CHICKENPOX

Cause by varicella – zoster virus (human herpes virus 3)

Mode of transmission is by droplet infection from the upper respiratory tract or from the discharged by ruptured lesions on the skin.

The disease is contagious till pustules disappear.

Clinical Features

Prodromal Phase – low grade fever, malaise, headache and anorexia.

Rash

Rash on the Trunk

• First appears on the trunk and then face and finally on the limbs. The lesions are maximum on the trunk and minimum on the limbs.
• Appears as macules and then progress to papules, vesicles and pustules. The lesions finally dry up to form scales.
• These lesions are very itchy
• New lesions occur in every 2 – 4 days, each crop associated with fever.

Complications

• Myocarditis
• Hepatitis
• Meningitis
• Acute glomerulonephritis
• Secondary bacterial infection
• Cerebellar ataxia
• Pneumonitis
• Arthritis
• Congenital varicella

Diagnosis

• Mainly clinical.
• A Tzanck smear of vesicular fluid demonstrates multinucleated giant cells and epithelial cells with eosinophilic intranuclear inclusion bodies.
• Isolated the virus – culture
• Direct immunofluorescence test
• PCR – identify viral gene

Management

• No treatment required in majority of cases.
• Symptomatic treatment – antihistaminic and calamine lotion.
• Acyclovir (15 mg/kg 5 times a day for 7 days) – for adults and immunocompromised patients. It reduces the complications of chickenpox if given within 24 hours.
• Secondary bacterial infection is treated with local antiseptic or systemic antibiotics like cloxacillin.

Prophylaxis

• Live Attenuated Vaccine is given to prevent chickenpox in immunocompromised children and adult who are at high risk of infections. It should not be given to pregnant and immunocompromised patients.
• Passive Prophylaxis for immunocompromised patient or pregnant women with history of significant exposure within last 96 hours.

SMOKING

All forms of tobacco smoking including cigarettes, cigar, pipes and hookahs can produce ill health effects and addiction.

There are more than 4000 substances in cigarette smoke

It contains:

• Carcinogens – Tar, polynuclear aromatic hydrocarbons, benzopyrene, nickel, arsenic, nitrosamine, hydrazine, vinyl chloride
• Co-carcinogens – Phenol, cresol, catechol
• Addicting Agents – Nicotine
• Other – Carbon monoxide

Main stream smoke – smoke emerging from mouthpiece during puffing

Side stream smoke – smoke emitting between puffs at the burning end and from mouth end. Contains more carcinogens than main stream smoke.

Smoking Index

Number of cigarettes/ day X number of years smoked

• Mild smoker - <100
• Moderate smoker – 100 to 300
• Heavy smoker - >300

Pack Year

Number of packs of cigarette/day X number of years smoked (1 pack = 20 cigarette)

Passive Smoking

• Also known as second hand smoking, involuntary smoking and environmental tobacco smoke exposure.
• Occurs when smoke from one person’s burning tobacco product is inhaled by others.
• It increases the risk of CAD, cancer, respiratory illness and death.

Health Effects of Chronic Smoking

Effects of Smoking

• Cancers
• Lung
• Oral cavity
• Larynx
• Esophagus
• Stomach
• Urinary bladder
• Kidney
• Colon
• Cervix
• Coronary artery disease
• Stroke
• Chronic obstructive lung disease
• Infertility
• Aortic aneurysm
• Peripheral vascular disease
• Periodontitis

Nicotine Withdrawal Symptoms

Withdrawal symptoms in chronic users begin to appear approximately 30 minutes after every dose.

Features includes-

• Confusion
• Restlessness
• Anxiety
• Insomnia
• Dizziness
• Depression
• Feeling of frustration and anger
• Nightmares
• Poor concentration
• Headache
• Increased appetitie

Smoking Cessation

Nicotine Replacement Therapy

• Use of nicotine patches, nicotine gums, lozenges and nasal sprays.
• Contraindicated in unstable coronary artery disease, untreated peptic ulcer, recent MI and recent stroke.

Methods of gum use:

• Chew slowly until a strong taste or tingling sensation felt.
• Stop chewing and place the gum between cheek and gums.
• Chew again wen intensity of tingling decreases.
• Repeat this cycle of “park and chew” for about 30 minutes or until the tingling sensation subsides.

Bupropion

• Antidepressant
• Dose is 75-150 mg twice a day
• Side effects include dry mouth, insomnia and skin rash

Varenicline

• More effective than nicotine and bupropion
• Contraindicated in pregnancy and lactation
• Side effects include nausea, insomnia, abnormal dreams, agitation, depressed mood, suicidal ideation, visual disturbances and alteration in consciousness.

Other medications – Clonodine and Nortryptyline

Electronic Cigarettes

• A battery-powered vaporizer which contains nicotine derived from tobacco plant and gives the feeling of smoking a cigarette.
• Reduces various health effects of cigarette smoking.

DEPRESSION

Depression

Depressive disorders are characterized by persistent low mood, loss of interest and enjoyment and reduced energy. They often impair day-to-day functioning.

It is characterized by one of more major depressive episodes for at least 2 weeks

OBESITY

Obesity

The term obesity implies excess of the fat (adipose tissue) in the body.

Measurement

Body Mass Index (BMI)

It is defines as person’s weight (kg) divided by the square of person’s height (meters).

BMI (kg/m²) is classified as the following:-

• Normal: 18.5 – 24.9
• Underweight: < 18.5
• Overweight: 25 – 29.9
• Obesity Class I : 30 – 34.9
• Obesity Class II : 35 – 39.9
• Obesity Class III : >40

MUMPS

It is the acute viral infection characterized by painful enlargement of salivary gland (Parotid gland).

Caused by the paramyxovirus.

Mode of the spread is droplet infection, direct contact and fomites containing saliva and urine

Incidence high in winter and spring

Clinical Features

Parotid Swelling

• Malaise
• Anorexia
• Fever
• Headche
• Unilateral / bilateral swelling of angle of mouth
• Ear ache
• Jaw tenderness
• Dryness of mouth
• Earlobe appears to be pushed outward and backward due to the swelling

Investigations

• Raised serum amylase
• Isolation of virus (throat, spine and urine)
• ELISA
• PCR
• IgM raised

Complications

1. Epididymo-orchitis
2. Oophoritis
3. Pancreatitis
4. Aseptic meningitis
5. Encephalitis
6. Myocarditis
7. Nephritis
8. Mastiits

Treatment

• Symptomatic treatment
• Antipyretic drug
• Warm saline mouthwash
• Steriods – Prednisolone (orchitis and arthritis)
• Prevention by the Mumps Vaccine at the age of 15 month

MEASLES

Caused by paramyxovirus (RNA virus) infection.

Mode of spread is by droplet infection.

Period of infectivity is from 4 days before and 2 days after the onset of rash.

Clinical Features

Prodromal Stage

• Fever
• Cough, coryza and conjunctivitis
• Photophobia
• Malaise

 Koplik’s Spots

They are small, red and irregular lesions on the buccal mucosa with blue-white centers opposite to the lower molar. They appear 1-2 days before and disappear 1-2 days after the appearance of the rash. They are pathognomic of measles.

Exanthematous Stage (Rash)

Maculopapular Rash

• Red maculopapular rash
• Pattern – Starts from the back of ear and then spreading downward over the face, neck, trunk and feet. They fades in the same manner.
• The malaise and fever subside as the rash fades that takes 4 – 5 days.

 Complications (DROPSEA)

1. Diarrhea
2. Reactivation of latent TB
3. Otitis media
4. Pnemonia
5. Subacute sclerosing panencephalitis (SSP)
6. Encephalitis
7. Vitamin A deficiency
8. Myocarditis
9. Hepatitis
10. Keratitis and corneal ulcer
11. Acute glomerulonephritis

 Treatment

Supportive

• Antipyretic
• Fluid
• Nutrition
• Treat bacterial superinfection

Vitamin A supplementation

Treat the complication –For SSP use ribavirin

Prevention

Passive Immunization for:-

• Contact under 12 month of age
• Debilitated children, esp. with malignant disease
• Pregnant females
• Patient with active TB
• Immunodeficient patient

 Active Immunization

• Given in combination with rubella and mumps vaccine (MMR vaccine) at 9 month
• Vaccination within 72 hours of exposure is the intervention of choice for susceptible individuals older than 12 months of age.

TYPHOID

Typhoid is also known as enteric fever. It is caused by Salmonella typhi and Salmonella paratyphi A and B. A range of clinical syndrome includes the diarrheal disease. These organisms are transmitted by the feco-oral route, usually by the carriers, often food handlers, through the contamination of food, milk and water.

Pathogenesis

The typhoid bacilli reach the small intestine, penetrate the mucosa and enter intestinal lymphatics via Peyer’s patches to be carried to the bloodstream. The bacilli are disseminated throughout the body and intracellular multiplication takes place. The organisms re-enter the bloodstream producing bacteremia when all organs are repeatedly exposed to typhoid bacilli.

Clinical Features

Symptoms of Typhoid

1^st week

• Step ladder fever
• Malaise
• Headache
• Diarrhea
• Vomiting
• Constipation – rarely
• Relative bradycardia

 2^nd Week

• Transient maculopapular rash (Rose Spot – present at lower trunk and upper abdomen)
• Spleenomegaly
• Abdominal distension
• Diarrhea
• Cough

 3^rd Week

• Delirium
• Altered sensation
• Complications are seen
• Coma Death

 Complications

• General – Toxaemia, dehydration, circulatory failure, DIC
• Gastrointestinal – Perforation of intestine, intestinal hemorrhage
• Neurological – Delirium, psychosis, meningitis, encephalopathy, coma
• Miscellaneous – Myocarditis, endocarditis, pericarditis, pyelonephritis, pneumonia, arthritis, osteomyelitis

 Investigations

• Complete Blood Count – Total and Differential Count, Hb
• Blood Culture (B) – 1^st week
• Agglutination Test (A) (Widal test) – 2^nd week
• Stool Culture (S) – 3^rd week
• Urine Culture (U) – 4^th week
• Bone Marrow Culture
• Bile Culture
• PCR
• ELISA
• Scratch Test from rose spot
• USG – hepatomegaly, splenomegaly
• CPR

 Management

• Bed rest
• Isolation
• Maintenance of nutrition and fluid intake
• Antibiotics (2 weeks) – Ciprofloxacin (500mg BD is drug of choice) or Cotrimoxazole or Amoxicillin
• If the disease is severe – IV antibiotic

 Prevention

• Good hygiene
• Proper sewage disposal
• Proper water treatment
• If endemic area – Typhoid vaccine

AIDS

AIDS (Acquired Immunodeficiency Syndrome) is the caused by the HIV virus (Human Immunodeficiency Virus). There are 2 subtype that is HIV-1 and HIV-2. But the most common subtype worldwide is HIV-1. HIV-2 is found in West Africa.

Transmission

1. Transfusion of blood and blood product
2. Needle sharing in drug user
3. Splash of body fluids on mucosa of eye, nose and mouth
4. exual intercourse – homosexual and heterosexual
5. Vertical transmission from mother to fetus
6. During delivery of the child
7. Breast feeding from infected mother

High Risk Groups

1. Injecting Drug User
2. Female Sex Workers
3. Clients of Female Sex Worker
4. Men sex with Men
5. Labor Migrants

 Stages

 a. Primary Infection (2 – 12 weeks)

Symptoms of  HIV Infection

1. Fever with rash
2. Pharyngitis
3. Headache
4. Cervical Lymphadenopathy
5. Arthralgia
6. Myalgia

 b. Asymptomatic Infection ( 7 – 10 years)

• No evidence of disease.
• Except there may be persistent of generalized lymphadenopathy

c. AIDS Related Complex

1. Impairment of cellular immunity.
2. Unexplained diarrhea >1 month
3. Fatigue
4. Malaise
5. >10 % of body weight loss
6. Mild opportunistic infection – oral thrush, generalized lymphadenopathy

 d. AIDS

    Specific opportunistic infections:-

1. Kaposi sarcoma
2. Pulmonary and extra pulmonary TB
3. Candidiasis
4. Ulcerative stomatitis and gingivitis
5. Toxoplasmosis

 Investigations

• Rapid test for HIV
• ELISA Test
• Western Blot Test – Confirmatory Test
• DNA PCR
• CD4 count
• Complete Blood Count
• Liver and Renal Function Test
• Hepatitis B and C

Management

    General Measures

1. Balanced Diet
2. Quitting smoking and drinking alcohol
3. Adequate rest
4. Safe sex
5. Treat the opportunistic infections with proper antibiotics

    Antiretroviral Drug Combinations: -

2 NRTI + 1 NNRTI

OR

2 NRTI + 1 PI

• NRTI (Nucleoside Reverse Transcriptase Inhibitor) – Zidovudine, Didanosine, Lamivudine, Stavudine, Abacavir, Tenofovir
• NNRTI (Non- Nucleoside Reverse Transcriptase Inhibitor) – Nevirapine and Efavirenz
• PI (Protease Inhibitor) – Indinavir, Ritinavir, Lopinavir

 Supportive Policy and Social Environment

1. Psychological counselling
2. Orphan care
3. Community support service
4. Spiritual support
5. Stigma and discrimination reduction
6. Economic security
7. Preventive therapy
8. Palliative care
9. Nutritional support
10. Management of STDs

URINARY TRACT INFECTIONS

Urinary Tract Infection

Definition

Multiplication of organisms in urinary tract and is associated with >10^5 organisms/ml in midstream sample of urine.

Etiology

Organisms – E.coli, Klebsiella, Proteus, Enterococcus, Pseudomonas aeuroginosa, Chlamydia trachomatis, N. gonorrhea.

Pathogenesis

1. Ascending Infection Route – This is the most common route. The organism enter the bladder via the urethra and ascend towards the kidney. 
2. Hematogenous and Lymphatic Pathways – Less common. The spread of the organism occur from the adjacent organs.

Females are more prone due to following reasons:-

1. Short urethra – 4cm
2. Absence of prostatic secretion
3. Sexual intercourse may cause minor urethral trauma and transfer bacteria from perineum into bladder.
4. Gram negative organisms residing near the anal region colonies the periurethral region.

But during the neonatal period, the incidence of UTI is slightly higher in males than females because infant more commonly have congenital urinary tract anomalies.

Risk Factors of UTI

1. BPH
2. Prostatic Cancer
3. Urethral Stricture
4. Calculi
5. Posterior Urethral Valve
6. Spina Bifida
7. Tabes Dorsalis
8. Diabetic Neuropathy
9. Uterine Prolapse
10. Urinary Catheter

Clinical Features

1. Fever with chills and rigor
2. Frequency
3. Dysuria
4. Urgency
5. Hematuria
6. Suprapubic Pain
7. Strangury
8. Loin pain, guarding and vomiting in case of acute pyelonephritis

Investigations

1. Midstream urine sample collection for leukocytes, cast cells and red cells
2. Dipstick Test – Nitrite and leukocyte esterase test
3. Culture and sensitivity of urine
4. Full blood count
5. Urea and Creatinine
6. Renal Ultrasound – To see obstruction
7. Cystoscopy
8. DMSA renal scan
9. Micturating Cystourethrogram – To identify reflux

Treatment

1. Fluid intake >2 L/day
2. Regular complete bladder emptying
3. Analgesic and antispasmodic agents
4. Remove the catheter if symptomatic
5. Maintain perineal hygiene
6. Empty bladder before and after the intercourse
7. Antibiotic – Trimethoprim (3 days), Nitrofurantoin (7 days) 
8. If asymptomatic no need for treatment unless pregnancy, renal transplant or urological surgery.
9. If complicated UTI then hospitalization and IV treatment needed.