TYPHOID FEVER

Other Terms:

ü  Enteric fever

ü  Typhus abdominalis

It is a general infection usually affects the Digestive system by the bacterium salmonella Typhi, causing a generalized weakness, ladderlike fever, red spots on chest and abdomen, sweating, chills, delirium and in serious cases inflammation of the spleen and bone.

Typhoid fever also characterized by ulceration of the Peyer’s Patches that leads to erosion of the intestinal wall resulting to internal hemorrhage as manifested by the enlargement of the spleen (Spleenomegaly).

Despite the fact that the disease commonly affects the gastrointestinal system, the following body systems might as well be affected:

1.      Muscular System

2.      Genito-urinary system

3.      Cardio-pulmonary system

Mode of Entry – Fecal-oral route through infected urine and feces.

Principal Vehicles

1.      Feces

2.      Foods

3.      Foamites

4.      Flies

5.      Fingers

Causative Agent

1.      Salmonella Typhi

2.      Typhoid Bacillus

3.      Salmonella Typhosa

Mode of Transmission –

            Typhoid Fever may be transmitted via Fecal-oral route through infected feces and urine of the patient.

ü  Eating of contaminated foods like meat, eggs, shellfish and other meat and poultry products.

ü  Ingestion of uncooked or undercooked foods.

ü  Hands of infected persons.

ü  Flies and other flying insects.

ü  Consumption of contaminated water, milk and other dairy products.

ü  Through convalescent carriers that continue to harbor organisms in their tissues for variable lengths of time

Source of infection: Contaminated food and water

Signs and Symptoms

1. Prodromal – stage wherein the patient may have a flulike symptom.

·         Fever, headache

·         Anorexia, lethargy

·         Constipation or diarrhea, vomiting

·         Abdominal pain due to ulceration of the Peyer’s patches

·         Feeling of unwellness

2. Fastigal

·         Ladder like curve body temperature

·         Rose spots – Maculopapular rashes appear on chest or abdomen of patient usually appear on 7 – 12 days.

·         Spleenomegaly

·         Typhoid state – A condition in which there is brain involvement resulting to “Typhoid Psychosis”.

1.      The patient could have altered level of consciousness.

2.      Coma state wherein the patient appears to stare without seeing and a vigil look.

3.      Locomotive disturbance carphologia through picking up of linens

4.      Sultus tendium observed through involuntary twitching of tendons part of wrist of the patient.

3. Defervescence

·         Fever gradually subsides – fever mild & symptoms subsides

Diagnostic exam

1. Hemoculture – confirmatory of typhoid (+) organism after 1 week
2. Widal’s test/ blood serum agglutination (+) end of 2^nd week
3. Fecalysis – Done by swabbing the rectal area.

ü   Advise the patient not to eat meat especially red meat 1-2 days prior to the test cause it may give a false positive internal bleeding result.

4.  Typhi Dot test- new method on diagnosing typhoid fever to detect IgH, IgG

Nursing Care

• Supportive care
• Proper positioning
• Use of enteric precautions
• TSB for high fever
• Increase fluid intake
• Administration of prescribed medications
• Monitor for possible complications

Prevention

• Handwashing
• Decontamination of water sources milk pasteurization,

Immunization – vaccine of C.T. cholera typhoid, oral vivotif.

Complications

           

1. Perforation of the intestine
2. Intestinal hemorrhage
3. Thrombophlebitis
4. Urinary infection
5. Meningitis

Ø  Note that typhoid fever may relapse.

Treatment

• Chloramphenicol – 14 days
•  Amoxicillin – (oral) in case the patient is resistant to Chloramphenicol

ü  Monitor CBC to detect Chloramphenicol toxicity SE of Chloramphenicol: Bone depression

·         If with resistance to both, use trimethoprim-sulfamethoxazole as an alternative drug.

Read More

SCHISTOSOMIASIS

Definition

            Schistosomiasis also called as Snail fever and or Bilharziasis. The disease was named after Theodor Bilharz, which is considered to be the first person to identify the parasite on 1851 in Egypt. The disease is common in tropical and subtropical country and it has relatively low mortality rate but a high morbidity cases.

Schistosomiasis is often related to the water resource development projects like irrigations or dams, where the snails (main host of the parasite) breed.

            The disease commonly affects farmer in which the nature of their job gives way in contacting directly with the parasite.

            The disease may also affect the following system:

1.      Urinary

2.      Central Nervous System

3.      Gastrointestinal system

Infectious Agents

1.      Schistosoma Japonicum  - a type that is endemic in the Philippines

2.      Schistosoma Mansoni      - it is found in Africa and the only specie found in Latin America. Oncomelania snail is the main host for this type.

3.      Schistosoma Haematobium –Specie that is most common in Africa and in Middle East. This type is contracted through a snail called Bulinus snail.

4.      Schistosoma Intercalatum

5.      Schistosoma Mekongi – This type of specie is found only in Laos and Cambodia.

The Infection Process and its Pathophysiology

ü  Schistosomiasis is contracted through direct contact of an open skin with water contaminated by a parasite.

ü  Upon contact with human, it burrows on skin, and matures into larval stage called (Schistosomula), then migrates into lung and liver where it matures to Adult worm.

ü  The adult worm then travels to different organ like bladder, rectum, intestines, portal venous system and spleen.

“The male and female parasites (s. Japonicum) lived in the blood vessels of the intestines and liver. The eggs of the parasite are laid in the terminal capillary vessels in the submucosa of the intestines and through ulceration reach the lumen of the intestines and pass out with the feces and upon contact with fresh water hatches into a larva (miracidium). The free-swimming larva seeks and penetrates soft part of the intermediate host – a tiny snail called Oncomelania quadrasi, multiples and within two months becomes the infective stage called the cercaria. This fork tailed larva emerges from the snail onto water and enters the skin of man and other warm blooded animals as cows, dogs, carabaos, cats, rats, horses and goats who come contact with infected water through the lymphatic and then the veins, it eventually goes to the heart, systemic circulation, and into the intrahepatic portal circulation where they mature, copulate and start laying eggs in about one month’s time.” (CHN 9^th edition pg.222)

Eggs       miracidia (hatched)       snail        sporocyst and cercaria (inside the snail)       human skin (open skin)       schistosomulae       human veins       lungs and  liver (maturation to become adult worm)       travels to differen organs of the body       Schistosomiasis

Incubation Period - 4-6 weeks

Sign and Symptoms

• Rash (Swimmers Itch) –Pathognomonic sign
• Hematuria
• Diarrhea                                             
• Bloody stools                                       
• Enlargement of abdomen
• Spleenomegaly
• Enlargement of the liver
• Enlargement of the lymph node
• Chills
• Painful urination
• Glomerulonephritis
• Pulmonary hypertension
• Ureteritis
• Cystitis
• Hematemesis
• Eosinophilia
• Abdominal pain
• Cough
• Fever
• Weakness
• Anemia
• Inflamed liver

Diagnostic Exam:

1.      Serology

Ø  Tool used for epidemiological cases.

Ø  It detects antibody that is specific to S. Mansoni, S. Japonicum, and S. Haematobium adult worm microsomal antigen.

a.       Mansoni Adult worm Microsomal Antigen    (MAMS)

b.      Haematobium Adult worm Microsomal Antigen (HAMA)

c.       Japonicum Adult worm Microsomal Antigen (JAMA)

Ø  These three have been reported to be highly specific when used in the Falcon assay screening test (FAST), enzyme linked immune-assays.   (CD 5^th edition Untalan pg.477)

2.      Stool Exam is used to determine the type of eggs in the stool.

3.      Urine exam is used in identifying the severity of the infection.

Ø  Below 100 eggs per gram – light infection

Ø  100-400 eggs per gram is a moderate infection

Ø  Above 400 eggs per gram is a severe infection

4.      Egg Viability Test is done to examine the effectiveness of the treatment

5.      Detecting circulating antigen to assess an active infection.

6.      Intradermal test

7.      Immunodiagnostic test

Assessment

ü  Inspect the frequency of evacuation of stools.

ü  Auscultate hyperactivity of the bowel sounds

ü  Palpate if there is enlargement of the spleen and to assess tenderness in the abdominal area.

ü  Intradermal test

ü  Direct fecal smears

ü  Kato Kats technique

ü  Concentration technique

ü  Circumoval precipitin test

Nursing Diagnosis

ü  Pain

ü  Potential infection

ü  Impaired skin integrity

ü  Altered nutrition

ü  Fluid volume deficit

ü  Knowledge deficit

ü  Self care deficit

ü  Activity intolerance

Method of Control

·         Educate people about the disease and how to prevent it.

·         Proper disposal of the excreta contaminated with parasite.

·         Improve water resources facilities.

·         Treat the snail breeding site.

·         Minimize if not prevented the exposure to contaminated water.

·         Provide water for drinking, boiling of water is recommended.

·         Treat the patient as soon as possible to prevent the progression of the disease.

·         Travelers should be informed if the place is endemic for Schistosomiasis.

·         There’s no need for the patient to be isolated.

·         Quarantine: None

·         Immunization of contacts: None

·         Concurrent disinfection: sanitary disposal of infected urine and stools.

Treatment

1.      Praziquantel (Biltricide) a drug given 30 mg/kg, orally, twice a day for the treatment of infection caused by the parasite Schistosoma. The main action of the drug is to detach the adult worm from the wall of the vein and die.

2.      Nitidazole is given once a day, orally, 25mg/kg/per day to a maximum of  1.5gm for ten days.

3.      Oxamniquine is the best treatment for the infection caused by S. Mansoni.

4.      N-diethyl-m-toluamide is a very potent topical drug for killing cercaria (cercaricidal). The action of this drug is to prevent the entry of the cercaria into the human skin as a result it prevents the person to acquire the disease.

5.      LIPODEET is best preventive measures to people who work on field. It is applied before working in the field because the drug can effectively last up to 60 minutes so that farmers can work safely.

6.      Trivalent Antimony

a.       Tartar emetic administered through vein only

b.      Stibophen (Fuadin) is given through intramuscular. This drug can effectively cure the disease if given in correct dosage and compliance to drug.

    

Prevention

• Avoid washing cloths and bathing in streams
• Proper and sanitary disposal of human feces
• Destruction of snail host –control the multiplication of snails by using snail killing chemicals.
• Improve irrigation and agriculture projects to reduce snail habitat

Read More

LEPTOSPIROSIS

Other Terms:

Ø  Weil’s Disease	Ø  Mud Fever
Ø  Canicola Fever	Ø  Food Fever
Ø  Swineherd’s Disease	Ø  Japanese Seven Days Fever
Ø  Icterohemorrhagica	Ø  Trench Fever
Ø  Spinochetal Jaundice

Definition

            Leptospirosis is an infectious seasonal disease caused by bacteria of the genus Leptospirae that affect human and variety of animals like pig, dog, and skunk rat. The disease may be transmitted to human whose work brings them into contact with these infected animals. Rat is considered the main host for the disease. Leptospirosis is most common on rainy season and affects male more than female ages below 15 years old.

It was first explained in 1886 by Adolf Weil in his report entitled “Acute Infectious Disease with Enlargement of Spleen, Jaundice and Nephritis”
Hepatic failure is usually the common cause of death in Leptospirosis. It last 1-3 weeks however may be extended and in addition relapse may occur.

Causative Agent –

Ø  Normally found:

o   Leptospira Interrogans (found in moist humid soil)

o   Leptospira pyrogenes

o   Leptospira Manilae

Ø  And other species like:

o    L. Icterohemorrhagica

o   L. Canicola, L. Batavia

o   L. Pomona, L. Javinica

Stages

1.      Leptospiremic Stage

Stage wherein the causative agent enters the blood circulation which may affect the Central Nervous System as manifested by sudden onset of high ever, headache, nausea and vomiting, calf pain, and conjunctivitis

2.      Toxic Stage or the immune stage

In this stage the patient may or may not have fever. Rashes will set in followed by an inflammation of the iris (iritis), meningial irritation, damage to the liver which causes jaundice and lastly Kidney Failure (Leptospiuria). It is important to know that the urine of a person having a Leptospirosis is an infectious substance.

Mode of Transmission

·         Direct inoculation into broken skin, mucus membrane. E.g. bathing in flooded water

·         Ingestion of urine/ fecally contaminated food & water

Source of Infection
Infection comes form contaminated food and water, and infected wild life and domestic animals especially rodents.

Ø  Rats (L. leterohemoragiae) are the source of Weil’s disease commonly observed among miners, sewer, and abattoir workers.

Ø  Dogs (L. Canicola) can also be the source of infection along with veterinarians, breeders, and owners of dogs.

Ø  Mice (L. grippotyphosa) may as well be a source of infection that attacks farmers and flax workers.

Ø  Rats (L. bataviae) are the source of infection that attacks rice field workers.

Incubation period – 7 – 13 days or 1-3 weeks

Signs and Symptoms

• Abrupt onset with chills, vomiting & headache followed by a high fever and severe pains in the extremities (Myalgia).
• Intense itching of the conjunctivae – orange eyes
• Myalgia/myosites particularly calf pain
• Abdominal pain
• In some cases, acute renal failure and meningitis – complications

Diagnostic Exam:

1. Blood culture
2. Urine culture
3. CSF Culture (for the CNS affection)
4. LAT – leptospira Agglutination Test

LAAT – Leptospira Antigen Antibody test

Nursing Care- supportive and symptomatic Prevention:

• Eradication or rodents
• Environmental sanitation
• Urine precaution

Treatment:

Pharmacologic Treatment

Ø  First line: Aqueous penicillin G (50,000 units/kg/day in 4-6 divided doses intravenously for 7-10 days Antiserum or convalescent serum

Ø  Antiserum or convalescent serum

Ø  Second line: Erythromycin, or Tetracycline (20-40 mg/kg/day in 4 doses); may not be given to children < 8 years old

Ø  Doxycycline (Vibramycin)

      Symptomatic & supportive care

Ø  IVF for the replacement of fluid and electrolytes loss.

Ø  Dialysis particularly peritoneal dialysis for kidney failure.

High Risk

            Leptospirosis is common among:

ü  Miners

ü  Farmers

ü  Veterinarian

ü  Sewer workers

ü  Swimmers

Synonym:
Weil’s Dse, Mud fever, Canicola fever, Flood fever,
Swineherd’s Dse, Japanese Seven Days fever
Definition & Background:

• a bacterial zoonotic disease caused by spirochaetes of the genus Leptospira that affects humans and a wide range of animals, including mammals, birds, amphibians, and reptiles

• first described by Adolf Weil in 1886 when he reported an “acute infectious disease with enlargement of spleen, jaundice and nephritis”

Causative Agent:

• Leptospira-genus bacteria was isolated in 1907 from post mortem renal tissue slice
• commonly found: Leptospira pyrogenes, Leptospira manilae, & other species like L. icterohemorrhagiae, L. canicola, L. batavia, L. Pomona, L. javinica
• in animals often is subclinical; an infected animal may appear healthy even as it sheds leptospires in its urine; humans are dead-end hosts for the leptospire

Predisposing Factors:

• age: < 15 years of age
• sex: male
• season: rainy months
• geographic: prevalent in slum areas

Source of Infection
Infection comes form contaminated food and water, and infected wild life and domestic animals especially rodents.

1. Rats ( L. leterohemoragiae) are the source of Weil’s disease frequently observed among miners, sewer, and abattoir workers.
2. Dogs (L. canicola) can also be the source of infection among veterinarians, breeders, and owners of dogs.
3. Mice (L. grippotyphosa) may alos be a source of infection that attacks farmers and flax workers.
4. Rats (L. bataviae) are the source of infection that attacks ricefield workers.

Modes of Transmission
Incubation Period:

• 6 – 15 days/ 2 – 8 weeks

Clinical Manifestations:
1st stage:    Septicemic/ Leptospiremic Phase (4 – 7 days)
-    onset of high remittent fever, chills, headache, anorexia, nausea & vomiting, abdominal pain, joint pains, muscle pains, myalgia, severe prostration, cough, respiratory distress, bloody sputum.
2nd stage:    Immune/ Toxic Phase (4 – 30 days)
-    if severe, death may occur between the 9th & 16th day
2 types:

• Anicteric (without jaundice) – return of fever of a lower degree with rash, conjunctival injection, headache, meningeal manifestations like disorientation, convulsions & signs of meningeal irritations (with CSF finding of aseptic meningitis)

• Icteric (with jaundice) – Weil syndrome; hepatic & renal manifestations: hemorrhage, hepatomegaly, hyperbilirubinemia, oliguria, anuria with progressive renal failure; shock, coma & congestive heart failure in severe cases

3rd stage:    Convalescence Phase
-    Relapses may occur during 4th or 5th week
Diagnosis:

• culture:    blood (1st week)

CSF (5th to 12th day)
Urine (after 1st wk til pd of convalescence)

• agglutination tests ( 2nd or 3rd week)

PATHOPHYSIOLOGY
Complications:

• pneumonia
• iridocyclitis, optic neuritis
• peripheral neuritis

Prognosis:

• cause of death: renal & hepatic failure
• dse usually last 1 – 3 weeks but may be more prolonged; relapse may occur

Treatment:

• specific measures: beneficial if done < 4 days of dse

• Aqueous penicillin G (50,000 units/kg/day in 4-6 divided doses intravenously for 7-10 days
• Tetracycline (20-40 mg/kg/day in 4 doses); may not be given to children < 8 years old

• general measures

• symptomatic & supportice care
• administration of fluid, electrolytes & blood as indicated
• peritoneal dialysis (for renal failure)

Read More

HEPATITIS

HEPATITIS

It is an extensive inflammation of the liver tissues caused by viruses, toxic substances, or immunological abnormalities leading to destruction of the liver cell. Hepatitis is the basis for the hepatic cell to degenerate and develop liver necrosis.

Hepatitis can cause proliferation of the Kupffer cells and inflammation of the periportal areas hence it obstruct the flow of bile.

	Hepatitis A	Hepatitis B	Non A, Non B, (Hepatitis C)
Synonyms	ö      Epidemic hepatitis ö      Catarrhal Jaundice ö      Infectious hepatitis	ö      Serum hepatitis ö      Transfusion hepatitis ö      virus, viral hepatitis	ö      Post transfusion
Prognosis	0 – 1% mortality	2 –10% mortality	No data
Carrier state	NO	YES	YES
Risk	ö      Crowding ö      Homosexuals ö      Food handlers ö      Poor sanitation ö      Unsafe water supply ö      e.g. Travelers	ö      multiple sex partners ö      Members of medical team, blood, drug addicts. ö      blood transfusion ö      Promiscuous partners	ö      Blood recipients – blood transfusion received.
Incubation period	2 – 6 wks	6 wks – 6 months	7 weeks – 8 months  or  5 – 6 wks
M.O.T.	ö      Fecal – oral ö      Oral – anal	ö      person to person ö      parenteral          ö      percutaneous ö      placental 3 P’s ö      blood, semen ö      cervical secretions	ö      percutaneous ö      blood transfusion
Source of infection	Feces
Causative Agent	HAV (Hepatitis A virus)	HBV Hepatitis B virus	NANBV or others- > hepatitis C virus
Prevention	ö      proper handwashing ö      sanitation ö      serum food handlers ö      enteric precaution ö      immunization CAN’T DONATE BLOOD.	ö      vaccine ö      sterile disposal needle ö      monogamous sexual partners	ö      Same with hepatitis B except vaccine

Signs and Symptoms

 

1. Pre-icteric stage

·         Flu-like symptoms

·         Slight RUQ pain

·         Anorexia

·         Nausea and vomiting

·         Fatigue

·         Constipation or diarrhea

·         Weight loss

·         Hepatomegaly

·         Spleenomegaly

·         Lymphadenopathy

2. Icteric stage

·         Light colored stools (alcoholic stool)

·         Jaundice – sclera

·         Tea colored urine (dark urination)

·         Pruritus

·         The continued enlargement of the liver is associated with tenderness.

3. Post-icteric

·         Easy fatigability but there is a sense of well-being.

·         The enlargement of liver is gradually decreasing.

·         All the symptoms are gradually subsiding.

Diagnostic Exam

1. All three types

a.)   SGPT (ALT) serum

b.)   SGOT (AST) enzyme      all inc in pre-icteric

c.)   Alkaline phosphate        LF test

d.)   Bilirubin

2. Ultrasound of liver

3. Liver agglutination test

4. Liver biopsy

5. HbsAg – Hepa B

   Anti – HAV – hepa A

   Anti – HCV – hepa B

Treatment

1. Essential phospholipids – Jelapor
2. Sylimarine – helps in liver regeneration

Chronic hepa B antiviral drug

1. Lamivudine (Zeffix) – necrotic hepa B

ö      Inhibit reproduction of  hepa B virus

ö      100 mg/tab OD P.O. x 1 yr

ö      Effective to Asian $5000

2. White people alpha interferon $5000

Nursing Care

1. Provide a quiet and calm room environment. Bed rest.
2. Include high CHON, CHO, and low fat in the diet. This is suggested to simple cases only
3. Increase protein in the diet for faster healing of the damage liver.
4. Increase carbohydrate to restore glycogen reserve needed in energy production.
5. Low fat diet especially when the patient has steatorrhea.
6. Consider oral care for the patient.
7. Provide psychological support
8. Note that it takes 3 – 6 months to1 year before the liver can regenerate.
9. Assess pruritus and apply comfort measures such as cool or warm compress.
10. Apply preventive precautions to prevent the spread of infection.
11. Proper handwashing.
12. Careful handlings of needle.
13. Maintain on prescribe diet.
14. Assess pain level and provide comfort measures.

Prevention

ö      All patients with hepatitis should never donate blood!

ö      Utilize contact precaution when meeting with a person known to have the infection.

Hepa A

ö      Proper hand washing

ö      Good personal hygiene

ö      Sanitary serving of food handlers

ö      Passive immunization  - ISG to exposed individual & prophylaxis for travelers to developed countries

Hepa B

ö      Screen blood donors Hb3Ag

ö      Correct use disposable needles and syringes

ö      Registration of all carriers

ö      Passive immunization ISG – hepatavax B vaccine given in 3 doses.

Read More