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Borrelia demonstrates remarkable antigenic variation and strain heterogeneity which help the parasite to escape the immune response of the host and result in recurrence of febrile episodes discount cephalexin 250mg line. In Ethiopia the diseases affects mostly homeless men living crowded together in very unhygienic circumstances especially during rainy seasons buy cheap cephalexin 250 mg on-line. Pathophysiology In humans buy cephalexin 500mg overnight delivery, borreliae after entering the body multiply in the blood and circulate in great number during febrile periods. Severity is related to spirocheatal density in blood but systemic manifestations are related to release of various cytokines. The disease is characterized by sub capsular and parenchymal hemorrhage with infarcts of spleen, liver, heart and brain is seen. Thus, patients will have enlarged spleen and liver with variable edema and swelling of brain, lung and kidneys. Complications:- Life threatening complications are unusual in otherwise healthy persons if the disease is diagnosed and treated early. Without treatment, symptoms intensify over 2-7 days period and subside with spontaneous crisis during which borrelia disappear from the circulation. Such cycles of febrile periods alternating with afebrile periods may recur several times. Define rickettsial diseases with Special Emphasis on Epidemic and Endemic Typhus 2. Identify the clinical manifestations of the different types of rickettsial diseases 8. Describe the most commonly used tests for the diagnosis of rickettsial diseases 10. Refer complicated cases of rickettsial diseases to hospitals for better management 12. Design appropriate methods of prevention and control of rickettsial diseases Definition: Rickettisiae are small intracellular bacteria that are spread to man by arthropod vectors, namely human body lice, fleas, ticks & larval mites. The organisms inhabit the gastrointestinal tract of these arthropods & spread to human host by the direct bite of the vector or the inoculation of the organism contained in the feces of the vector by bite induced body itching. These infections are characterized by persistence in the body, widespread vasculitis (invading endothelial cells of small blood vessels) & multi-system involvement. Except in louse borne typhus humans are accidental hosts in most rickettisial diseases. Classification Rickettsial diseases are classified into five general groups Tick and mite borne spotted fever group Flea and louse borne typhus group Chigger borne scrub typhus Ehrlichiosis Q-fever 29 Internal Medicine Etiology and Epidemiology of Epidemic and Endemic Typhus : Epidemic Typhus (Louse born ): is caused by R. Lice acquire the rickettsia while ingesting a blood meal from an infected patient, the rickettsia multiply in the midgut epithelial cells of the louse and are excreted via louse faeces. The infected louse defecates during a blood meal and the patient autoinoculates the organisms by scratching. Humans and rats are infected when rickettsia laden fleas are scratched in to pruritic bite lesions. Endothelial proliferation coupled with peri-vascular reaction causes thromboses and small hemorrhages. However, tissue and organ injury is commonly due to increased vascular permeability with resulting edema, hypovolemia and organ ischemia. This leads to multi-system involvement with complications such as non-cardiogenic pulmonary edema, cardiac dysrhythemia, encephalitis, renal and hepatic failure and bleeding. Clinical Features Signs and symptoms: Incubation period of 1 week Abrupt onset of illness with prostration, severe headache and rapidly rising fever of 38. Brill-Zinsser disease (recrudescent typhus): This is a mild form of epidemic typhus caused by reactivation of dormant R. Endemic typhus (Flea borne typhus) Epidemic typhus (also known as murine typhus) is a relatively milder. Complications of Endemic and Epidemic Typhus Skin necrosis, gangrene of digits, Venous thrombosis Interstitial pneumonia in severe cases Myocarditis Oliguric renal failure Parotitis Diagnosis of rickettsial diseases is based on History, clinical course of the disease and epidemiologic of the disease may give a clue for diagnosis. Isolation of the organism by inoculation into laboratory animals is possible, it is time consuming and technically demanding. Delousing louse borne typhus Supportive Therapy Attention to fluid balance, prevention of bed sores, Treat agitation with diazepam Steroid treatment (prednisolone 20 mg daily for adults) in severe cases Prognosis: Untreated disease is fatal in 7 to 40 % of cases, depending on condition of host. In untreated survivors, renal insufficiency, multiorgan involvement and neurologic manifestations (12 %) are common. Prevention For flea borne typhus Elimination of fleas on clothing & bedding using insecticides like 1% Malathion powder Apply residual insecticide powder on the floor & bedding to kill hatching fleas. Protective wearing smeared with insect repellents is recommended for nurses and other attendants Chemoprophylaxis: Doxycycline 100mg weekly will protect those at risk. Helminthic Infections Intestinal Nematodes Tissue Nematodes Filariasis and Related Infections Schistosomiasis & Other Trematodes Cestodes 3. Design appropriate methods of prevention and control of intestinal nematodes Nematodes are elongated, symmetric round worms.

It was then that I realized that one day I would be in a position to save someones life discount 500 mg cephalexin fast delivery. Most importantly buy cephalexin 250 mg with mastercard, I understood the important role that I must be prepared for in helping families deal with such a life tragedy cheap cephalexin 250mg with mastercard. As I was walking back to the locker room, I started to reflect on the joy I got from volunteering in the hospital and mentoring community kids, combined with my passion for science. I knew at that moment that I would love working as a physician who could not only heal and alleviate pain, but who can educate and innovate. The opportunity to change even a fraction of the lives of those in a city or underserved country is quite amazing. With the untimely death of various community members due to the advanced stages of cancer and the higher incidence of human immunodeficiency virus infection in minority women, I am inspired to join the struggle against deadly diseases and sickness. As I continue to strive for more, I can remember a quote by author Anna Eleanor Roosevelt: When you cease to make a contribution, you begin to die. The tent that housed the trauma bay hummed intensely yet somberly as the medical staff began evaluating the casualties. My trauma shears ripped through the soldiers charred uniform while I performed an initial assessment of the casualty with the attending physician. Exposing the injuries, I found that the soldier was badly burned due to the blast. He was unconscious, suffering from a compromised airway and his skin was peppered with shrapnel. I attached monitoring equipment, started a peripheral line and began cleaning the burns that blanched the majority of the soldiers upper body. Through the synchronized chaos of surgeons directing treatment, anesthetists intubating and nurses administering initial medications, I understood the fluid relationship between the levels of medical hierarchy. I became part of an intricate network of communication, and the demanding process of saving a life. Nothing has been more rewarding than serving my fellow soldiers and the local Afghan community during a year long deployment overseas. Working in a combat support hospital under personalized mentorship of a cardiothoracic, orthopaedic and general surgeon gave me the opportunity to learn about long and short term care, processes of diagnosis and proactive medical treatment in trauma situations. After serving in a combat zone I realized that a life is the most magnificent and powerful force in existence. It compels us to bridge language and cultural barriers, and it is the common denominator amongst all human beings. As a physician, my priority is the preservation of that which is most precious to us all. The curriculum focused on writing and communication skills, medical ethics and core science knowledge. Additionally, the program encouraged team building, small group discussions about current medical developments and molding the future of healthcare. The following summer I participated in the Infectious Diseases Undergraduate Research Program at the University of Iowa. The summer long project added perspective to the obligations and responsibilities of being a physician. At the culmination of the eight weeks I understood the importance of medical research and the interdependency between the laboratory and clinical realms. I realized that it is critical to be immersed in medical literature and to foster an atmosphere that encourages aggressive medical research. I also learned that the term medical community signifies a constant discourse between the many facets of medicine. The commission of every physician is to juxtapose ideas, plans and research with the unified goal of improving the quality of life. Lastly, when I think of the role of a physician I am reminded of a quote by Robert Browning that states, But a mans reach should exceed his grasp. I will fill that necessity and I will provide the same quality of care that I desire to receive. As our chants reverberate off the empty walls, Cherry, a pregnant inmate who has been in this facility most of her adult life, takes the lead and we echo her moves. When I "go inside" I forget where I am; the women are eager to clip pictures for a collage, learn West African dance steps that I myself perform at Brown, or write poems on romance or motherhood. I, in turn, am humbled by the poems and artwork the women produce as the workshops provide a creative outlet to assert their unique stories. While researching the off- praised fifty-year-old cooperative between Brown University and Tougaloo College, a historically Black private school located in rural Mississippi, I examined the past through narrative, and I unearthed personal accounts outlining a history that had long been forgotten. One day, I found a letter with "To be read and destroyed" scribbled in the margin.

Need to drain pus and iv antibiotics Sphenoidal and frontal sinusitis can cerebral complications (eg cavernous thrombosis) Chronic sinusitis: puss buy cheap cephalexin 250 mg online, smell generic cephalexin 750 mg visa, no pain order cephalexin 250 mg overnight delivery. Can cause mucosal atrophy nose bleeds Desensitisation: Injections of increasing doses of allergen. Severe: pharyngeal exudate/erythema, shallow ulcers, vascular rash on lips Epstein Barr Virus Infectious Mononucleosis Usually adolescents/young adults. Severe: Marked C pharyngeal erythema & florid tonsillar exudate, high fever, cervical lymphadenopathy, leucocytosis on blood film. Mixed anaerobes Gingivitis/Pharyngitis Polymicrobial infection, due to poor dental hygiene, bad breath Corynebacterium Diphtheria Pharyngeal diphtheria rare. Characteristic greyish-green membranous exudate on pharynx Neisseria gonorrhoeae Pharyngitis Mostly asymptomatic. Pain/difficulty swallowing Fungal causes: Agent Disease Symptoms Candida Albicans Thrush Usually immunocompromised. Complication of asthma steroids and long-term antibiotics th th 64 4 and 5 Year Notes Diagnosis Throat swabs: For routine bacterial culture: especially to confirm/exclude Strep Pyogenes Low sensitivity (? See Acute Otitis Media, page 605 Acute Sinusitis Strep pneumoniae, H influenzae Acute Epiglottitis H influenzae type B. See Epiglottitis, page 609 Chronic Bronchitis (acute infectious Strep pneumoniae, H influenzae, Branhamella catarrhalis exacerbations) Bronchiolitis Respiratory Syncytial Virus. Late treatment as effective as early treatment Risks of over treatment with antibiotics: Penicillin resistance 2 to 9 times, risk of subsequent otitis media, pneumonia, bacteraemia or meningitis being caused by resistant S. Improves with muscle tone/innovation Subglottic stenosis: congenital or trauma (eg too big a ventilation tube) Croup: = Laryngo-tracheo bronchitis. Dont examine throat may cause spasm and obstruct Emergency treatment: Geudal airway and ambubag. If unsuccessful cricothyroidotomy with 14 gauge needles Tonsillitis: Tonsils are not normal lymph nodes: dont have capsule or afferent vessels Bulk of lymphoid tissue is in base of tongue Decrease in size with age. Granulation tissue/inflammatory Reinchers disease: in middle aged female smokers. Degenerative, gelatinous polyps of surrounding mucosa hoarse voice, obstruction. Infection centered on a bronchus or bronchiole, involving immediately adjacent alveoli. Usually fulminant course Legionella pneumonia: characteristic morphology is acute fibrino-purulent exudative pneumonia neutrophils + macrophages within a fibrinous exudate. Inflammatory response spares alveolar Respiratory 67 walls, so no necrosis or haemorrhage. Characteristic in air conditioning (ie plumbers, office workers, etc) and carriage in potting mix (ie gardeners). Lobar pneumonia Involves whole lobe uniformly, often with reactive fibrinous pleuritis 95% of cases are Strep pneumoniae Pathogenesis: bacteria inhaled profuse fluid exudate (good growth medium) infection spreads through interalveolar pores throughout lobe Macroscopic and Microscopic appearance: 4 stages based on macroscopic appearance: Congestion: 12 24 hours, oedema Red hepatisation: 2 3 days. There are two patterns: Multiple abscess: haematogenous spread or bronchopneumonia from a virulent organism that causes necrosis Solitary abscess: usually due to anaerobic organism eg following aspiration in alcoholic with depressed reflexes Infectious Granulomas Three possibilities for a granuloma: Tb: no neutrophil infiltrate in granuloma caseating necrosis Fungal: causes abscess neutrophils/puss in the middle Sarcoidosis: non-necrotising (non-infectious) Mainly Mycobacterial Tuberculosis: can infect any organ but commonly the lung Immune cells in granulomas: Histiocyte = epithelioid cell = macrophages (eating phase as opposed to circulating in blood when its called a monocyte) Bigger and more cytoplasm than a lymphocyte If cytoplasm fuses giant cell with multiple nuclei Tuberculosis See also Mycobacteria, page 502 Usually Mycobacterium Tuberculosis. Can have isolated involvement of the intestine or adrenals ( acute Addisons Disease). Side effects: rash, peripheral neuropathy, hepatotoxicity Rifampicin: Destroys rapidly dividing bacilli quickly ( good for fulminant disease). In kids too young to monitor visual acuity, use streptomycin Regime: 2 months of isoniazid + rifampicin + pyrazinamide + 4 months of just isoniazid and rifampicin Compliance a major issue ( directly observed therapy. Treatment completion rates up to 90% are possible), also toxicity May need steroids (in addition to antibiotics) if adrenal suppression, miliary Tb or pleural effusion Pathology: Bacterium is ingested by macrophages, but resists lysis due to waxy coat. Immune response forms granuloma through unknown mechanisms Macroscopic appearance: lesions in any organ but mainly in lungs and lymph nodes. Initially small focus of consolidation < 3cm with central caseation, which cavitates if it communicates with a bronchiole. Large nodules have extensive cavitation and necrosis, and are lined with a ragged white material containing millions of mycobacteria Microscopic appearance: granulomas composed of epitheliod cells surrounded by fibroblasts and lymphocytes, containing giant cells and Langhans cells (nuclei around the edge). Oral commensal multiple scattered lesion in the lung Aspergillus: a saprophytic hyaline mould causing bronchopneumonia, possibly with vascular invasion and dissemination haemorrhage and necrosis. Most common in immunocompromised especially acute leukaemia Mucormycosis (Zygomycosis): 2 infectious types: Rhizopus and Mucor. Tendency to invade blood vessels and cause haemorrhagic pneumonia Cryptococcus neoformans: pleomorphic round to oval 4 10 micron yeast with thick mucinous capsule. Stains with Indian Ink stain Others: histoplasma capsulatum, coccidioides immitis and blastomycosis dermatitidis Respiratory 69 Viral pneumonias Usually acquired through inhalation Typically result in diffuse interstitial oedema and lypmhocytic cellular infiltrates in the septae. If severe microvascular injury pneumocyte necrosis and leakage of proteinaceous fluid into alveoli hyaline membrane formation Most due to influenza viruses (elderly), respiratory syncytial virus (kids) and rhinovirus (kids) Viruses of note: Cytomegalovirus: Herpes virus causing cytomegaly or enlargement of infected cells. Two patterns of spread: Necrotising Tracheobronchitis mechanism (spread by contiguity through necrotic mucosa) or Haematogenous dissemination (more random distribution through lung) Varicella Zoster: Lung involvement similar to H. Causes a bronchiolar lesion with neutrophil rich exudate, and bronchiolar metaplasia Pneumocystis Carinii Pneumonia: Extracellular protozoan parasite almost exclusively infects the lung. Microscopic appearance: interstitial infiltrate of lymphocytes and plasma cells, and foamy intra-alveolar exudate containing the organism.

Systemic dissemination of the ameba may involve other organs generic 750mg cephalexin with amex, such as the brain cephalexin 250mg mastercard, lung discount cephalexin 250 mg mastercard, pericardium and liver. Therapeutic agents used for the treatment of amebiasis act at selected sites: intraluminally, intramurally or systemically. However, because metronidazole is less effective against organisms within the bowel lumen, iodoquinol (650 mg t. Shaffer 218 - Cryptosporidia Cryptosporidia are a genus of protozoa classified within the subclass Coccidia. In immunocompetent persons, cryptosporidia infection presents as a transient, self-limiting diarrheal illness lasting from one to seven days. This electron micrograph of cryptosporidiosis in the small bowel shows the characteristics intracellular but extracytoplasmic location of the organisms. Drugs and Chemicals Since almost every drug can cause diarrhea, the first question to ask a patient is What medications, both prescribed and over-the-counter, are you currently taking? Although many drugs can cause diarrhea, little is understood about the ways in which they do so. It may occur months after antibiotic exposure, and may occur without a past history of antibiotic use. The frequency of diarrhea or colitis does not appear to be related to dose or route of administration of the First Principles of Gastroenterology and Hepatology A. Symptoms can occur while the patient is on the antibiotic, or within six weeks following its discontinuation. The diarrhea can be devastating, with up to 30 bowel movements in a 24-hour period. The diarrhea may be associated with varying degrees of abdominal pain and low-grade fever. Depending on the severity of the diarrhea and the amount of fluid loss, hypotension, shock and even death have been reported. In many patients the problem is self-limiting and resolves spontaneously with discontinuation of the antibiotic. In recent years, a number of newly recognized and apparently more virulent strains of C. The presence of copious amounts of mucus and typical raised white pseudomembrane plaques which are not washed away are characteristic features seen on sigmoidoscopy. Colonoscopy is recommended, because the plaques may be seen in the right colon beyond the reach of the sigmoidscope, and the diagnosis would be otherwise missed. If it is certain that there is no other likely cause for the diarrhea, treatment can be undertaken while awaiting assay results, although it is usually possible to quickly obtain a sigmoidoscopy to demonstrate the pseudomembranes. If symptoms are resolving with discontinuance of the antibiotic, no further therapy may be indicated. Vancomycin is poorly absorbed and central nervous system and renal toxic effects are uncommon. The high cost of this medication limits its use, even though the eradication rate of the C. It must be stressed that the vancomycin must be given orally, and not systematically. If oral therapy cannot be used, as with severe ileus or recent surgery, parenteral metronidazole is used. Cholestyramine (Questran) binds the toxin and can provide symptomatic relief even though it will not eliminate the microorganism. In extreme cases of fulminant non- responsive disease, colectomy, may be necessary. Magnesium-Containing Antacids The osmotically-induced diarrhea produced by Mg2+ is usually mild. A change to a magnesium-free, aluminum-containing antacid is all that is required to control the diarrhea. The use of magnesium-containing antacids is a common cause of diarrhea in dyspeptic patients. Magnesium can be used to induce diarrhea by rare patient with the Mnchausen syndrome who seek medical attention for self-induced problems. Antiarrhythmic Drugs The antiarrhythmic drugs most commonly associated with diarrhea include quinidine, procainamide and disopyramide. Other Medications Colchicine, often administered for acute gout, produces diarrhea as a common side effect. The mechanism of the diarrhea is unknown, but may relate to an intestinal cytotoxic effect of colchicine.