Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 8)

Inhalational Anthrax (See also Chap. 214) Inhalational anthrax, the most severe form of disease caused by Bacillus anthracis, had not been reported in the United States for more than 25 years until the recent use of this organism as an agent of bioterrorism (Chap. 214). Patients presented with malaise, fever, cough, nausea, drenching sweats, shortness of breath, and headache. Rhinorrhea was unusual. All patients had abnormal chest roentgenograms at presentation. Pulmonary infiltrates, mediastinal widening, and pleural effusions were the most common findings. Hemorrhagic meningitis was seen in 38% of these patients. Survival was more likely when antibiotics were given...
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Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 8) Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 8) Inhalational Anthrax (See also Chap. 214) Inhalational anthrax, the most severe form of diseasecaused by Bacillus anthracis, had not been reported in the United States for morethan 25 years until the recent use of this organism as an agent of bioterrorism(Chap. 214). Patients presented with malaise, fever, cough, nausea, drenchingsweats, shortness of breath, and headache. Rhinorrhea was unusual. All patientshad abnormal chest roentgenograms at presentation. Pulmonary infiltrates,mediastinal widening, and pleural effusions were the most common findings.Hemorrhagic meningitis was seen in 38% of these patients. Survival was morelikely when antibiotics were given during the prodromal period and if multidrugregimens were used. In the absence of urgent intervention with antimicrobialagents and supportive care, inhalational anthrax progresses rapidly to hypotension,cyanosis, and death. Avian Influenza (H5N1) Infection (See also Chap. 180) Human cases of avian influenza were first reported inHong Kong. Recent cases have occurred primarily in Southeast Asia, particularlyVietnam. However, evidence of a rapidly expanding geographic distribution of thevirus throughout the world is of grave concern. Avian influenza should beconsidered in patients with severe respiratory tract illness, particularly if they havebeen exposed to poultry. To date, human-to-human transmission is rare. Patientspresent with high fever, an influenza-like illness, and lower respiratory tractsymptoms. Watery diarrhea may develop and may precede respiratory symptoms.Dyspnea develops a median of 5 days after the onset of symptoms and canprogress to respiratory distress syndrome, multiorgan failure, and death within 9–10 days after the onset of illness. Early antiviral treatment with neuraminidaseinhibitors should be initiated along with aggressive supportive measures. Hantavirus Pulmonary Syndrome (See also Chap. 189) Hantavirus pulmonary syndrome (HPS) has beendocumented in the United States (primarily the southwestern states), Canada, andSouth America. Most cases occur in rural areas and are associated with exposureto rodents. Patients present with a nonspecific viral prodrome of fever, malaise,myalgias, nausea, vomiting, and dizziness that may progress to pulmonary edemaand respiratory failure. HPS causes myocardial depression and increasedpulmonary vascular permeability; therefore, careful fluid resuscitation and use ofpressor agents are crucial. Aggressive cardiopulmonary support during the firstfew hours of illness can be life-saving. Conclusion Acutely ill febrile patients with the syndromes discussed in this chapterrequire close observation, aggressive supportive measures, and—in most cases—admission to intensive care units. The most important task of the physician is todistinguish these patients from other infected febrile patients who will not progressto fulminant disease. The alert physician must recognize the acute infectiousdisease emergency and then proceed with appropriate urgency. Further Readings Beigel JH et al: Avian influenza A (H5N1) infection in humans. N Engl JMed 353:1374, 2005 [PMID: 16192482] Darouiche RO: Spinal epidural abscess. N Engl J Med 355:2012, 2006 Hasham S et al: Necrotising fasciitis. BMJ 330:830, 2005 [PMID:15817551] Idro R et al: Pathogenesis, clinical features, and neurological outcome ofcerebral malaria. Lancet Neurol 4:827, 2005 [PMID: 16297841] Kyaw MH et al: Evaluation of severe infection and survival aftersplenectomy. Am J Med 119:276.e1, 2006 Nguyen HB et al: Severe sepsis and septic shock: Review of the literatureand emergency department management guidelines. Ann Emerg Med 48:28, 2006 Osborn MK, Steinberg JP: Subdural empyema and other suppurativecomplications of paranasal sinusitis. Lancet Infect Dis 7:62, 2007 Stephens DS et al: Epidemic meningitis, meningococcaemia, and Neisseriameningitidis. Lancet 369:2196, 2007 van de Beek D et al: Community-acquired bacterial meningitis in adults. NEngl J Med 354:44, 2006 Wills BA et al: Comparison of three fluid solutions for resuscitation indengue shock syndrome. N Engl J Med 353:877, 2005 [PMID: 16135832] Bibliography Anaya DA, Dellinger EP: Necrotizing soft-tissue infection: Diagnosis andmanagement. Clin Infect Dis 44:705, 2007 Annane D et al: Effect of treatment with low doses of hydrocortisone andfludrocortisone on mortality in patients with septic shock. JAMA 288:862, 2002[PMID: 12186604] Bachli EB et al: Drotrecogi ...