Chlamydia

Chlamydial infections

Introduction 

-Chlamydiae are obligate intracellular bacteria, possess both DNA and RNA, and have a cell wall similar to that of gram-negative bacteria.

-Chlamydiae that infect humans are divided into three species, Chlamydia trachomatis, Chlamydia pneumoniae, and Chlamydia psittaci

Chlamydia trachomatis: Chlamydia trachomatis infects only humans; incubation period: 1-3 weeks 

Eye infections: Conjunctivitis, trachoma (leading cause of preventable infectious blindness)

Lung infections: Pneumonia 

Genital infections: Urethritis, Lymphogranuloma venereum 

Joint infections: Reiter’s syndrome 

 Chlamydia pneumoniae: Chlamydia pneumoniae infects only humans; it can cause upper and lower respiratory infections 

Chlamydia psittaci: Chlamydia psittaci infects birds, humans and other animals; it causes psittacosis 

Symptoms & Signs 

Genital infection: Dysuria, urethritis, discharge, which is clearer and less purulent than seen with gonorrhea; Chlamydial infection is asymptomatic in 75% of females

Diagnosis 

Nucleic acid amplification test (NAAT): is the recommended test for screening asymptomatic at-risk and symptomatic individuals 

Culture: In culture, C. trachomatis forms intracytoplasmic inclusions containing glycogen, whereas C. psittaci and C. pneumoniae form inclusions that do not contain glycogen.

Serologic tests:  mainly to diagnose infections by C. psittaci and C. pneumoniae 

Treatment 

-All chlamydiae are susceptible to tetracyclines, such as doxycycline, and macrolides, such as erythromycin and azithromycin.

-Treatment should be offered to sex partners 

-Because of the high rate of coinfection with C.trachomatis and gonococci, any patient with a diagnosis of chlamydia should also be treated for gonorrhea and vice versa 

-Chlamydia urethritis: Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice a day for 7 days 

-The drug of choice for neonatal inclusion conjunctivitis and pneumonia caused by C. trachomatis is oral erythromycin. 

-The drug of choice for C. psittaci and C. pneumoniae infections and for lymphogranuloma venereum is a tetracycline such as doxycycline.

Prognosis 

Untreated chlamydia can cause serious complications 

Men: Epididymitis, sterility

Women: PID, ectopic pregnancy, infertility 

Prevention 

-There is no vaccine against any chlamydial disease

-Educate patients on safer sex practices.

Q.What are the tests of choice for the diagnosis of genital C.trachomatis infections? Nucleic acid amplification tests (NAATs) Q.What is the drug of choice for Chlamydia trachomatis sexually transmitted disease? Azithromycin



Rabies

Running German Shepherd

Introduction

Rabies is a rapidly progressive, acute, fulminant, and fatal encephalitis in humans and animals that is caused by infection with rabies virus.

-Rabies virus is usually transmitted to humans by the bite of an infected animal.

-Live virus enters the nerve tissue at the time of the bite, multiplies at the site, and then spreads centripetally along peripheral nerves toward the spinal cord or brain stem via retrograde fast axonal transport. It replicates in gray matter and then spreads  to the salivary glands, adrenal glands, and heart. 

Symptoms & Signs 

-The average incubation period is one to three months. 

-The clinical spectrum can be divided into three phases

1.Prodromal phase: 

-The first symptom is usually the paresthesia at the bite site 

-Patient later develops malaise, headache, photophobia, fever, anorexia, nausea, vomiting and sore throat 

2.Acute neurologic phase: 

Hydrophobia (fear of water), Aerophobia (fear when feeling a breeze) 

-Sympathetic overactivity (Increased salivation, ‘foaming at the mouth’, perspiration, lacrimation, pupillary dilatation, nervousness)

-Psychotic symptoms (hallucinations, delusions, bizarre behavior)

-Two acute neurologic forms of rabies are seen in humans: 

the encephalitic (furious) form in 80% and

the paralytic form in 20%.

3.Coma: Convulsive seizures, coma and death

-The major cause of death is cardiorespiratory arrest. 

Diagnosis 

1.Rabies antigens: diagnosis by rabies specific antigens 

2.Serology: Diagnosis by rabies specific antibodies,  detected by immunofluorescence or neutralization tests. 

3.Viral isolation: Isolation of the virus in the brain neurons. 

Negri bodies: the most characteristic pathologic finding in rabies; They are eosinophilic cytoplasmic inclusions in the brain or the spinal cord. They are composed of rabies virus proteins and viral RNA 

4.Animal observation: 

‘Rabid or suspected rabid’ animals: should be killed humanely immediately after the bite and sent for laboratory examination of neural tissues 

‘Normal’ animals: should be held for observation for 10 days 

If they appear abnormal during or after 10 days: kill humanely and send tissues to laboratory 

If they appear normal during or after 10 days: individualized treatment 

Prevention

Avoid contact with any unfamiliar domestic animals and wild animals 

Immunize all household dogs and high risk pets 

Vaccination: Four 1-mL doses of rabies vaccine should be given IM in the deltoid area. 

Post-Exposure Prophylaxis 

It involves wound cleaning, vaccination and passive immunity 

Wound cleaning: 

-Thoroughly clean the wound with soap and antiseptics 

-Animal bite wounds should not be sutured

Vaccination: Four doses of rabies vaccine over a 14 day period 

-Give the vaccine only in deltoid region in adults or anterolaterial thigh in children 

Never administer the vaccine in the gluteal area because antibody responses have been lower after administration at this site 

-Pregnancy is not a contraindication for immunization.

Passive immunity: One dose of HRIG along with the first dose of the vaccine 

-HRIG is not indicated beyond the 7th day after vaccination is begun, because an antibody response is most likely occurred 

-HRIG should never be administered in the same syringe or into the same injection site as the vaccine, because the antibody and vaccine will neutralize each other.

-HRIG should not be given to those with immunoglobulin A deficiency, because small amounts of immunoglobulin A present in HRIG might cause a severe allergic reaction.

Treatment 

-There is no successful treatment for clinical rabies. 

-Symptomatic and Palliative treatment using sedatives, antipsychotics, anxiolytics, and pain killers


Poliomyelitis

Poliomyelitis is a disease of the anterior horn motor neurons of the spinal cord and brainstem caused by the poliovirus. 

-Anterior horn cells control the skeletal muscle cells of the trunk and limbs 

-In up to 95% of cases, poliovirus infection is asymptomatic 

-the viral transmission is oral to oral or fecal to oral 

-Acutely, the polio virus enters the body through the GI tract, reproduces in the GI lymphoid tissue, and then spreads to the large motor nuclei of the spinal cord, the brainstem, reticular formation, hypothalamus, thalamus, cerebellum and cerebral cortex. 

Symptoms & Signs

Thankfully, not every polio infection results in paralysis. It can be divided into following types based on the severity. 

Abortive poliomyelitis: fever, headache, vomiting, diarrhea, constipation, and sore throat lasting 2–3 days.

Nonparalytic poliomyelitis: Above symptoms plus meningeal irritation and muscle spasm but no frank paralysis 

Paralytic poliomyelitis: 

Asymmetrical paralysis; Proximal limb muscles are more often involved than distal, and lower limb involvement is more common than upper. 

1.Spinal poliomyelitis: involves the muscles innervated by the spinal nerves, flaccid and weak muscles, absent tendon reflexes and fasciculations 

2. Bulbar poliomyelitis: involves the muscles innervated by the cranial nerves  IX and X; seen in up to 20 percent of polio patients with paralysis; affects swallowing, speech, facial muscles 

Post-poliomyelitis syndrome:  Fatigue, pain, respiratory problems, sleep problems, increased risk of falls 

Guillain-Barré syndrome: Always think of GBS in the differential diagnosis of polio paralysis. GBS is distinguished from polio by its symmetry, disturbances in sensation, lack of preceding aseptic meningitis, absence of a CSF pleocytosis, presence of multifocal demyelination on electrodiagnostic testing 

Diagnosis

Virus isolated and typed from throat swabs and rectal swabs; PCR amplification of poliovirus RNA from the CSF 

Treatment 

Treatment of poliomyelitis is supportive 

-Pain relief, physical therapy

-Mechanical ventilation for respiratory failure 

-Intubation or tracheostomy for secretion control 

Prevention 

the trivalent live OPV, the inactive (Salk) parenteral vaccine is currently used in the United States for all four recommended doses (at ages 2 months, 4 months, 6–18 months, and at 4–6 years).


Rubella Infection

Introduction 

Rubella is an acute febrile illness caused by Rubella virus, a single-stranded RNA virus of Togavirus family 

-It is commonly known as German measles or 3-day measles. 

-the virus enters the body through inhalation 

-it replicates in the upper respiratory tract and spreads in the bloodstream to other organs, skin and lymphoid tissues 

-the incubation period is 14 to 21 days 

-the virus has high infectivity but low virulence

Symptoms & Signs 

A.Infection in young children and adults: Fever, rash, malaise, arthralgia, lymphadenopathy, which is most prominent in the posterior cervical and postauricular areas.

Arthralgia: The most common complication of Rubella is arthralgia, and it occurs most frequently in women 

Rubella rash: A fine, pink maculopapular rash begins on the face and rapidly spreads to the trunk and extremities. It lasts for 3 days.  

B.Congenital Infection

-The greatest significance of rubella is not the acute illness but the risk of fetal damage in pregnant women. 

-the risk of fetal malformation is highest in the early stages of pregnancy 

-Intravenous immune globulin injected into the mother does not protect the fetus against rubella infection 

-The classic triad of congenital rubella consists of cataracts, cardiac abnormalities, and deafness. 

-The most common developmental manifestation of congenital rubella is mental retardation.

A.General: Failure to thrive, growth retardation, malabsorption  

B.Cerebral: Microcephaly, encephalitis

C.Ocular: Cataracts, glaucoma, microphthalmia, chorioretinitis 

D.Deafness: Sensorineural in most cases 

E.Cardiac: Pulmonary artery stenosis, pulmonary valvular stenosis,

patent ductus arteriosus, ventricular septal defect

F.Hematologic: Thrombocytopenia, lymphopenia, intravascular coagulation 

G.Skin: Blueberry muffin purpura on head, neck and trunk 

Diagnosis 

Confirmation of the diagnosis requires laboratory studies. 

A. Nucleic Acid Detection: Rubella virus nucleic acid is detected using RT-PCR 
B. Isolation and Identification of Virus: Rubella virus isolated from nasopharyngeal or throat swabs 
C. Serology: Rubella HI test 

Treatment 

Infection in young children and adults: Rubella is a mild, self-limited illness; no specific treatment is indicated; Patients should be isolated for 7 days after rash onset

Congenital infection: there is no specific treatment 

Prevention 

The primary purpose of rubella vaccination is to prevent congenital rubella infections. 

-Live attenuated rubella vaccine (MMR or MMRV) given in two doses, first dose at 12 to 15 months of age and the second dose at 4 to 6 years of age

-Pregnancy should be avoided for at least 28 days after vaccination.

-Pregnant women should not receive the vaccine, but should be screened for rubella IgG antibodies