Emerging Infections and some Pearls - summahealth.org/media/Files/SummaMeded/CME/Naples2012...EMERGING INFECTIONS New, Re-emerging, or Drug-resistant infections whose incidence in

Thomas M. File, Jr. MD MSc MACP

Chair, Infectious Disease Division

Summa Health System;

Professor of Internal Medicine,

Master Teacher, Chair ID Section

NEOMED

Emerging Infections and some

Pearls

It is time to

“close the book on infectious diseases.”

Congressional testimony by the Surgeon General of the United States, 1969

Congressional testimony by the

Surgeon General of the United

States, 1969

EMERGING INFECTIONS

New,

Re-emerging, or

Drug-resistant

infections whose incidence in humans

has increased within the past 2

decades or whose incidence threatens

to increase in the near future.

Institute of Medicine Report 1992

From:

Woolhouse M

Microbe 2006

1: 511

NEW INFECTIONS (>100)

Campylobacter Chlamydia pneumoniae Clostridium difficile Community associated Methicillin-resistant S. aureus Hantavirus Helicobacter HIV Hepatitis C Human Herpes virus 6,7,8 Influenza H5N1; Influenza 2009 H1N1 Lyme Severe Acute Respiratory Syndrome (novel

coronavirus) West Nile viru

NEJM Feb 1, 2012; 366: 454-61

NEJM Feb 1, 2012; 366: 454-61

NEJM Feb 1, 2012; 366: 454-61

NEJM Feb 1, 2012; 366: 454-61

Multistate Fungal Meningitis Outbreak

Exserohilum rostratum (Black/brown mold)

Contaminated preservative-free methylprednisolone from New England Compounding Center (NECC)

Lots #05212012; 06292012;08102012

? Other products from NECC (All recalled)

14,000 received spinal epidural injections (5/21-9/26/12)

Cases (Nov 29): 38; 32 deaths

Incubation-up to 6 weeks (< 1.2% after)

Neutrophilic meningitis; basilar-artery stroke common

Therapy: voriconazole (? Duration; prob minimum 3 months)

www.cdc.gov/hai/outbreaks/meningitis; Kauffman CA et al. NEJM Oct 19, 2012

http://www.cdc.gov/hai/outbreaks/meningitis

Deaths: Tenn 12; Mich 7; Fla 3; Ind 3; Vir 2; Maryland 1, N Car 1

Nov 2; www.cdc.gov/hai/outbreaks/meningitis

Multistate Fungal Meningitis Outbreak

Date of download:

10/31/2012

Copyright © The American College of Physicians.

All rights reserved.

From: Fatal Exserohilum Meningitis and Central Nervous System Vasculitis after

Cervical Epidural Methylprednisolone Injection

Ann Intern Med.2012;():.doi:10.7326/0003-4819-158-1-

201212040-00557

•51 y/o female presented to ED 9/7 with neck

pain, new occipital HA

•Cervical epidural steroid injection 8/31

•Next day: diploplia, vertigo, nausea, ataxia

•MRI –’normal’

•Day 3: slurred speech, hemiparesis

•MRI-Abn

•LP-Opening press 34, Glucose 36, Protein

153, WBC-850 (84% PMNs)

•Rx: Mulitple antimicrobials/steroids

•Day 7: studies neg for EBV, CMV, WNV,

Crypto, Histo, Bacteria

•Day 9: worse, absent pupillary reflex

•ampho B added

•Day 10: Death

Fungal Meningitis Outbreak

What Should Clinicians do

Evaluate pts who received injections

Did patient receive from identified lot #?

If any symptoms: CSF exam unless contraindicated (perform at site other than injection site)

If no symptoms, watch for any mild signs or symptoms

• Greatest risk within 6 weeks of injection (usually 1-4 weeks)

• Possible option for surveillance LP (may reduce risk of stroke or death by 0.1% if within 6 weeks)

If + CSF (> 5 WBCs, usually PMNs) Routine studies and send sample to CDC for PCR

(arrange with local health department)

Treat with voriconazole

www.cdc.gov/hai/outbreaks/meningitis; Kauffman CA et al. NEJM Oct 19, 2012

http://www.cdc.gov/hai/outbreaks/meningitis

SEVERE ACUTE RESPIRATORY

SYNDROME (SARS) Started in Guangdong Province China(11/02); Spread

worldwide; profound impact on travel

Spread by close contact (air droplet)

Highest mortality in elderly and debilitated

Epidemic terminated July 03 No significant numbers of asymptomatic infection

No transmission prior to clinical illness

“We don’t know if we’re going to see anther SARS patient or

not…But I think we’re living in the age of the new normal of

emerging health threats and this preparedness for SARS is

going to pay off sooner or later, because if it’s not SARS, it

will be something else, and we’ll be ready for it”

J. Gerberding (CDC, Sept, 26, 2003)

Novel betacoronavirus (HCoV-EMC)

2 patients with severe pneumonia (Saudi Arabia; Qatar)

in otherwise healthy

Identified Sept, 2012; Similar to SARS virus

NEJM Oct 17,2012

AVIAN INFLUENZA

Fall 2003-new outbreak of respiratory illness

Young affected; high mortality

Stimulated worldwide Pandemic Preparedness Plans

Avian Influenza (H5N1) 2003-2012

SE Asia; China; Indonesia;Azerbaijan; Turkey; Iraq; Egypt, Nigeria, + others

Primarily contracted from poultry • Numerous countries with poultry infection

• (Asia, Africa, Europe)

• NONE in Western Hemisphere

NEW OUTBREAK: Influenza

A(H1N1) MMRW Report, April 2009

MMWR, April 24, 2009 Swine Influenza A in two children in Southern

California

No exposure to pigs

MMWR, April 28, 2009 / 58(Dispatch);1-3 47 patients reported to CDC with known ages (out of

64) the median age was 16 years (range: 3-81 years)

38 (81%) were aged <18 years

Of 14 patients with known travel histories • 3 had traveled to Mexico

• 40 of 47 patients (85%) had not been linked to travel or to another confirmed case

Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm

RECENT VIRAL OUTBREAKS

Characteristic SARS Avian Flu H1N1 (Swine)

Flu

Onset Nov 2002; Guangdong

Province China

Winter 2003; SE

Asia (Thailand,

Vietnam)

March 2009; Mexico

Origin Civit Cat Poultry Recombinant: Swine,

Avian, Human

# cases 8500 (3/09) 590 (3/1/12) Mulitple millions

Worldwide

Millions US

Mortality 9.5% 59% 0.45% World;

0.05% US

Status Terminated 7/03;

Surveillance

Ongoing (slowly) Emerging

Evolving

RECENT VIRAL OUTBREAKS

Requirement for Pandemic

Requirements

for Pandemic

SARS Avian Flu H1N1 (Swine)

Flu

Novel Virus + (Coronavirus) + (H5N1) + (Hsw1N1)

Disease in

Humans

+ + +

Degree of spread

Human to human

+* - +**

*Transmissible only during symptomatic disease

**Transmissible prior to symptoms and many ‘subclinical ‘ cases

2009/H1N1 Influenza

Hallmark of influenza virus is ability to undergo constant change

Many different animals get infected, but the virus usually is confined to one species

Flu virus may jump to other species

H1N1 Swine Influenza A is novel virus; contains genetic sequences from: North American swine

North American avian

North American human and

Eurasian swine

2009/H1N1 Influenza-Epidemiology I New Pandemic

Most cases mild but severe cases reported

(often in younger age)

• Highest rate of infection in < 24 year olds

• US mortality 1/2000

– Majority < 50 years of age

– Risks: Asthma, Obesity, Pregnancy, Chronic disease

• Higher rate of GI symptoms than seasonal flu

(virus shed in stool)

• 2nd attack rate (20-30%) higher than seasonal flu

(10-20%)

2009/H1N1 Influenza-Epidemiology II Those > 60 years less susceptible

–Some seroprotection from exposure to H1N1

prior to 1957

–No outbreaks in LTCFs

Severe Infection

• FLAARDS (Flu A Associated ARDS)

• Viral pneumonia

• 2nd Bacterial infection variable

–4-50% in serious/mortality cases--S.

pneumoniae; S. aureus (MRSA), S. pyogenes

2009 H1N1 Mortality

“The pandemic’s impact is better

gauged by the number of life-years lost

because of the younger age of victims

compared with seasonal flu. If you look

at years of personal life lost, it’s much

higher, and that’s the point we have to

get across. A death in an otherwise

healthy 24-year-old, to me, is a major

defeat for society.”

Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research

and Policy in Minneapolis

Percentage distribution of Deaths from 2009 H1N1 Influenza, Mexico

Chowell et al. NEJM 2009; 316

Detection of Influenza using Rapid Influenza Diagnostic Tests Laboratory diagnostic tests

Direct antigen detection tests

virus isolation in cell culture

PCR

Rapid tests Rapid influenza diagnostic tests (RIDTs)

• Commercially available; can provide results < 30 minutes

• Cannot differentiate influenza A subtypes

• The sensitivity ranges between 10-70%; a negative test does not exclude influenza infection

PCR Highly sensitive, but not readily available at present or very expensive from outside labs

Susceptibility of Influenza strains to Antiviral agents

Amantadine Rimantadine Oseltamivir Zanamivir

Influenza B 0 0 + +

A/H3N2 0 0 + +

A/seasonalH1N1

+ + 0 +

A/2009H1N1

0 0 + +

Infectious Disease after a Disaster

Skin

MRSA, water borne bacteria (Vibrio spp.; Aeromonas,

Plesiomonas), Mold, insect infestations, trench foot

Diarrhea

E. coli, Cryptosporidiosis, Salmonella, Shigellosis, Norvirus,

Giardiasis

Respiratory

Legionnella,

Systemic

Hepatitis, Leptospirosis, tetanus

www.cdc.gov/flu

Influenza A 63% (H3-49.6%, No Subtype done 49.6%,

2009 H1N1 0.8%); Influenza B 37%

variant ‘Swine Flu’ virus

Sep 6, 2011 (CIDRAP News) – Two more children in

Pennsylvania were infected with a novel swine

influenza A/H3N2 virus that includes a gene from the

2009 pandemic H1N1 virus.

Nov 28, 2011 (CDC)-Total of 18 cases over past 2

years; associated with mild illness. “Not as bad as the

H1N1 2009 strain

Aug, 2012: CDC confirms new cases of influenza

A/H3N2 variant virus

Twelve new cases of influenza A/H3N2 variant virus were identified

in Hawaii, Indiana and Ohio in the past week, making 29 total cases

since the virus was first detected in humans in July 2011

Why test for Hepatitis C

Hepatitis C: Major public health problem; leading cause

of liver disease and liver CA

4.1 million infected in US (80% viremic)

Mortality (2nd liver failure or CA) expected to increase

Detection and treatment

Reduce illness, death

Reduce transmission

(more deaths than 2nd HIV)

West Nile Fever

West Nile Virus: A newly

emergent epidemic disease

Mosquito borne virus of genus Flavivirus,

closely related to Japanese encephalitis

complex (e.g. St Louis Encephalitis)

WN-wide distribution globally; 1st seen in US in

1999 in NY

Primary reservoir host is birds (esp. crows, blue

jays

Human Infection

Spread by mosquitoes

Rarely by transfusion, transplantation, breast feeding

West Nile Virus activity US, Sept 18, 2012

Total cases (Nov 6, 2012): 2559; 228 deaths

West Nile Human Infection “Iceberg”

<1 % with CNS

disease(10% of

CNS fatal)

20%

“West Nile Fever”

Approx 80%

Asymptomatic

West Nile Virus: therapy/prevention

Supportive

Antiviral agents

Ribavirn, Interferon

Effective in vitro (Anderson and Rahal.

Emerg Infect Dis 2002; 8: 107);

No controlled patient studies

IVIG

Prevention

Mosquito avoidance

DEET (>20%)

Blood supply screening

Vaccine

Emerging and retreating Mosquito- borne Infections: Dengue

Everywhere (most prevalent mosquito-borne disease)

US

Travels, (22 million to risk areas/ year; Most common

cause of fever post travel; Most cases of suspected

malaria)

Mexican border; Hawaii; Key West

Clinical

Incubation: 4-7 days

Dengue Fever: fever, HA, myalgia, arthralgia, some rash

Hemorrhagic fever: Purpura, bleeding, renal

Lab: thrombocytopenia; LFT abnormality

Mosquito- borne Infections: Dengue (H. Margolis. CDC)

Dengue

Venectomy scar

56 y/o with recurrent cellulitis of leg

Psoriasis

Recurrent Cellulitis of lower extremity in

patients with prior Heart Surgery

Almost always due to hemolytic Streptococcus sp. Usually NOT Grp A Strep

Responsive to most antimicrobials

Associated with disruption of venous and/or lymph drainage Can occur after injury

Can be seen in upper extremeties (e.g., after breast surgery)

Look for associated tinea pedis or other chronic skin condition Treat with antifungal

Use antibacterial soaps

The 3 most common skin and soft tissue infections in

residents of LTCFs are CELLULITIS, INFECTED

PRESSURE SORES and which of the following?

A. B. C. D. E.

20% 20% 20%20%20%

:10

A. Scabies

B. Herpes zoster

C. Herpes simplex

D. Tinea pedis

E. Conjunctivitis

Skin and Soft Tissue Infection

3rd most common infection in LTCF

1-9% or prevalence of 1-2/1000 patient days

Typically results from breaks in skin or mucosa as a consequence of trauma, maceration,pressure, or devices

Most common

Cellulitis

Infected pressure ulcer

scabies

High K. et al. Clin Infect dis. 2009; 48: 149-71; can access via www.idsociety.org

Scabies

Presentation may be atypical

Burrows, inflammatory changes in intertrigenous areas,

pruritis may be absent

May only present with hyperkeratosis, papules, or

vesicles

Often presents by occurrence of > 1 unexplained rash in

residents

Diagnosis: skin scraped with scalpel and examined

under oil immersion (low power)

High K. et al. Clin Infect dis. 2009; 48: 149-71; can access via www.idsociety.org

Scabies

Diagnosis: Scrapping

Treatment

5% permethrin cream (Elimite)

Oral ivermectin (200 mg X 1)

Bed bugs bite U.S.--worst outbreak since WWII

•Bed bugs, Cimex lectularius , feed solely on the blood of animals, can go > 500 days between meals. Adult bugs 1/4 inch long and reddish brown, with oval, flattened bodies. Immatures (nymphs) are smaller and somewhat lighter in color. Do not fly, can move quickly over floors, walls, other surfaces.

52

BED BUG Bites • Infestation reports in NY: 2004-82; 2009->4000

• Symptoms range from no reaction to severe welts; in

some rare occasions severe Unlike fleabites, which

occur mainly around the ankles, bed bugs feed on any

bare skin exposed while sleeping (face, neck,

shoulders, arms, hands, etc.); bite is unnoticed due to

chemical which numbs skin

• May be selective within family

• Antihistamines and corticosteroids

may be reduce allergic reactions

Bed bugs bite U.S.: Prevention

Cover up. Bedbugs don't tend to burrow under clothing.

Preventing :

Inspect used mattresses or upholstered furniture carefully before bringing them into your home.

Hotel precautions. Check mattress seams for

bedbug excrement and place your luggage

on racks or dressers instead of on the floor.

Intra Abdominal Infections:

IDSA Guidelines (IDSA 2010)

62 y/o male with increasing Abd Pain and

Fever

PE: Temp 38.70 C (1.1.70F); Pulse 110; BP

110/60; RR-22; Abd-tender and lower abd

guarding, Bowel sounds

Lab: WBC 19,800

Abd CT:

Source Control for Infections

Patients with diffuse peritonitis should undergo an

emergency operative procedure as soon as is

possible, even if ongoing measures to restore

physiologic stability need to be continued in the

operating room (B-II).

For hemodynamically stable patients without evidence

of acute organ failure, an urgent approach should be

taken. Intervention may be delayed for a longer time, if

appropriate antimicrobial therapy is given and if

careful clinical monitoring is provided. (C-III).

Where feasible, percutaneous drainage of abscesses

and other well-localized fluid collections is preferable

to operative drainage (B-II).

Solomkin JS, Mazuski JE, et al. Infections. Clinical Infectious Diseases 2010 in press

Empiric Therapy

Antibiotics used for empiric treatment of

community-acquired intra-abdominal

infections should be active against enteric

gram-negative aerobic and facultative bacilli

and enteric gram-positive streptococci (A-I)

Coverage for obligate anaerobic bacilli should

be provided for distal small bowel,

appendiceal and colon-derived infections and

for more proximal gastrointestinal perforations

in the presence of obstruction (A-I)


Facultative and Aerobic

Gram-Negatives

Escherichia coli

Klebsiella spp

Pseudomonas

aeruginosa

Proteus spp

Enterobacter spp

Others

71.3%

14.3%

14.1%

5.2%

5.1%

12.3%

Gram-Positive Organisms

Streptococcus spp

Enterococcus faecalis

Enterococcus faecium

Enterococcus spp

Staphylococcus aureus

38.0%

11.6%

3.4%

7.8%

3.5%

Anaerobic Organisms

Bacteroides fragilis

Other Bacteroides

Clostridium spp

Prevotella spp

Peptostreptococcus spp

Fusobacterium spp

Eubacterium spp

Others

34.5%

71.0%

29.2%

12.0%

16.7%

8.6%

16.5%

19.4%

Solomkin JS, Yellin AE, Rotstein OD et al. Ann Surg 2003; 237(2):235-245. Solomkin JS, Wilson SE, Christou NV et al. Ann Surg 2001; 233(1):79-87. Solomkin JS, Reinhart HH, Dellinger EP et al. Ann Surg 1996; 223(3):303-315.

COMMON PATHOGENS IN COMMUNITY-

ACQUIRED INTRA-ABDOMINAL INFECTIONS

Empiric Therapy

Empiric coverage of Enterococcus is not necessary in

patients with community acquired intra-abdominal

infections (A-I)

Empiric therapy for Candida is not recommended for

adult patients with community-acquired intra-abdominal

infections (C-III)

The use of agents listed as appropriate for higher

severity community-acquired infections and healthcare-

associated infections is not recommended for patients

with mild-to-moderate community-acquired infections

since such regimens may carry a greater risk of toxicity

and facilitate acquisition of more resistant organisms (B-

II)


Community-Acquired Infections

Mild to Moderate Severity High Severity

Single agents Cefoxitin Ertapenem1

Moxifloxacin2

Tigecycline3

Ticarcillin/clavulanic acid

Doripenem Meropenem

Imipenem/cilastatin Piperacillin/tazobactam

Combination

regimens

Cefazolin Cefuroxime Ceftriaxone Cefotaxime Ciprofloxacin2

Levofloxacin2

Cefepime Ciprofloxacin2

Levofloxacin2 in combination with metronidazole

1: Caution for risk of increased carbapenem usage resulting in resistance 2: Caution for increasing resistance of E. coli in the community 3. Caution for very broad spectrum including MRSA and enterococci

in combination with Metronidazole


Empiric Therapy

Ampicillin/sulbactam is not recommended for use

because of high resistance rates of community-

acquired E. coli to this agent (B-II)

Cefotetan and clindamycin are not recommended

for use because of increasing resistance of the

Bacteroides fragilis group to these agents (B-II)

Because of the availability of less toxic agents

demonstrated to be of at least equal efficacy,

aminoglycosides are not recommended for routine

use in community-acquired intra-abdominal

infection (A-I)


High Severity/High Risk Patients

TABLE 1: CLINICAL FACTORS PREDICTING FAILURE OF SOURCE

CONTROL FOR INTRA-ABDOMINAL INFECTIONS

Delay in the initial intervention (> 24hrs)

High severity of illness (APACHE II > 15)

Advanced age

Comorbidity and degree of organ dysfunction

Low albumin

Poor nutritional status

Degree of peritoneal involvement/diffuse peritonitis

Inability to achieve adequate debridement or control of drainage

Presence of malignancy

Appropriate Regimens for Community Acquired

Infections of Mild-Moderate Severity

Community-Acquired

Infections in Pediatrics

Community-Acquired Infections

in Adults

Single

agents

Ertapenem

Meropenem

Imipenem/cilastatin

Ticarcillin/clavulanate

Piperacillin/tazobactam

Cefoxitin

Ertapenem

Moxifloxacin

Tigecycline

Ticarcillin/clavulanic acid

Combinatio

n regimens

Ceftriaxone

Cefotaxime

Cefepime

Ceftazidime

Cefazolin

cefuroxime

ceftriaxone

cefotaxime

ciprofloxacin

levofloxacin

in combination with metronidazole



High Severity Community-Acquired Infections

Children Adults

Single

agents

Ertapenem

Meropenem

Imipenem/cilastatin


Doripenem

Meropenem

Imipenem/cilastatin


Combinatio

n regimens

Cefepime in combination

with metronidazole

Cefepime

Ciprofloxacin

levofloxacin


Duration of Therapy for Patients with

Complicated Intra-abdominal Infection

Recommendation

Antimicrobial therapy of established infections should be limited

to no more than four to seven days unless it is difficult to

achieve adequate source control. Longer durations of therapy

have not been associated with improved outcome (B-III).

Evidence Summary

Resolution of clinical signs should be used to judge the

termination point for therapy…risk of subsequent treatment

failure is quite low in patients who have no clinical evidence of

infection at the time of cessation of antimicrobial therapy.

This usually implies that the patients are afebrile, have

normal WBC, and are tolerating an oral diet.

Guidelines by the Surgical Infection Society and the

Infectious Diseases Society of America1

1. Solomkin et al. Clin Infect Dis. 2010;50:133-164. 2. Hedrick TL et al. Surg Infect. 2006;7:419–432.

3. Lennard ES et al. Ann Surg. 1982; 195:19–24.

Painless chronic skin ulcer enlisted person

coming home from Iraq

Cutaneous Leishmaniasis

Treatment: pentavalent antimonial compound, pentamidine, or

amphotericin B

Case: Patient presents to ER with

fever, cough, chest pain

The diagnosis is most likely by?

a. Sputum culture

b. Blood culture

c. Sputum PCR

d. IgM ELISA

e. Urinary Antigen

EMERGING INFECTIONS

“Humanity has but three great

enemies: fever, famine and war; of

three by far the greatest, by far the

most terrible, is fever.”

Sir William Osler

Case Study A

A 42 y.o. man presents to your office 48 hours after returning from his CME trip Fla. Two days previously he noted the onset of a severely pruritic sensation on the medial distal ventral left foot that has progressively worsened during the last 24 hours.

The patient is afebrile but a linear rash appeared about 12 hours after the onset of symptoms and has significantly lengthened in the patient’s visual self-evaluation of the lesion by the time he sees you in the office. See Figure # 1.

Case Study A

Case Study B A 39 y.o. male falls into the water from a boat

while on a Bahamas cruise. While making his way back to the boat, he noted sudden onset of severe stinging, burning, and almost numbing pain on the right anterior chest extending down to the right lower quadrant of his abdomen.

A couple of hours later, he notes severe burning abdominal and chest pain and has the rash noted on Figure # 7. VS show only a mild tachycardia, but no fever or change in blood pressure.

Case Study B

Case Study B

Dx: Jellyfish Sting Diagram of Jellyfish

Case Study B

Mechanism of single nematocyst function –

Thousands of these are on each jellyfish tentacle.

Which of the following is/are appropriate

treatment(s)

For jellyfish sting?

a. Prompt removal of tentacles

b. Wash off with SEAWATER

c. Avoidance of cold fresh water

d. Application of acetic acid (e.g.,

vinegar)

e. All Above

Case Study B

Diagnosis: Jellyfish sting – the stinging tentacles

are filled with thousands of stinging nematocysts

Treatment:

Remove any remaining tentacles promptly

Do NOT immerse in cold fresh water (osmotic pressure of fresh

water causes nematocysts to “fire”)

Seawater CAN be used to wash off tentacles

Scrape off with credit card or plastic object

Case Study B

Treatment (continued):

Acetic acid (vinegar) inhibits discharge of nematocysts

Heat vs. cold application: studies have varied BUT heat

appears to be an effective treatment for at least some jellyfish

stings.

Papain meat enderizer: a well-performed study compared hot

water immersion with papain meat tenderizer: hot water

superior in relieving pain to meat tenderizer!

Case Study B

Treatment (continued):

“Other”: in vitro studies of ethanol and human urine show a

marked increase in release of nematocyst toxin from

Australian box jellyfish! So these remedies are neither

proven nor rational.

REMOVAL OF TENTACLES IS THE KEY, THE SOONER THE

BETTER.

Anti-venom is available for severe Australian box jellyfish stings.

Case Study C

A 37 y.o. woman and her husband just returned from a 3-day CME trip to Nassau. She noted the onset of discomfort in the area beneath her swimming suit immediately after coming out of the water on the last day of their vacation (Saturday) before leaving for home that evening.

On her first day at home (Sunday), her rash appeared with redness and raised tender lesions. These lesions also caused tremendous itching.

Her husband developed no such rash but never actually went into the water. He only sunbathed on the beach.

Case Study C

Rash as seen on patient exam.

Case Study C

How rash might look on the buttocks (left) and on a woman with one-

piece suit (right).

Case Study C

Diagnosis: Seabather's eruption is an itchy

dermatitis that occurs on parts of skin that

are covered by a swim-suit and is believed is

caused by jellyfish and sea anemone larvae,

which become trapped and pressed between

the outfit and the person's skin (see next

slide).

The skin reaction may recur when the outfit

is worn again, due to persistence of

nematocysts in the suit.

Malaise, fever, and gastrointestinal

symptoms can also occur in a minority of

patients with this condition.

Case Study C

Case Study C

Diagnosis: Seabather’s eruption – stings, usually

within clothing covered areas, with jellyfish or

sea anemone larvae who sting with their

nematocysts.

Treatment: Usually responds to topical

antihistamines and topical corticosteroids. Must

adequately rinse suit so that all larvae

(nematocysts) are eliminated from inside the suit.

Documents

Emerging Infections and some Pearls - summahealth.org/media/Files/SummaMeded/CME/Naples2012...EMERGING INFECTIONS New, Re-emerging, or Drug-resistant infections whose incidence in