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Infectious Diseases in the Tropical North Bart Currie Infectious Diseases Department, Royal Darwin Hospital Global and Tropical Health Division, Menzies Northern Territory Medical Program, Flinders & CDU Remote community 570 km SE of Darwin 24yo yo Indigenous woman on prednisolone and azathioprine for autoimmune hepatitis 3d fevers, cough, dyspnoea, hemoptysis, hypoxic Plane evacuation to RDH after ceftriaxone and gentamicin ICU; intubated & ventilated Sputum and blood cultures ST93 CA-MRSA CA-MRSA pneumonia Remote community 570 km SE of Darwin 24yo yo Indigenous woman on prednisolone and azathioprine for autoimmune hepatitis 3d fevers, cough, dyspnoea, hemoptysis, hypoxic Plane evacuation to RDH after ceftriaxone and gentamicin ICU; intubated & ventilated Sputum and blood cultures ST93 CA-MRSA Community-acquired MRSA in the NT NT CA-MRSA CC 75 Divergent from others Usually low virulence PVL gene –ve Skin sepsis Scabies Virulent CA-MRSA ST 30: Pacific Clone ST 93: Queensland Clone Both PVL gene +ve Necrotising pneumonia ST 30 CA-MRSA: Pacific Clone Virulent CA-MRSA August 2013 8yo Indigenous girl Disseminated disease ST 93: Queensland Clone PVL gene +ve 33yo increasing cough and sputum+++ Plane evacuation to RDH after ceftriaxone and gentamicin ICU; intubated & ventilated 33yo increasing cough and sputum+++ Plane evacuation to RDH after ceftriaxone and gentamicin ICU; intubated & ventilated Melioidosis • Infection with Burkholderia pseudomallei • Environmental bacterium – in soil and surface water in endemic areas • Disease in infected humans and animals • Strong association with rainfall and environmental damage Melioidosis in Australia 1949 Outbreak in sheep Winton Queensland (22.5oS) Cottew Aust J Exp Biol Med Sci 1950 1950 First Australian human case 32yo diabetic in Townsville Fatal septicemic melioidosis Rimington Med J Aust 1962 1960 First case in the Northern Territory Crotty Med J Aust 1962 The Darwin Prospective Melioidosis Study 948 cases over 25.5 years 117 deaths (13%) Darwin 23 years of the Darwin Prospective Melioidosis Study Cases by Year 1989/90 – 2011/12 97 100 91 90 TC Carlos Number of Cases 80 TCTC LesLes 70 TCTC Monica Monica TCTC Thelma Thelma 60 48 45 50 40 30 20 10 6 TCTC Ingrid Ingrid 37 30 30 27 27 18 33 32 31 32 23 25 22 14 7 0 Year TCTC Helen Helen 25 28 64 Royal Darwin Hospital Intensive Care Unit January 8th 2012 Royal Darwin Hospital Intensive Care Unit April 2nd 2012 Melioidosis Clinical Presentations • 55% blood culture +ve • 22% present with septic shock – 75% of these pneumonia is primary site – mortality 50-90% if septic shock Pneumonia 55% Genitourinary 14% Australia: prostate in 20% of all males with melioidosis Skin 13% Bacteraemia with no focus 11% fluorescent in-situ hybridisation & confocal laser scanning microscopy shows B. pseudomallei thriving within native and imported grasses Kaestli et al. Env Microbiol 2012;14:2058-70 Scrub typhus 40yo male; sick 2 weeks Headaches, fevers, lethargy, myalgia, dry cough, truncal rash Pig hunting Woodcutter’s monsoon vine thickets Incubation period 11 days Scrub typhus Fatal scrub typhus Litchfield Park 38yo Green Ant Creek track contractor 17 cases, 11 Litchfield, Recently Groote Eylandt, Melville Island, Woodcutter’s 15/17 had eschar 1 cm Leptospirosis Nov 2013 19yo Indig male elite athlete; ED – fever, headaches 2d later ED LP normal; Next day ED SOB++ Sats 91% 15L O2 ICU intubated & ventilated; merop/vanco/doxy/oseltamivir CRP 377, WCC 7.7 poly 6.5 lymps 0.5, platelets 24, AKI Cr 299, BR 26 ALT 85 GGT 68 Alb 24, CK peak 8192 Difficult ventilation - prone and high PEEP; extubated after 5d Leptospirosis PCR blood +ve; IgM +ve; Australis MAT <50 to 800 Leptospirosis Nov 2013 19yo Indig male elite athlete; ED – fever, headaches 2d later ED LP normal; Next day ED SOB++ Sats 91% 15L O2 ICU intubated & ventilated; merop/vanco/doxy/oseltamivir CRP 377, WCC 7.7 poly 6.5 lymps 0.5, platelets 24, AKI Cr 299, BR 26 ALT 85 GGT 68 Alb 24, CK peak 8192 Difficult ventilation - prone and high PEEP; extubated after 5d Leptospirosis PCR blood +ve; IgM +ve; Australis MAT <50 to 800 Murray Valley Encephalitis 1° hosts-water birds Herons & Egrets Rufous Night Heron Aeromonas hydrophila 11yo attacked by Fresh water crocodile Crocodilis johnstoni Bats and emerging human viral diseases Australian bat rabies (lyssavirus) Nipah & Hendra virus SARS & MERS Ebola What next?? Bat-filled tree may have been ground zero for the West African Ebola epidemic Borneo Sulawesi Papua Timika Jakarta Lombok Bali Java Wallace’s Line Timor Darwin Northern Territory Borneo Sulawesi Papua Timika Jakarta Lombok Bali Java Wallace’s Line Timor Darwin Northern Territory
