Clinical overview

Infectious Diseases in Singapore

 Test Question
• I would rather be:

0% 1. In this lecture

0% 2. At the swimming pool

0% 3. At the ION or some other mall
0% 4. At home with my playstation
 Case #1
• 8 yr old Chinese boy
• No PMHx, no meds, unremarkable development
• 2 weeks ago returned from holiday to Xiamen,
Fujian, China.
• Hiked up a mountain
• Unwell for 4 days
• Fever, anorexia
• Dry cough
• Vomitting, constipation
• Intermittent peri-umbilical abdo pain.
 What is the most common
cause of fever of unknown
origin?

0% 1. Infection

0% 2. Cancer
0% 3. Auto-immune diseases
0% 4. Idiopathic
 Comparative Etiologies

Vanderscheuren et al Arch Intern Med.2003;163:1033-

1041.
 Exam
• Macular rash, whole
body
• Cervical LN++
• Hepatosplenomegaly
 Cervical lymph nodes can be
enlarged in…

0% 1. Lymphoma
0% 2. Epstein-barr virus infection
0% 3. Streptococcal pharyngitis
0% 4. All of the above
 Labs
• WCC 2.8, neutrophils 1.8, left shift
• Platelets 75, Hb 13
• Renal function normal
• CRP 74, (elevated)
• Ferritin 1750 (elevated)
• ALT 111, ALP normal, Bili normal
• CXR normal
These results and clinical findings
are more suggestive of….

0% 1. A bacterial infection
0% 2. A malignancy
0% 3. An autoimmune disease
0% 4. An intracellular pathogen
This was the progress of his lab
tests....
250 7

6
200

WCC
150
4 Hb
% react
Platelets
3 ALT
100
Lymph

50
1

0 0
06/30/2007 02-Jul 07/04/2007 07/06/2007 07/08/2007 07/10/2007 07/21/2007
 Which diagnostic procedure
was done?

0% 1. A bone marrow aspirate

0% 2. A repeat blood culture
0% 3. A repeat physical examination
0% 4. A dengue PCR
The
repeat
detailed
physical
exam
revealed...
 The eschar is typical of…

0% 1. Dengue
0% 2. Chikungunya
0% 3. Scrub typhus
0% 4. Typhoid fever
A painful wrist
• 80 year old woman
• History of
Thyrotoxicosis(RAI),
1980s Ca colon
• Preparing lunch after
a trip to the market
• Pain in hand
• Saw GP, given
ampicillin and
cloxacillin
 What are the most common
causes of skin and soft tissue
infections?
0% 1. Pseudomonas and Klebsiella
0% 2. Staphylococci and Streptococci
0% 3. Enterococci and Streptococci
0% 4. Meningococcus and pneumococcus
A painful wrist
• Not better: 12 June
1430 EMD NUH
• Admitted 2150 on 12
June BP:80/60
– Imp: septic shock:
clox,ceftri,dopamine,
– placed on the DIL
(Dangerously ill list)
 What is the drug of choice for
Staphylococcal infections?

0% 1. Cloxacillin
0% 2. Imipenem
0% 3. Vancomycin
0% 4. Ceftriaxone
Transferred to ICU
• 13 June 0100 to HD
for hypotension
• 0230 ICU for
intubation
• 0430 Hand review
• 1020 CVVHD for
renal failure
• 1200 Xigris
• 1315 OT debridement
• 14 June 2200 died
 What was the anatomic
diagnosis?

0% 1. Pyoderma gangrenosum
0% 2. Streptococcal myositis
0% 3. Necrotizing fasciitis
0% 4. Septic arthritis
Getting past the barricade
 Bacteria which can
directly stimulate
the immune system
without the need for
intracellular
processing are
called….
0% 1. Hyperinfectors
0% 2. Superspreaders
0% 3. Superantigens
0% 4. Extraantigens
 The gram-stain shows…

0%
1. Gram negative cocci
0%
2. Gram negative bacilli
0%
3. Gram positive cocci
0% 4. Gram positive bacilli
Culture
report
 What did she buy at the
market?
0% 1. Pork
0% 2. Melons
0% 3. Fish
0% 4. Watercress
 Vibrio grow best in…..

0% 1. Dextrose-saline
0% 2. 0.45% saline
0% 3. 0.9% saline
0% 4. 3.0 % saline
 Another case where geography
matters
• 49 yr old male bus
driver
• No travel history,
smoker, DMx20 yrs
on TCM
• Adm 5 am 17 Mar 04
with 5d fever, 3d
cough with sputum
• EMD temp 36.8, BP
85/50, SaO297%
 He most likely has….

0% 1. Heart failure
0% 2. Pneumocystis jiroveci (carinii) pneumonia
0% 3. A lobar pneumonia
0% 4. Tuberculosis
 Hospital course
• Admitted to HD
• Wbc 11.3
• Intubated 8 am,
converted to Imipenem +
levo
• Died 2 pm
• What did his blood
cultures grow?
• 1. S.aureus
• 2. S. pyogenes
• 3. E.coli
• 4. B.pseudomallei
 The organism is found in..

0%
1. Water
0%
2. Soil
0%
3. Air
0%
4. Mosquitoes
 The drug of choice for
melioidosis is..

0% 1. Doxycycline

0% 2. Ceftazidime

0% 3. Chloramphenicol

0% 4. Trimethoprim
Melioidosis treatment
Should we still use ceftazidime
alone???
 Clinical overview

Infectious Diseases in Singapore

T.B.P 9 year old Indonesian Chinese boy from
Batam, previously well. Immunisation as per
Indonesian schedule

• Started with sore throat 26th Sept 09

3 days later :
• Fever
• Right-sided neck pain and progressive swelling
• Pain and swelling of right index DIPJ
• Painful rash over lower limbs
• Malaise
Clinical examination at presentation
• Toxic, febrile T40. hemodynamically stable
• No respiratory distress/ stridor
• Bilateral eyelid redness and mild swelling
• Significant lower facial, jaw and neck cellulitis. No crepitus
• Facial congestion, with dilated superficial veins ? SVCO
• Throat injected but no exudates/ pseudomembranes or tonsillar
enlargement
• Left ankle arthritis
• Right index finger DIPJ arthritis
• Bilateral lower limb pitting edema
• Rashes over lower limbs
• No subcutaneous nodules
• Cardiovascular exam normal
• Hepatomegaly L5 firm, no splenomegaly
• CNS normal.
Progressive swelling of neck
Bilateral ankle swelling, pitting. Left ankle arthritis with tenderness on joint movement
Multiple tender lesions
 The rash is…
0% 1. Erythema chronicum migrans

0% 2. Erythema nodosum

0% 3. Janeway lesions

0% 4. Erythema migrans
 Significant investigations
• FBC : TW 40.4
• CRP 266 mg/dL
• ESR 80mm/hr
• Liver enzymes normal
• Serum albumin 25mmol/L
• No proteinuria
• Blood culture negative
• Throat culture negative
 The diagnosis is…

0% 1. Bacterial endocarditis
0% 2. Juvenile rheumatoid arthritis
0% 3. Acute rheumatic fever
0% 4. Tuberculosis
 Diagnosis
• ASOT 12800 IU/ml

• 1 Major (Arthritis)
• 2 Minor (Fever, Raised ESR and CRP)
And raised ASOT

Throat swab negative (taken after IV abx)

 Progress
• Neck swelling and LL edema resolved.
• Fever initially settled but subsequently persisted,
low grade
• Worsening joint pain and arthritis, debilitating
• Persisted despite high dose aspirin
100mg/kg/day
• Cultures remained negative with decline in
TW 18, CRP 90 but ESR increased to 95
• Started on oral prednisolone 30mg bd with
dramatic response
• SLE screen negative
 In 1964, Ernest-Charles
Lasegue said…

“______ licks at the joints, but

bites at the heart”
Sheares et al Ann Acad Med Sing
http://www.moh.gov.sg/mohcorp/statistics.aspx?id=4464#7
 Group A strep causes ARF by…

0% 1. A pyrogenic exotoxin
0% 2. Molecular mimicry
0% 3. Direct invasion
0% 4. Complement mediated necrosis
Mechanism for HLA assn???
 The treatment of choice for
Rheumatic Fever is….

0% 1. Penicillin
0% 2. Cloxacillin
0% 3. Imipenem
0% 4. Vancomycin
 An older Singaporean woman..
Which system is involved?

0% 1. Liver

0% 2. Venous
0% 3. Fascia
0% 4. Lymphatic
 What is the pathogen?

0% 1. Brugia malayi
0% 2. Loa loa
0% 3. Onchocerciasis volvulus
0% 4. Ascaris lumbricoides
 The vector is…

0% 1. The anopheline mosquito

0% 2. The culicine mosquito
0% 3. The sandfly
0% 4. The tsetse fly
 The treatment is…

0% 1. Doxycycline
0% 2. Cloxacillin
0% 3. Amphotericin
0% 4. Itraconazole
 The treatment targets…

0% 1. The larval stage of the parasite

0% 2. The adult parasite
0% 3. A bacteria in the parasite
0% 4. The ova of the parasite
A young man just finished reservist
training in Lim Chu Kang…
•He is admitted with high spiking fevers….
•There are no other signs or symptoms.
•Which is the most likely diagnosis?
0% 1. Malaria

0% 2. Dengue

0% 3. Typhoid
0% 4. Gonorrhea
What is the diagnosis based on the
peripheral blood smear?

0% 1. Dengue
0% 2. Chikungunya
0% 3. Typhoid
0% 4. Malaria
Diagnosed by
PCR
 What is the natural host?

0% 1. Gibbon
0% 2. Rhesus monkey
0% 3. Macaque
0% 4. Chimpanzee
Child with a rash:
Differential diagnosis
0% 1. Dengue

0% 2. Chikungunya

0% 3. Kawasaki disease
0% 4. Too early to tell

Pialoux G et al. Lancet Infect Dis. 2007;7:319-27.

 Lab results
• Hb normal, wbc normal, plt slightly low
• Liver function slightly abnormal
• Renal function normal
• Dengue PCR negative, serology negative
• Chikungunya PCR positive
 Chikungunya: The vectors

1. Anopheles sundaicus
2. Culex quinqufasciens
3. Aedes aegypti
4. Anopheles maculatus

Pialoux G et al. Lancet Infect Dis. 2007;7:319-27.

Chikungunya: Clinical Features

Pialoux G et al. Lancet Infect Dis. 2007;7:319-27.

 Young boy in trouble
• 17 year old Singaporean
• History of weight loss, mouth ulcers, diarrhea
• Had scope done in AH Aug 05:gastritis, Rx
Augmentin (amoxicillin-clavulanate),acyclovir,
panadiene
• Admitted to NUH 22 Oct with fever, drowsiness
and confusion
• On exam, hypotensive, BP 90/60, HR 103,
“incoherent”, ?no focal neurol signs, abd soft
 He has….

0% 1. Meningitis

0% 2. Tuberculosis

0% 3. Encephalitis
0% 4. Delirium
Labs
 More history + tests
• Rx at DSC in Sep 05 for Syphilis
• HIV ELISA positive, WB indeterminate,
gp160 positive, p24 weak, gp120, g41
negative
 He has

0% 1. Syphilis and a false positive HIV

0% 2. Confirmed advanced HIV
0% 3. Syphilis and early HIV
0% 4. Syphilis and gonorrhea
 More history + tests
•Blood culture positive
•Stool culture positive
•What is the likely organism?

0% 1. Pneumocystis jiroveci

0% 2. Mycobacterium tuberculosis

0% 3. Salmonella enteritidis

0% 4. Staphylococcus aureus
 His NS status will be

0% 1. Pes B

0% 2. Pes C
0% 3. Pes E
0% 4. Pes F
 His life expectancy is….

0% 1. 20+
0% 2. 30+
0% 3. 50+
0% 4. 70+
Which city?