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Recognizing and Managing Emerging Infectious Diseases in the Emergency Department

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Recognizing and Managing Emerging Infectious Diseases in the Emergency Department

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  About This Issue

With increased global travel, emergency clinicians are often on the front lines in identifying and halting outbreaks of emerging or re-emerging infectious diseases. This issue reviews management of patients with suspected Middle East respiratory syndrome, chikungunya virus infection, and Zika virus infection. To safeguard the health of the public – and hospital staff – it is essential for emergency clinicians to:

•  Know the current status of worldwide infectious disease outbreaks
•  Ask about and document the travel history of patients presenting with signs of infection
•  Order the recommended diagnostic tests for specific diseases, based on history, signs, and symptoms
•  Manage patient illness based on the best information available
•  Safeguard public health through correct disposition and follow-up

  Issue Information

Author: Ramón Millán, MD, MPH, FACEP; Deepti Thomas-Paulose, MD, MPH; Daniel Egan, MD

Peer Reviewers: Christopher Baugh, MD, MBA; Roland C. Merchant, MD, MPH, ScD

Publication Date: May 1, 2018

CME Expiration Date: May 1, 2021

CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2A or 2B Credits. Specialty CME credits also include 4 hours  Infection Control credit.

PubMed ID: 29697919

  Issue Features
  Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Etiology and Pathophysiology of MERS
    2. Etiology and Pathophysiology of CHIKV
    3. Etiology and Pathophysiology of ZIKV
  6. Differential Diagnosis
    1. Differential Diagnosis of MERS
    2. Differential Diagnosis of CHIKV Infection
    3. Differential Diagnosis of ZIKV Infection
  7. Prehospital Care
    1. Prehospital Care for MERS
    2. Prehospital Care for CHIKV Infection
    3. Prehospital Care for ZIKV Infection
  8. Emergency Department Evaluation
    1. Triage
    2. History
    3. Physical Examination
  9. Diagnostic Studies
    1. Diagnostic Studies for MERS
    2. Diagnostic Studies for CHIKV Infection
    3. Diagnostic Studies for ZIKV Infection
  10. Treatment
    1. Treatment for MERS
    2. Treatment for CHIKV Infection
    3. Treatment for ZIKV Infection
  11. Special Populations
    1. CHIKV Infection in Pregnant Women and in Children
    2. ZIKV Infection in Pregnant Women
  12. Controversies and Cutting Edge
    1. MERS
    2. CHIKV Infection
    3. ZIKV Infection
  13. Disposition
    1. Disposition for Patients With MERS
    2. Disposition for Patients With CHIKV Infection
    3. Disposition for Patients With ZIKV Infection
  14. Summary
  15. Risk Management Pitfalls for Managing Emerging Infectious Diseases
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathways
    1. Clinical Pathway for Management of Suspected Middle East Respiratory Syndrome
    2. Clinical Pathway for Management of Suspected Chikungunya Virus Infection
    3. Clinical Pathway for Management of Suspected Zika Virus Infection
  19. Tables and Figures
    1. Table 1. Signs and Symptoms, Incubation Period, Tests, and Complications of Middle East Respiratory Syndrome, Chikungunya Virus Infection, and Zika Virus Infection
    2. Table 2. Travel Risk Exposures and Associated Infections
    3. Table 3. Traveler Health Websites
    4. Figure 1. Zika Virus Rash on Arm
    5. Figure 2. Zika Virus Rash on Chest
    6. Figure 3. Chest X-Ray Showing Interstitial Infiltrate in a Patient With Middle East Respiratory Syndrome
  20. References


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With population shifts, increased travel, and climate change, the spread of emerging and re-emerging infections is increasing. Although encountering a patient with an emerging infection on any given emergency department shift is unlikely, missing a diagnosis could have profound consequences for the patient, healthcare workers, and the patient’s close contacts. This review provides a framework to evaluate, diagnose, and treat a returning traveler with suspected Middle East respiratory syndrome, chikungunya virus, or Zika virus—3 recently emerged infections. All may present with nonspecific viral-like symptoms and are easily missed if an appropriate travel history is not obtained. A high level of vigilance and proper disposition will enable the emergency clinician to effectively diagnose, manage, and contain these diseases.


Case Presentations

A 60-year-old man presents to the ED complaining of a fever. The triage note reports that the patient has had 2 days of cough, fever, and mild diarrhea, and he feels short of breath. His temperature is 39.1°C (102.4°F); blood pressure, 138/72 mm Hg; pulse, 104 beats/min; respiratory rate, 18 breaths/min; and oxygen saturation, 98% on room air. On physical examination, you hear scattered rhonchi in both of the patient’s lungs. On further questioning, he tells you that he was in Saudi Arabia for a business trip last week. You remember hearing about an illness in that region that causes fever, and you wonder what you should do next...

A 42-year-old nursing colleague of yours presents to the ED with fever, headaches, and severe joint pain. She has a history of diabetes, hypertension, and early arthritis. She frequently visits the Dominican Republic for work and returned 5 days ago from a trip there. She is convinced that she has dengue fever because she had heard there was an outbreak of this disease while she was there. On physical examination, she looks uncomfortable. She has pain and swelling over her fingers, wrists, and ankles. You consider whether isolation and testing are called for...


Emerging infections are broadly defined as diseases “…whose incidence in humans has increased in the past 2 decades or threatens to increase in the future.”1 They usually cross national boundaries and are determined by complex interactions between the environment and human and animal ecosystems.2 Re-emerging infections are diseases once considered to be major global health problems that had fallen to such low levels that they were no longer considered public health threats, but are now showing upward trends in incidence or prevalence worldwide. Malaria, tuberculosis, Zika infection, and chikungunya are examples of re-emerging infections.

Occurring less frequently, an emerging infection can also be defined as a newly identified and previously unknown infectious agent that causes public health problems either locally or internationally. These new diseases often result from changes in the environment and the interaction between humans and disease vectors. Less frequently, an emerging disease can be a previously unrecognized infection in the process of undergoing ecological transformation.3 Ebola and Lassa fever are classic examples of this. In this article, Middle East respiratory syndrome (MERS) can be classified as an emerging infectious disease. Factors such as urbanization, deforestation, ease of global travel, climate change, and weak healthcare systems are contributing factors associated with the occurrence of both categories of diseases.4,5

MERS, chikungunya virus (CHIKV) infection, and Zika virus (ZIKV) infection have had recent emergence and re-emergence worldwide. Globalization, rapid urbanization, and ease of travel bring patients with emerging or re-emerging infections to emergency departments (EDs) all over the world. While these diseases infrequently cause primary infection in the United States, the emergency clinician must recognize the ill traveler and alert public health authorities when appropriate. This vigilance requires active awareness of the current outbreaks on a global scale and risk factors for illness. This issue of Emergency Medicine Practice reviews 3 diseases—MERS, CHIKV infection, and ZIKV infection—that remain active and pose a public health threat.


Critical Appraisal of the Literature

A search was performed in PubMed for literature published between 2012 and 2017. For MERS, the search term Middle East respiratory syndrome yielded 10,009 articles; Middle East respiratory syndrome coronavirus yielded 1074 articles in English, and Middle East respiratory syndrome AND emergency yielded 324 articles in English. Articles included review articles, commentaries, case-control and cohort studies, and observational studies. No randomized controlled trials exist for the treatment of this disease. Ultimately, 104 articles were identified for close review. Reviews of the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC) and the Saudi Arabian Ministry of Health websites were also performed.

For CHIKV, the search term chikungunya yielded over 3400 articles in English; using chikungunya alphavirus yielded over 2000 results; and chikungunya alphavirus AND travel yielded 194 articles. Most articles were reviews, expert opinions, case reports, and observational studies of pharmacologics, viral microbiology, and characterization of outbreaks occurring largely in Africa, South and Southeast Asia, the Caribbean, and Central and South America. There is a paucity of vigorous studies for this disease. There were only 4 randomized controlled trials related to vaccines and treatment. A total of 82 articles were included for final review. A seminal study on the disease describing clinical progression and treatments was conducted during a large outbreak on La Reunion Island in the Indian Ocean. Updated guidelines and reports from the WHO and the CDC also were also reviewed.

For ZIKV, a literature search with the single term Zika yielded 2082 articles in the English language. Searching Zika AND travel yielded 267 articles, and the terms Zika AND emergency yielded 220 articles. There were no randomized controlled trials, and the articles focused primarily on reviews and case reports, evaluation studies, epidemiological reports, and summaries of biochemical research and pharmacologic interventions. A total of 38 articles were included for final review, and WHO and CDC updates and guidelines were also examined.


Tables and Figures

Recognizing and Managing Emerging Infectious Disease Emergency Departmen Travel Risk Exposures Associated Infections



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. Most informative references cited in this paper, as determined by the author, are highlighted.

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  3. Morse SS. Factors and determinants of disease emergence. Rev Sci Tech. 2004;23(2):443-451. (Review)
  4. Ali S, Gugliemini O, Harber S, et al. Environmental and social change drive the explosive emergence of Zika virus in the Americas. PLoS Negl Trop Dis. 2017;11(2):e0005135. (Review)
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  6. Zaki AM, van Boheemen S, Bestebroer TM, et al. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012;367(19):1814-1820. (Case report)
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  9. World Health Organization. World Health Organization Middle East respiratory syndrome coronavirus (MERS-CoV). 2017; http://www.who.int/emergencies/mers-cov/en. Accessed May 8, 2017. (WHO website)
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  11. Kim SW, Park JW, Jung HD, et al. Risk factors for transmission of Middle East respiratory syndrome coronavirus infection during the 2015 outbreak in South Korea. Clin Infect Dis. 2016. (Retrospective cohort; 186 cases)
  12. Aleanizy FS, Mohmed N, Alqahtani FY, et al. Outbreak of Middle East respiratory syndrome coronavirus in Saudi Arabia: a retrospective study. BMC Infect Dis. 2017;17(1):23. (Retrospective; 190 cases)
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  47. Wang JZ, Guo XH, Xu DG. Anatomical, animal, and cellular evidence for Zika-induced pathogenesis of fetal microcephaly. Brain Dev. 2016;39(4):294-297. (Review) DOI: https://doi.org/10.1016/j.braindev.2016.10.012 
  48. Faizan MI, Abdullah M, Ali S, et al. Zika virus-induced microcephaly and its possible molecular mechanism. Intervirology. 2017;59(3):152-158. (Review)
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  CME Information

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Infection Control CME credits, subject to your state and institutional approval.

Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Millán, Dr. Thomas-Paulose, Dr. Egan, Dr. Baugh, Dr. Merchant, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

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Last Modified: 05/24/2018
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