homicide.

3. No, because the cause


0% 0%0%0%

3. No, because the cause

of death is known.

4. No, because an autopsy

would expose other

individuals to the

infectious agent.

Jernigan DB, et al. Investigation of

bioterrorism-related anthrax, United

States, epidemiologic findings.

Emerg Infect Dis 2002;8: 1019-28.

Guarner J, et al. Pathology and

pathogenesis of bioterrorism-related

inhalational anthrax . Am J Pathol


inhalational anthrax . Am J Pathol

2003;163:701-709.

Shieh WJ, et al. The critical role of

pathology in the investigation of

bioterrorism-related cutaneous

anthrax. Am J Pathol,

2003;163(5):1901-10.

QUESTION: A Laboratory technologist brings to your attention

a Giemsa stained blood smear that shows “very funny

bacteria”. How would you describe the organisms that you see

in this image?


0% 0%0%0%

1. Gram-positive rod-shaped

bacteria containing spores

2. Bipolar staining bacteria

3. Gram-positive, rod-shaped

bipolar bacteria

4. Rod-shaped bacteria in chains

QUESTION: What organisms should be included in the

differential diagnosis based on this Giemsa stain?

1. Burkholderia

pseudomallei, Yersinia

pestis

2. Clostridium perfringens,


0% 0%0%0%

Clostridium perfringens,

Listeria monocytogenes

3. Staphylococcus aureus,

Streptoccous

pneumoniae

4. Legionella spp.,

Chlamydiophila

pneumoniae

Case:

�53 year old diabetic man from New Mexico

vacationing in New York.

�On admission, he complained of fatigue and had

diaphoresis, rigors, tender left inguinal adenopathy

with overlying edema, and lower extremity necrosis.


with overlying edema, and lower extremity necrosis.

�Temperature 40.2°C, blood pressure 78/50 mm Hg.

�WBC 24,700/µl, platelets 72,000/µl.

�He was admitted to the ICU with the diagnosis of

septic shock. Guarner J, et al. Persistent Yersinia pestis antigens in ischemic tissues of a patient

with septicemic plague. Hum Pathol 2005;36:850-853.

QUESTION: 48 hours later the following plate and Gram

stain are available from microbiology. What is the possible

diagnosis?


0% 0%0%0%

1. Burkholderia pseudomallei

2. Francisella tularensis

3. Yersinia pestis

4. Salmonella typhi

Pathology of pneumonic plaguePrimary Secondary

Guarner J,et al.


Guarner J,et al.

Immunohistochemi

cal detection of

Yersinia pestis in

formalin-fixed,

paraffin-embedded

tissue. Am J Clin

Pathol 2002;117:

205-209.

QUESTION: Why is it important to distinguish between

primary and secondary plague pneumonia?

1. Treatment is different

2. Possible bioterrorism

3. Worse prognosis

4. Chest X-ray interpretation


0% 0%0%0%

4. Chest X-ray interpretation

QUESTION: What term is used to describe an illness

acquired by a traveler in one area who becomes ill in

another area where the illness is not endemic?

1. Peripatetic

2. Endemic

3. Dislocated

Autochthonous


0% 0%0%0%

4. Autochthonous

QUESTION: What is the vector for transmission of plague?

1. Fleas

2. Mosquitoes

3. Ticks

4. Tsetse flies


0% 0%0%0%


Clinical history

�A 35 years old a farm worker originally from

Central America presented with fever and was

found to have a lung nodule in a Chest X ray. A

PPD was placed.

�His first sputum AFB smears shows:


�His first sputum AFB smears shows:

QUESTION: How many AFB organisms need to be present

in 1 µL of sputum so as to have a positive smear?

1. 100

2. 1,000

3. 10,000


0% 0%0%0%

4. 100,000

Siddiqi K et al. Clinical diagnosis of

smear-negative pulmonary tuberculosis in

low-income countries: the current

evidence. Lancet Infect Dise 2003;3:288

QUESTION: The sputum culture exposed to light grew the

following colonies within 1 week, how would you classify this

mycobacteria?


0% 0%0%0%

1. Rapid grower

2. A photochromogen

3. A scotochromogen

4. Not in the Runyon

classification

Runyon classification


Not in the classification:

M. tuberculosis, M. bovis

End of case

�The patient took his treatment which included

isoniazid, ethambutol, rifampin, pyrazinamide, and

vitamin B6, but did not go for his monthly follow ups.

�At 2 months he started feeling weak and having

nausea. He went to a physician and his liver


nausea. He went to a physician and his liver

function tests were markedly elevated.

�Even though isoniazid was discontinued the patient

went into liver failure and he has been placed in the

waiting list for a liver transplant.


GERMANY - CIRCA 2005: Robert Koch

http://www.shutterstock.com/gallery-166210p1.html

USA - CIRCA 1975: Emily P. Bissell -

http://www.shutterstock.com/gallery-89286p1.html ?

MALI - CIRCA 1975: ambulance car and lungs


POLAND - CIRCA 1982: Odo Bujwid (1857-1942),

bacteriologist,

http://www.shutterstock.com/cat.mhtml

wheel=1#id=67821679

SPAIN - CIRCA 1953: charity to fight tuberculosis,


� In January of 2003, an American businessman that

had been travelling in China and Vietnam presented

with a severe influenza-like illness to a Hanoi

hospital.

The patient rapidly went into respiratory failure

Case


�The patient rapidly went into respiratory failure

requiring intubation.

�Hospital officials suspected avian influenza.

�However, Dr Carlo Urbani contacted WHO for

assistance since he thought the disease was not

avian influenza.

QUESTION: Hospital officials were thinking the patient had

avian influenza (H5N1). Why?

1. Severe respiratory disease

is frequently caused by

influenza viruses

2. Avian influenza viruses are

easily transmissible from


0% 0%0%0%

easily transmissible from

human to human

3. This patient had eaten

chicken and other birds

while traveling

4. Influenza pandemics always

start in Asia

QUESTION: What test is used for avian influenza viruses

(H5N1)?

1. Using commercially

available fluorescent

antibodies

2. Culturing nasopharyngeal


0% 0%0%0%

2. Culturing nasopharyngeal

specimens

3. Testing for IgM antibodies

against avian influenza

viruses

4. All of the above

Detection of influenza viruses

Direct fluorescent Assays

(DFA)

Viral cultures


QUESTION: What test is used in your institution to diagnose

seasonal influenza viruses?

1. Viral cultures/ R-mix

2. PCR for respiratory

viruses

3. Direct fluorescent

2011 ASCP Annual Meeting1 2 3 4 5

0% 0% 0%0%0%

3. Direct fluorescent

antibody testing from

primary specimen

4. Rapid antigen testing

5. Other

Sensitivity and specificity of influenza tests during the

2009 H1N1 pandemic

Rapid

antigen

DFA R-mix PCR

Luminex

Sensitivity 17.8 46.7 88.9 97.8

Specificity 93.6 94.5 100 100


Specificity 93.6 94.5 100 100

PPV 77.4 91.3 100 100

NPV 47.9 58.9 87.9 97.3

Ginocchio CC et al. Evaluation of multiple test methods for the detection of the novel 2009

influenza A (H1N1) during the New York City outbreak. J Clin Virol. 2009;45:191-5.

QUESTION: When people talk about influenza viruses they

mention H (number) and N (number) to refer to them. What

do H and N stand for?

1. Hydroxylysine and

neuraminidase

2. Hemagglutinin and

nalidixic acid


0% 0%0%0%

nalidixic acid

3. Hemolysin and nucleotide

4. Hemagglutinin and

neuraminidase

QUESTION: What is the best way to protect yourself from

getting influenza?

1. Wash hands frequently

2. Avoid contact with sick

individuals

3. Avoid having wet


0% 0% 0%0%0%

3. Avoid having wet

hair/clothing while in cold

environments

4. Vaccination

5. Avoid contact with

children

�Dr. Carlo Urbani, saw the patient in Hanoi and 2

weeks later, while attending a conference in

Thailand, became sick.

�He had respiratory failure and persistent fevers.

In a matter of weeks, Dr. Urbani and five other

Back to our case


� In a matter of weeks, Dr. Urbani and five other

health care professionals that took care of the

patient died.

� Influenza testing was negative.

�Specimens obtained from Dr. Urbani were sent

to the CDC for study. Ksiazek TG, el al. A novel coronavirus associated

with severe acute respiratory syndrome. N Engl J

Med 2003; 348: 1953-1966.

QUESTION: Electron microscopy of the viral culture showed

the following virus, which family does it belong to:


0% 0%0%0%

1. Togavirus

2. Flavivirus

3. Coronovirus

4. Rhabdovirus

RabiesHerpes

Adenovirus SARS coronavirus


Influenza Ebola

Pox

�During the 2003 SARS

outbreak, symptoms

included:

� Fever

� Non-productive cough

� Muscle aches


� Muscle aches

� Difficulty breathing

� Chills and shivering

QUESTION: During the 2003 outbreak, what was the

method used for diagnosing a patient with SARS?

1. Reverse-transcriptase

Polymerase Chain

Reaction (RT-PCR)

2. Electron microscopy


0% 0%0%0%

3. Culture

4. Differential white blood

cell count

Usual appearance of Ag & Ab


QUESTION: What was the use of serology during the outbreak?

1. Diagnose exposure

2. Diagnosis for isolation of

the patient

3. Screening of subjects


0% 0%0%0%

3. Screening of subjects

4. 1 and 3 are correct

�Quarantine all patients with symptoms

�Ensure that healthcare staff are protected

appropriately and come to work healthy

�Enforce personal hygiene (hand washing)

Measures that hospitals used to decrease the

spread of SARS included:


�Enforce personal hygiene (hand washing)

�Constant and active communication with staff as

well as with state and national health

departments

�Ensure that uninfected patients and their family

members are not exposed

QUESTION: Which of the following could potentially be the

next deadly global outbreak that necessitates strategies to

evaluate and respond to the infection?

1. Another form of SARS

2. Influenza H5N1

3. Influenza H1N1


0% 0% 0%0%0%

3. Influenza H1N1

4. A novel microbial

pathogen

5. All of the above

�Hospitals need to produce a preparedness plan for outbreaks and pandemics so that they can take care of patients and staff.


Infections without bordersdn3g20un7godm.cloudfront.net/2011/AM11SA/152.pdf · 2011-11-16 · bioterrorism-related anthrax, United States, epidemiologic findings. Emerg Infect Dis

Documents