Uncategorised - Midwives Revision

Severe Acute Respiratory Syndrome (SARS)

Severe Acute Respiratory Syndrome (SARS) is a viral respiratory illness caused by the SARS coronavirus (SARS-CoV), first identified in 2002.

It’s characterized by a rapid onset of fever, cough, and shortness of breath, often progressing to pneumonia and acute respiratory distress syndrome (ARDS).

While the 2003 outbreak was effectively contained, the emergence of SARS-CoV-2 (the virus causing COVID-19) highlights the ongoing threat of novel coronaviruses.

SARS is considered a zoonotic disease, meaning it originated in animals and then spread to humans.

The exact animal origin remains uncertain, but evidence suggests it may have originated in bats, possibly with an intermediate animal host facilitating transmission to humans.

Forms and Routes of Transmission:

SARS primarily transmits through close contact with an infected individual. There are no known distinct “forms” of SARS like there are for anthrax (cutaneous, inhalation, etc.). The routes of transmission include:

Droplet Transmission: The primary route. Large respiratory droplets expelled during coughing, sneezing, or talking can infect individuals within close proximity (generally within 6 feet).
Contact Transmission: Touching contaminated surfaces (e.g., doorknobs, handrails) and then touching one’s face (eyes, nose, mouth) can lead to infection.
Fecal-Oral Transmission: Although less common, SARS-CoV RNA has been detected in stool samples, suggesting potential fecal-oral transmission, especially in healthcare settings.

Incubation Period:

The incubation period for SARS is usually 2-10 days, with a median of about 5 days. This means that symptoms may not appear until several days after exposure.

Causes/Etiology:

The causative agent is the SARS coronavirus (SARS-CoV), a positive-sense single-stranded RNA virus belonging to the Coronaviridae family.

Clinical Features

SARS presents with a range of symptoms, often starting with a relatively mild prodrome:

High Fever: Typically above 38°C (100.4°F).
Dry Cough: Often a prominent symptom.
Shortness of Breath: Progressing to dyspnea (difficulty breathing).
Myalgia (Muscle Aches): Widespread muscle pain.
Headache: Often reported.
Chills: Feeling cold and shivering.
Fatigue: Significant exhaustion and weakness.
Malaise: A general feeling of illness and discomfort.
Diarrhea: Can occur in some patients.
Sore Throat: May be present.
Pneumonia: Often develops, leading to respiratory distress.
Acute Respiratory Distress Syndrome (ARDS): A life-threatening complication involving severe lung inflammation.

Definitive Diagnosis and Investigations:

Diagnosis is confirmed through laboratory testing:

Reverse Transcription-Polymerase Chain Reaction (RT-PCR): Detects the SARS-CoV RNA in respiratory samples (e.g., nasal swabs, sputum). This is the gold standard for diagnosis.
Serological Tests: Detect antibodies against SARS-CoV in blood samples. These tests are helpful for retrospective diagnosis but may not be positive early in the course of infection.
Chest X-ray or CT Scan: May show characteristic findings of pneumonia. These imaging techniques help assess lung involvement but are not specific for SARS.

Management:

Aims of Management:

Supportive care to manage symptoms and complications.
Prevention of secondary infections.
Prevention of the spread of the virus.

Emergency Management:

Patients with severe respiratory distress (e.g., hypoxia, ARDS) require immediate emergency care including oxygen therapy, mechanical ventilation, and intensive care unit (ICU) admission.

First Aid/Initial Management:

Isolate the suspected patient to prevent further spread.
Provide supportive care: fluids, rest, fever control (acetaminophen).
Seek immediate medical attention.

Medical Management:

Antiviral Medications: No specific antiviral treatment proved definitively effective against SARS-CoV during the 2003 outbreak. Research is ongoing. However, supportive care is paramount.
Oxygen Therapy: For patients with hypoxia.
Mechanical Ventilation: For patients with severe respiratory failure and ARDS.
Corticosteroids: May be used in some cases to reduce inflammation, but their benefit is still debated.

Nursing Care:

Strict Infection Control: Use appropriate personal protective equipment (PPE) – gowns, gloves, masks, eye protection – to prevent transmission.
Respiratory Support: Monitor oxygen saturation, provide oxygen therapy, and assist with mechanical ventilation.
Fluid Balance: Monitor fluid intake and output, and administer intravenous fluids as needed.
Monitoring Vital Signs: Closely monitor temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation.
Psychological Support: Provide emotional support to the patient and their family.
Isolation and Ventilation: Admit patients to a well-isolated and ventilated area to prevent further spread.
Protective Gear: Wear appropriate personal protective equipment (PPE) like gowns, gloves, masks, and eye protection when caring for SARS patients.
History and Physical Examination: Take a thorough history and perform a general physical examination.
Vital Signs: Monitor temperature, pulse, respiration, and blood pressure regularly and record the findings.
Temperature Management: For high fever, tepid sponging may be used to reduce body temperature.
Oxygen Therapy: Provide supplemental oxygen for patients with hypoxemia (low oxygen levels in the blood).
Medication Administration: Administer prescribed medications following proper protocols.
Hygiene: Practice strict hand hygiene – washing hands before and after caring for the patient.
Limit Staff Exposure: Minimize the number of healthcare workers caring for the patient to reduce transmission risk.
Reporting: Report suspected cases to the appropriate authorities for effective case management.

Management Up to Discharge:

Patients must meet specific criteria for discharge, including resolution of fever, improvement in respiratory symptoms, and two negative RT-PCR tests.

Advice on Discharge:

Continue to monitor for any recurrence of symptoms.
Contact a healthcare provider immediately if symptoms worsen.
Follow up appointments as scheduled.

Prevention:

Infection Control: Strict adherence to infection control measures in healthcare settings and other high-risk environments.
Hygiene: Frequent handwashing with soap and water or alcohol-based hand sanitizer.
Respiratory Hygiene: Covering coughs and sneezes with a tissue or elbow.
Quarantine: Isolation of infected individuals to prevent transmission.
Contact Tracing: Identifying and monitoring individuals who have been in contact with infected persons.
Early Detection and Case Management: Prompt identification and treatment of infected individuals.

Complications:

Pneumonia: A common complication that can be life-threatening.
Acute Respiratory Distress Syndrome (ARDS): A severe lung condition leading to respiratory failure.
Sepsis: A systemic inflammatory response to infection.
Multiple Organ Failure: Can occur in severe cases.

Severe Acute Respiratory Syndrome (SARS) Read More »

Hepatitis B:

Hepatitis B is a common STI caused by the hepatitis B virus found in the large DNA. It is associated with three antigens of their antibodies, affecting the liver and can have a sudden onset.

Modes of transmission:

Blood and blood products.
Direct contact with saliva, tears, and sweats from an infected person.
Transplacental transmission during pregnancy and at birth.
Through vaginal fluids and semen during live sex.
Vertical transmission via breast milk (mother to child).

Risk factors:

Unborn children with an infected mother.
Babies of infected mothers who are breastfeeding.
Health workers due to exposure to fluids from infected persons.
Drug abusers who share needles, especially from injection.

Signs and symptoms:

Early signs and symptoms:

Skin eruptions.
Urticaria.
Arthralgia.
Lassitude (general weakness).
Anorexia.
Nausea and vomiting.
Headache, fever, and mild abdominal pain.

Later signs and symptoms:

Clay-colored stool.
Dark urine.
Increased abdominal pain.
Severe jaundice.

Screening and diagnosis:

Regular screening for all persons at high risk of contracting hepatitis B.
Hepatitis B antigen screening test to detect active infection.
Additional laboratory studies may include AnG HBC, S.G.O.T, alkaline phosphatase, and liver pares.

Management:

No specific management has been developed for Hepatitis B.
Recovery is usually spontaneous in 3-16 weeks.
Bed rest, high protein diet, low-fat diet, and increased intake of fluids are advised.
Persons are advised to avoid drugs, alcohol, and other medications metabolized in the liver.
Women with definite exposure to hepatitis B should be given hepatitis B immunoglobulin (HBIG) and begin the hepatitis B vaccine series within 14 days of the most recent contact to prevent infection.
High levels of personal hygiene are encouraged.

Treating Chronic Hepatitis B

For chronic cases, a number of prescriptions will be given to help alleviate your or your loved one’s condition. Be sure to discuss the potential side effects of treatment with the doctor beforehand. Among the medications you may be given include:

Antiviral medications: WHO recommends the use of oral medications, specifically tenofovir or entecavir, to combat HBV infection and reduce the chance of liver damage or other complications.
Interferon: Interferon alfa-2b is a synthetic version of a protein that the body naturally produces. Injections of interferon alfa-2b are given to suppress the growth of the HBV virus in the body. It can also help to reduce the intensity of liver damage.
Liver transplant: If liver damage has advanced significantly, you or your loved one may need to undergo a liver transplant. This surgical procedure removes the damaged liver and replaces it with a healthy one from either a living or deceased donor. As the liver can regenerate slowly, it is possible to use a part of a healthy liver for the transplant. An unfortunate side effect of a transplant is that the receiver will need to take anti-rejection drugs for as long as they live.

Prevention:

Hepatitis B vaccination is the most effective active means of preventing hepatitis B virus infection.
Recommended for all non-immunized persons with multiple sexual partners, intravenous drug users, health center workers, persons seeking STI treatment, sex workers, and women whose partners are IV drug users.
The vaccine is given in a series of three doses over a period of six months, with the first two doses given at least one month apart, and the first and third doses at least four months apart.
Administered in the deltoid muscles of adults.

Patient education:

Explanation of hepatitis B, including transmission, stages of infection, and series of infections.
Emphasis on the need for immune-prophylaxis for household members.
Advice for infected persons, especially women, to maintain a high level of personal hygiene (handwashing, proper disposal of pads, and avoiding sharing sharps).
If partners are not vaccinated, they should use condoms correctly and consistently.
Teaching all uninfected persons to avoid kissing, sharing dishes, or saliva, and to wear protection.
Education on the immediate cleaning of any spillages of blood or body fluids with soap and water.

Hepatitis B Read More »

Scabies:

Scabies is a highly contagious skin infestation caused by the mite Sarcoptes scabiei.

The female mite burrows into the stratum corneum (the outermost layer of the skin) to lay eggs, causing intense itching and a characteristic rash. It’s a significant public health problem, particularly affecting populations living in close proximity or with compromised hygiene.

Etiology

The causative agent is the Sarcoptes scabiei mite. The female mite burrows into the epidermis, depositing eggs and feces along its pathway. The mite’s saliva and fecal matter trigger an inflammatory response in the host, leading to the characteristic symptoms.

Forms and Routes of Transmission:

Scabies is transmitted primarily through direct, prolonged skin-to-skin contact. This is most common during sexual activity, close physical contact (e.g., hugging, cuddling, wrestling), or sharing bedding, clothing, or towels with an infested person. Transmission can also occur indirectly via contaminated fomites (inanimate objects), although this is less frequent than direct contact. The mites cannot survive for extended periods away from a human host.

Incubation Period:

The incubation period (the time between infestation and the appearance of symptoms) varies, but it typically ranges from 4 to 6 weeks for a primary infestation. In individuals previously exposed to scabies, symptoms may appear more rapidly (within 1-4 days) due to a hypersensitivity reaction.

Types of Scabies:

There are two main types of scabies:

Crusted scabies (Norwegian scabies): This is a severe form characterized by thick, crusted lesions containing a large number of mites. It’s highly contagious and commonly seen in immunocompromised individuals.
Typical scabies: This is the most common form, characterized by intense itching and a papular rash.

Clinical Features

Intense nocturnal pruritus (itching): The itching is often worse at night.
Papular rash: Small, raised, itchy bumps (papules) that may be clustered or widespread.
Linear burrows: Thin, slightly raised lines in the skin representing the mite’s burrow. These are often found on the hands, wrists, and interdigital webs.
Excoriations: Scratches and abrasions resulting from intense itching.
Nodules: Small, firm lumps that may be present.
Secondary bacterial infection: Infection can occur due to scratching and breaking the skin’s integrity.
Distribution: Classic scabies tends to favor areas of the body with thin skin, such as the wrists, hands, interdigital spaces, elbows, and axillae. It can also affect the groin, buttocks, and genitalia. Crusted scabies can have a more widespread distribution.
Intense itch: this is present in typical scabies

Definitive Diagnosis and Investigations:

The diagnosis of scabies is primarily clinical, based on the characteristic rash, intense itching, and burrow identification. However, microscopic examination of skin scrapings can confirm the presence of the mite, its eggs, or fecal matter under a microscope (this is known as a skin scraping).

Management:

Aims: The primary aims of scabies management are to eradicate the mites, relieve symptoms (itching), prevent complications, and prevent transmission.

Medical Management:

Scabicides: Topical scabicides are the mainstay of treatment. Common options include permethrin cream (5%), malathion lotion (0.5%), ivermectin (oral), and lindane (less commonly used due to potential neurotoxicity). Treatment typically involves applying the scabicide to the entire body from the neck down, leaving it on for the recommended duration (usually overnight), and then washing it off. A second application might be necessary after a week.

Nursing Care:

Education: Provide thorough patient and family education about scabies transmission, treatment, and prevention.
Hygiene: Teach meticulous hygiene practices, including frequent handwashing and cleaning of bedding, clothing, and towels.
Symptom management: Help patients manage itching with appropriate strategies, such as cool compresses, calamine lotion, and antihistamines.
Monitoring: Monitor for signs of secondary infection, such as increased redness, swelling, pain, or pus.
Medication Administration: Administer and monitor medication as prescribed.

Prevention:

Avoid close contact: Limit skin-to-skin contact with individuals known to have scabies.
Good hygiene: Practice frequent handwashing and avoid sharing personal items such as towels, bedding, and clothing.
Prompt treatment: Seek prompt medical attention if scabies is suspected.

Scabies Read More »

Anthrax

Anthrax is a serious infectious disease caused by the bacterium Bacillus anthracis.

It’s a zoonotic disease, meaning it can be transmitted from animals to humans. While rare in humans, anthrax remains a significant public health concern due to its potential for use as a bioweapon.

Etiology

Bacillus anthracis is a Gram-positive, rod-shaped bacterium that forms highly resistant spores.

These spores can survive in soil and on animal products for extended periods, even decades. When conditions become favorable (e.g., entry into a living host), the spores germinate into vegetative bacteria, which then produce toxins responsible for the disease’s pathogenesis. The toxins include edema toxin, lethal toxin, and protective antigen. These toxins disrupt cellular processes, leading to the characteristic symptoms of anthrax.

Forms of Transmission and Routes of Transmission:

Anthrax primarily occurs in three forms, each with its characteristic route of transmission: These are also the types of Anthrax

Cutaneous Anthrax: This is the most common form in humans. It occurs when spores enter the body through a break in the skin, often through contact with infected animals or contaminated animal products (e.g., hides, wool, hair). The spores germinate in the skin, leading to the development of a characteristic lesion.
Inhalation Anthrax: This is the most dangerous form. It occurs when spores are inhaled into the lungs. Inhalation anthrax typically starts with flu-like symptoms, but rapidly progresses to severe respiratory distress and potentially fatal sepsis. This route is less common than cutaneous anthrax but carries the highest mortality rate.
Gastrointestinal Anthrax: This is the rarest form. It occurs when spores are ingested, usually through consumption of contaminated meat. Symptoms include nausea, vomiting, abdominal pain, and bloody diarrhea. This form also has a high mortality rate if untreated.

Incubation Period:

The incubation period varies depending on the form of anthrax and the route of infection:

Cutaneous Anthrax: 1-7 days (typically 2-5 days)
Inhalation Anthrax: 1-60 days (typically 1-7 days)
Gastrointestinal Anthrax: 1-7 days (typically 1-5 days)

Clinical Features

The clinical presentation varies widely depending on the type of anthrax:

Cutaneous Anthrax: Begins as a painless papule (pimple-like lesion) that develops into a vesicle (blister) and then an ulcer with a characteristic black eschar (scab). Other features may include lymphadenopathy (swollen lymph nodes), edema, and fever.
Inhalation Anthrax: Initial symptoms are flu-like (fever, cough, fatigue, muscle aches). This progresses to more severe symptoms, including shortness of breath, chest pain, respiratory distress, shock, and disseminated intravascular coagulation (DIC).
Gastrointestinal Anthrax: Severe abdominal pain, nausea, vomiting, bloody diarrhea, and potentially fatal sepsis.

Definitive Diagnosis and Investigations:

Diagnosis relies on a combination of clinical presentation, epidemiological information, and laboratory tests:

Clinical Examination: Careful assessment of the patient’s symptoms and medical history is crucial.
Microscopic Examination: Gram staining of clinical specimens (blood, wound fluid, etc.) may reveal the characteristic Gram-positive bacilli.
Culture: Isolation and identification of B. anthracis from specimens is definitive. High biosafety level is required.
Serological Tests: Detection of antibodies against B. anthracis toxins can be helpful but is not always definitive.
PCR: Polymerase chain reaction can detect B. anthracis DNA in clinical samples.

Management:

Aims of Management:

To eliminate the infection.
To neutralize the toxins produced by B. anthracis.
To provide supportive care to manage complications.

Medical Management:

The cornerstone of anthrax treatment is antibiotic therapy:

First-line: Ciprofloxacin (or other fluoroquinolones) or doxycycline.
Alternative: If the patient is allergic to fluoroquinolones, other antibiotics such as penicillin, clindamycin, or vancomycin may be used.
Duration: Antibiotics are typically administered for 60 days.

Cutaneous

95% of anthrax infections occur through skin cut or abrasion
Starts as raised itchy bump that resemble an insect bite
Within 1-2 days, it develops into a vesicle and then a painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying) area in the centre (eschar)
Lymph glands in adjacent area may swell
About 20% of untreated cutaneous anthrax results in death
First line is ciprofloxacin 500 mg every 12 hours
Alternatives: doxycycline 100 mg every 12 hours
Or amoxicillin 1 g every 8 hours

Inhalation

Initial symptoms resemble a cold
After several days, symptoms may progress to severe breathing problems and shock.
Inhalation anthrax is usually fatal.
In addition to antibiotics, patients with inhalation anthrax may require supportive care including oxygen therapy, mechanical ventilation, fluid resuscitation, and treatment for shock and DIC. Raxibacumab (a monoclonal antibody targeting protective antigen) may be given in severe cases of inhalation anthrax.

Gastrointestinal

Acute inflammation of the intestinal tract
Initial signs of nausea, loss of appetite, vomiting and fever
Then abdominal pain, vomiting blood, and severe diarrhoea
Intestinal anthrax results in death in 25% to 60% of the cases

Nursing Care:

Nursing care focuses on:

Monitoring vital signs: Closely monitor the patient’s respiratory status, blood pressure, heart rate, and temperature.
Respiratory support: Provide oxygen therapy and assist with mechanical ventilation if necessary.
Fluid and electrolyte balance: Maintain adequate hydration and monitor electrolyte levels.
Wound care: For cutaneous anthrax, provide appropriate wound care to promote healing.
Infection control: Strict adherence to infection control protocols to prevent transmission.
Psychological support: Provide emotional support to the patient and their family.

Management up to Discharge:

Continue antibiotic therapy as prescribed. Monitor for any signs of relapse or complications. Provide patient education on medication, wound care (if applicable), and follow-up appointments.

Advice on Discharge:

Complete the entire course of antibiotics.
Monitor for any recurrence of symptoms.
Report any new symptoms to healthcare provider.
Follow-up appointments as scheduled.

Prevention:

Animal-focused Prevention:

Safe Carcass Disposal: Proper burial of animal carcasses, hides, and skins is crucial. Burning is ineffective as it can aerosolize spores, increasing the risk of spread.
Avoidance of Handling: Do not skin or handle dead animals suspected of anthrax infection, as this allows spore formation, which can persist in the soil for decades. Meat from such animals should never be consumed.
Movement Restriction: Restrict the movement of animals and animal by-products (e.g., hides, wool) from infected to unaffected areas to prevent disease spread.
Mass Animal Vaccination: Implement widespread vaccination programs for livestock in areas with a history of anthrax outbreaks.

Human-focused Prevention:

Vaccination: Human anthrax vaccination is recommended for individuals at high risk of exposure, including:

Laboratory personnel working directly with Bacillus anthracis.
Individuals handling potentially contaminated animal products (e.g., hides, wool).
People residing in or visiting high-incidence areas.

Health Education: Public health campaigns should educate communities about anthrax transmission, prevention, and early recognition of symptoms. This includes safe handling practices for animal products and seeking immediate medical attention if exposure is suspected.

Complications:

Sepsis: A life-threatening complication that can occur in any form of anthrax.
Respiratory failure: A common complication in inhalation anthrax.
Meningitis: Inflammation of the meninges (protective membranes surrounding the brain and spinal cord).
Shock: A life-threatening drop in blood pressure.
DIC: Disseminated Intravascular Coagulation.
Death: The mortality rate is high for untreated inhalation and gastrointestinal anthrax.

Anthrax Read More »

RABIES

Rabies, also known as hydrophobia, is a fatal viral infection of the central nervous system (CNS) characterized by inflammation and acute encephalitis. It’s caused by contact with the saliva of an infected animal.

Causes:

Rabies is caused by the rabies virus, a single-stranded RNA virus with a bullet-shaped morphology (130-300 nm). It belongs to the Lyssavirus genus of the Rhabdoviridae family and possesses an external envelope with short projections.

Source/Reservoir:

The primary reservoirs are infected wild animals, particularly those in the Canidae (dogs, foxes, etc.) and Felidae (cats, leopards, lions, etc.) families. Domestic dogs also serve as significant reservoirs, especially in areas with limited rabies control programs. Humans are accidental hosts.

Transmission:

Transmission primarily occurs through the saliva of a rabid animal, typically via a bite. Other less common routes include:

Direct inoculation: A bite from a rabid animal directly introduces the virus into tissues.
Mucosal contact: Saliva contact with mucous membranes (eyes, nose, mouth), particularly on broken skin.
Aerosolization (rare): Inhalation of aerosolized saliva, primarily in bat caves or during close contact with infected animals.

Routes of Transmission:

The routes highlight the direct entry of the virus into the body:

Neural route: The virus travels along peripheral nerves to the central nervous system (CNS). This is the primary route and explains the neurotropic nature of rabies.
Hematogenous route (less common): The virus can enter the bloodstream and spread throughout the body, though neural spread is the predominant mechanism.

Incubation Period:

The incubation period varies (2 weeks to 1 year, averaging 2-342 days), depending on:

Bite site: Bites closer to the CNS (head, neck) have shorter incubation periods.
Tissue penetration: Deeper wounds allow for faster viral dissemination.
Viral load: Higher viral loads result in shorter incubation periods.
Site of the bite: Bites on the head and neck tend to have shorter incubation periods than bites on the extremities due to proximity to the brain.

Pathology:

Following inoculation, the virus initially replicates at the bite site for approximately 96 hours. It then spreads via peripheral nerves to the spinal cord and brain, primarily replicating in the gray matter. The virus subsequently disseminates through autonomic nerves to various organs (salivary glands, adrenal medulla, kidneys, lungs, liver, skeletal muscles, and skin). At this stage, the patient’s saliva and secretions become infectious.

Clinical Presentations:

Rabies progresses through distinct stages:

Prodromal Stage(pre-encephalitic): This initial phase is characterized by nonspecific symptoms:

Pain at the bite site
Headache
Fever
Malaise
Weakness
Anorexia
Vomiting
Sore throat
Non-productive cough

Encephalitic Phase

Furious (Excitory) Stage: Neurological symptoms become prominent:

Excessive motor activity, agitation, excitation
Confusion, anxiety, hallucinations
Muscle spasms
Aggression
Seizures
Hypersensitivity to light, noise, touch, temperature
Dilated pupils, lacrimation (excessive tearing), drooling, sweating
Hydrophobia (fear of water)
Aerophobia (fear of drafts)

Paralytic Stage: Progressive paralysis sets in:

Pharyngeal spasms (difficulty swallowing), dysphagia, odynophagia
Weakness spreading from the bite site, leading to constipation, urinary retention, respiratory failure
Coma
Death

Survival beyond a week after the onset of encephalitic symptoms is uncommon.

Management:

Medical management of developed rabies is largely supportive and focuses on alleviating symptoms and maintaining vital organ function. Unfortunately, there is no specific treatment that cures rabies once clinical symptoms are evident.

Aims:

Prevent the progression of rabies to the encephalitic stage.
Provide supportive care to maintain vital functions.
Prevent further transmission of rabies if the patient is rabid.

First Aid Management:

Immediate wound care is crucial to minimize viral load:

Thoroughly wash the wound with soap and water for at least 15 minutes. Scrub the wound gently.
Rinse thoroughly with copious amounts of clean water.
Leave the wound open (do not suture).

Hospital Management:

Admission: Isolate the patient in a barrier room to prevent transmission.
Treatment:

Antibiotics: Systemic antibiotics (e.g., penicillin, metronidazole, doxycycline) to prevent secondary wound infections. Dosage adjustments are necessary for children and pregnant individuals (metronidazole and doxycycline are contraindicated in pregnancy).
Passive Immunization: Administer rabies immunoglobulin (RIG) to neutralize the virus. Infiltrate RIG around and into the wound and give any remaining dose intramuscularly at a site distant from the rabies vaccine injection. If RIG cannot be given immediately, it may be administered within 7 days.
Active Immunization: Administer rabies vaccine to stimulate an immune response. Vaccination schedules vary depending on pre- or post-exposure status and risk factors.
Pre-exposure prophylaxis: For high-risk individuals (lab workers, wildlife personnel, etc.), a pre-exposure vaccination schedule (0, 7, 21 days) provides long-term protection. Boosters are needed periodically.
Post-exposure prophylaxis: For those already bitten, a post-exposure regimen (2:1:1 schedule – 2 doses on day 0, 1 dose on day 7, 1 dose on day 21) is followed. This should be started as soon as possible after exposure.

Sedation: Sedatives (e.g., chlorpromazine, diazepam) to manage agitation, spasms, and convulsions.
Airway Management: Provide artificial ventilation and oxygen if respiratory failure occurs. Maintain a patent airway through suctioning or other appropriate measures.
Protection: Healthcare personnel should wear appropriate personal protective equipment (PPE), including gloves, gowns, masks,

Supportive Care:

Observation: Close monitoring of vital signs (heart rate, respiratory rate, blood pressure, temperature, oxygen saturation) is essential to detect early signs of respiratory or cardiac failure. Frequent monitoring (every 2-4 hours) and accurate charting are crucial.
Rest and Sleep: Provide a quiet, dimly lit environment to minimize stimulation. Rabies patients are hypersensitive to light, noise, touch, and temperature changes.
Nutrition: Nutritional support is critical. If the patient is sedated, feeding may be done via nasogastric tube (NGT) or intravenously (IV). If the patient is alert and able to swallow, oral feeding can be attempted. Close monitoring for aspiration is necessary.
Fluid Balance: Monitor fluid intake and output closely. Patients may experience dehydration due to excessive sweating or difficulty swallowing. Intravenous fluids may be necessary.
Hygiene: Maintain meticulous hygiene practices. Regular skin care, oral hygiene, and bladder care are essential.

Specific Treatment Considerations:

Cardiac Arrhythmias: Monitor for cardiac arrhythmias and treat as needed with appropriate medications (e.g., antiarrhythmics).
Respiratory Failure: If respiratory failure occurs, provide mechanical ventilation until spontaneous breathing resumes. The use of an ambu bag for artificial ventilation may be necessary if there’s paralysis of the respiratory muscles.
Seizures: Manage seizures with anticonvulsant medications (e.g., diazepam, phenytoin).
Pneumonia: Monitor for pneumonia and treat with appropriate antibiotics as needed.
Brain Edema and Increased Intracranial Pressure: Monitor for signs of increased intracranial pressure (e.g., headache, vomiting, altered mental status) and consider measures to reduce intracranial pressure (e.g., corticosteroids, osmotic diuretics).
Hyper- or Hypopyrexia: Treat fever or hypothermia with appropriate methods (e.g., antipyretics, cooling blankets).
Diabetes Insipidus: Monitor for signs of diabetes insipidus (e.g., polyuria, polydipsia) and treat with desmopressin.
Paralysis: Provide supportive care to manage paralysis. Range-of-motion exercises and physical therapy may be necessary once the acute phase has passed.
Hematemesis: Manage hematemesis (vomiting blood) with appropriate measures (e.g., intravenous fluids, blood transfusion).

Rabies Post-Exposure Prophylaxis (PEP) Management

Rabies PEP aims to prevent rabies development after contact with potentially rabid animal saliva through bites, scratches, or licks on broken skin or mucous membranes (ICD-10 Codes: Z20.3, Z23). Treatment should follow guidelines such as those provided by the Veterinary Public Health Unit.

Dealing with the Animal:

The management of the animal is crucial in determining the appropriate PEP for the exposed individual.

A. Identifiable and Catchable Animal:

1. Domestic Animal: Determine rabies vaccination status. If unvaccinated or status unknown, quarantine the animal for 10 days (dogs, cats, or endangered species only). Humane euthanasia and head submission to the veterinary department for rabies testing is necessary if quarantine is not feasible.

If no rabies signs within 10 days, release the animal and discontinue PEP for the human if already started.
If rabies signs develop, euthanize, submit the head for testing, and proceed with full PEP for the human.

2. Wild Animal: Humane euthanasia and head submission to the veterinary department for rabies testing are necessary.

If rabies is confirmed, initiate full PEP for the human.
If the test is negative, rabies PEP is not necessary but local wound care is advised

B. Unidentifiable Animal: Assume the animal was rabid and the patient is at risk; initiate full PEP.

Dealing with the Patient:

The cornerstone of rabies PEP is a combination of local wound treatment, passive immunization with rabies immunoglobulin (RIG), and active immunization with rabies vaccine (RV). Regardless of the time elapsed since exposure (even months later), treatment should be initiated as if exposure were recent.

A. Local Wound Treatment: Prompt and thorough local treatment significantly reduces infection risk. This includes:

Thorough cleansing: Wash the wound with soap and water for at least 15 minutes, followed by copious rinsing with clean water.
Mucous membrane contact: Thoroughly rinse with water or normal saline.
Deep wounds: Administer tetanus toxoid (TT) to prevent tetanus.
Wound closure: DO NOT suture the wound.
Late presentation: Local cleansing is indicated even if the patient presents late for treatment.

B. Immunization: The need for RIG and RV depends on the exposure type and animal status: (RV and RIG are both very expensive and should only be used when there is an absolute indication)

Animal Condition at Time of Exposure	Nature of Exposure	10 Days Later	Recommended Action
Healthy	Saliva contact with skin, no lesion	Healthy	Do not vaccinate
Rabid	Saliva contact with skin, no lesion	N/A	Vaccinate
Suspect/Unknown	Saliva contact with skin, no lesion	Healthy	Do not vaccinate
Suspect/Unknown	Saliva contact with skin, no lesion	Rabid	Vaccinate
Suspect/Unknown	Saliva contact with skin, no lesion	Unknown	Vaccinate
Healthy	Saliva contact with skin lesions, minor bites	Healthy	Do not vaccinate
Rabid	Saliva contact with skin lesions, minor bites	N/A	Vaccinate
Suspect/Unknown	Saliva contact with skin lesions, minor bites	Healthy	Vaccinate; stop if animal healthy after 10 days
Suspect/Unknown	Saliva contact with skin lesions, minor bites	Rabid	Vaccinate
Suspect/Unknown	Saliva contact with skin lesions, minor bites	Unknown	Vaccinate
Rabid or Suspect	Saliva contact with mucous membranes, serious bites (face, head, fingers, or multiple bites)	N/A	Vaccinate and give RIG
Rabid or Suspect	Saliva contact with mucous membranes, serious bites (face, head, fingers, or multiple bites)	N/A	Vaccinate; stop if animal healthy after 10 days

Rabies Vaccine Schedules

Intramuscular Regimen

DAY	Vaccine Dose	No. of Doses	Comments
0	0.5 ml	2 (one in each deltoid)	Into the deltoid muscle. NEVER IN THE GLUTEAL MUSCLE (buttocks).
7	0.5 ml	1	Children with less muscle mass: Anterolateral aspect of the thigh.
21	0.5 ml	1	Note: Day 14 is skipped. The 2:1:1 regimen uses 4 doses in 3 weeks. It has fewer patient appointments and it is easy to comply with. If the patient is on anti-malarial prophylaxis with Chloroquine, it should be withheld and an alternative malaria prophylaxis should be started if needed.

2-site Intradermal (ID) Regimen

DAY	Vaccine Dose	No. of Doses	Comments
0	0.1 ml	2 (one in each deltoid)	It is cheaper since it uses less drug.
3	0.1 ml	2 (one in each deltoid)	It requires special staff training in ID technique using 1 ml syringes with shorter needles.
7	0.1 ml	2 (one in each deltoid)	Note: Days 14 and 21 are skipped.
28	0.1 ml	2 (one in each deltoid)

Rabies Immunoglobulin

DAY	Vaccine Dose	No. of Doses	Comments
0	20 IU/kg	Infiltrate in the area around and in the wound at the same depth as the wound	The Immunoglobulin should be administered as far as possible from the vaccine to avoid antibody-antigen reaction.

Prognosis:

The prognosis for rabies is poor once clinical symptoms appear. Untreated rabies is virtually always fatal. Even with treatment, mortality remains significant. Early diagnosis and treatment are crucial to improving the chances of survival.

Prevention:

Animal Vaccination: Routine vaccination of pets (dogs, cats, etc.) is vital in preventing rabies transmission.
Public Health Education: Public health campaigns should educate people about rabies prevention, including avoiding contact with stray or wild animals and seeking immediate medical attention after a bite or exposure.
Wildlife Management: Controlling wildlife populations and reducing human-wildlife interaction can help prevent rabies transmission.
Education: Public education campaigns to inform people about rabies prevention and the importance of seeking medical attention after animal bites.
Avoid contact: Avoid contact with stray or wild animals, especially those exhibiting unusual behavior.
Safe handling of animals: Proper handling techniques when dealing with animals, including wearing protective gear if necessary.

Rabies Read More »

CHICKEN POX (Varicella-Zoster Virus)

Chickenpox (varicella) is a highly contagious viral infection caused by the varicella-zoster virus (VZV), a member of the Herpesviridae family.

It’s characterized by a pruritic (itchy) rash that progresses through macules (flat spots), papules (raised bumps), vesicles (fluid-filled blisters), pustules (pus-filled blisters), and finally crusts.

The colloquial name “Don’t Touch Me” reflects its contagious nature. The name “chicken pox” likely originates from the French “chich,” meaning chickpea, referring to the appearance of the vesicles.

Aetiology: VZV is a double-stranded DNA virus with an envelope. It’s transmitted via airborne droplets and direct contact with vesicle fluid.

Risk Groups:

Children under 10 years old (most commonly affected)
Immunocompromised individuals (those with weakened immune systems due to HIV, cancer, organ transplantation, etc.)
Pregnant women (risk of congenital varicella syndrome)
Adults who have not had chickenpox or the vaccine (risk of more severe illness)

Mode of Transmission:

Airborne: Inhalation of respiratory droplets from an infected person.
Direct contact: Touching the fluid from ruptured vesicles.
Indirect contact: Touching contaminated surfaces (fomites) then touching the eyes, nose, or mouth.

Epidemiology/Occurrence:

Chickenpox is globally prevalent, with most cases occurring in children. Mortality is very low, but scarring can occur, and these scars are susceptible to secondary bacterial infections. The infection typically confers lifelong immunity. However, the virus can remain latent in the nervous system and reactivate later in life, causing shingles (herpes zoster). This is especially likely in immunocompromised individuals or those with conditions like diabetes mellitus or leukemia.

Incubation Period: 10-21 days, averaging 14-16 days.

Pathogenesis:

The virus enters the body through the upper respiratory tract mucosa. Primary viremia (virus in the bloodstream) occurs, followed by secondary viremia, which disseminates the virus throughout the body. The virus then infects skin cells, causing the characteristic rash. The subcutaneous tissues and skin are primarily affected, with vesicle formation, rupture, and subsequent scarring during healing.

Signs and Symptoms:

Prodromal phase (1-2 days): Mild fever, headache, malaise, anorexia, body aches.
Maculopapular rash: Progresses to vesicles, pustules, and crusts. The rash is widespread, typically beginning on the face, scalp, and trunk, then spreading to the extremities. Different stages of lesions (macules, papules, vesicles, pustules, crusts) are often present concurrently.
Intense itching: A hallmark symptom.
Fever: Usually mild to moderate.
Lymphadenopathy: Swollen lymph nodes. (This is not explicitly mentioned in the provided text but is common).

Differential Diagnosis:

Impetigo
Multiple insect bites

Diagnosis

Diagnosis is primarily clinical, based on the characteristic rash and symptoms. Laboratory confirmation (viral culture, PCR, serology) might be done in ambiguous cases or for severe infections.

Management:

Aims:

Prevent spread of infection.
Prevent secondary bacterial infections.
Relieve symptoms (itching, pain, fever).
Prevent complications.

Actual Management:

Isolation: Strict isolation precautions are crucial to prevent spread until all lesions are crusted over (typically 5-7 days after rash onset). This includes contact precautions, airborne precautions (depending on local guidelines), and proper disposal of contaminated materials.
Skin care: Frequent bathing with lukewarm water, gentle patting dry, and application of calamine lotion or oatmeal baths to relieve itching. Keeping fingernails short is vital.
Medications:

Antivirals: Acyclovir, valacyclovir, or famciclovir are recommended for high-risk individuals (adults, immunocompromised individuals, pregnant women) if started early in the course of the illness.
Analgesics/Antipyretics: Acetaminophen (paracetamol) for fever and pain relief. NSAIDs (like ibuprofen) can be considered, but aspirin should be avoided due to the risk of Reye’s syndrome.
Antihistamines: To help control itching.
Topical corticosteroids: Might be used in severe cases to reduce inflammation, but this should be at the discretion of a doctor.
Antibiotics: Only necessary if secondary bacterial infections develop.

Diet: Nutritious, well-balanced diet to support healing and recovery.
Supportive care: Ensuring adequate fluid intake, rest, and emotional support.

Symptomatic and Supportive Treatment:

Skin Care: Frequent bathing with lukewarm water, gentle patting dry, and application of calamine lotion every 12 hours or as needed. Cool, wet compresses can also provide relief from itching.
Antihistamines: To alleviate itching.

Chlorpheniramine: Adults: 4 mg every 12 hours. Children under 5 years: 1-2 mg every 12 hours for a maximum of 3 days. (Always follow age-appropriate dosing guidelines; this information should be considered a general guideline only).

Analgesics/Antipyretics: Acetaminophen (paracetamol) for fever and pain relief. The dose is generally 10 mg/kg every 6 hours, but precise dosing should always be determined by a healthcare professional based on the child’s weight and age.
Antivirals: For adults and children over 12 years old, oral aciclovir 800 mg every 6 hours for 7 days may be considered, especially for severe cases or high-risk individuals. This decision should be made by a doctor, and early initiation is crucial for effectiveness.
Isolation: Keep the child home/away from school until all lesions are crusted over to prevent the spread of infection.

Complications:

Bacterial skin infections (impetigo, cellulitis): Most common complication resulting from scratching.
Pneumonia: VZV can directly infect the lungs.
Encephalitis: Rare but serious inflammation of the brain.
Hepatitis: Inflammation of the liver.
Myocarditis: Inflammation of the heart muscle.
Nephritis: Kidney inflammation (often due to secondary bacterial infection).
Congenital varicella syndrome: If a pregnant woman contracts chickenpox, particularly during the first 20 weeks of pregnancy, the fetus can suffer severe abnormalities.
Hemorrhagic chickenpox: Rare and severe, with bleeding into the skin.

Chicken Pox Read More »

MUMPS

Mumps, also known as epidemic parotitis, is an acute, contagious viral infection primarily affecting the salivary glands, most notably the parotid glands.

Mumps is an acute, systemic, communicable viral infection. Its most characteristic feature is the painful swelling of one or both parotid glands.

Aetiology:

Mumps is caused by the mumps virus (genus Rubulavirus, family Paramyxoviridae). This enveloped, single-stranded RNA virus is transmitted through respiratory droplets produced during coughing, sneezing, or talking by an infected individual. The virus replicates in the respiratory tract before spreading to other sites in the body, including salivary glands.

Forms and Routes of Transmission:

The primary mode of transmission is through direct contact with respiratory droplets from an infected person. This can occur through:

Droplet spread: Inhalation of aerosolized droplets expelled from an infected person.
Direct contact: Touching surfaces contaminated with respiratory secretions, and then touching the mouth, nose, or eyes. (This is less common than droplet spread).

Incubation Period:

The incubation period for mumps is usually 16–18 days (range 12–25 days), representing the time between infection and the onset of symptoms.

Clinical Features :

Prodromal Stage: Mild fever, malaise, and anorexia may precede other symptoms.
Parotitis: Painful swelling of one or both parotid glands usually develops within 24 hours (though it can be delayed up to a week). Other salivary glands may also be affected. Swelling is accompanied by tenderness in the area between the earlobes and the mandibular angle. Patients often report earache, difficulty eating, and difficulty speaking. Glandular swelling increases for a few days and then gradually subsides, usually disappearing within a week.
Orchitis: Most common in post-pubertal males, presenting as painful and tender enlargement of one or both testes. This can lead to testicular atrophy and potentially sterility.
Oophoritis: In females, it causes lower abdominal pain (LAP).
Mumps Pancreatitis: Causes abdominal pain, which can be difficult to diagnose.
Mumps Encephalitis: Presents with high fever and marked changes in the level of consciousness.
Parotitis: Painful swelling of one or both parotid glands (located below and in front of the ears). This is the hallmark feature of mumps. The swelling typically begins unilaterally but often becomes bilateral.
Fever: Often high-grade (39-40°C or higher).
Headache: A common and often severe symptom.
Myalgia (muscle aches): Generalized muscle pain and stiffness.
Malaise (general feeling of illness): Fatigue, weakness, and lack of energy.
Anorexia (loss of appetite): Reduced or absent desire to eat.
Nausea and vomiting: Occasional symptoms, particularly in children.
Facial pain: This can be intense and localized to the affected salivary gland(s).
Swelling of other salivary glands: Although less common, submandibular and sublingual glands can also be involved.
Painful swallowing: Due to inflammation of the salivary glands and surrounding tissues.
Dry mouth (xerostomia): From reduced salivary gland function.

Definitive Diagnosis and Investigations:

Diagnosis is primarily clinical, based on the characteristic swelling of the parotid glands and other symptoms. However, laboratory confirmation may be helpful, especially in atypical cases or suspected outbreaks. Tests include:

Serological tests: Detecting specific IgM and IgG antibodies against the mumps virus. IgM indicates acute infection, while IgG suggests past infection or immunity.
Viral culture: Less commonly used due to its lower sensitivity and longer turnaround time than serology.
PCR (polymerase chain reaction): Can detect the viral RNA in saliva or other specimens. This is a highly sensitive and specific method for

Management:

Aims:

Relieve symptoms.
Prevent complications.
Prevent spread of infection.

Medical Management:

There’s no specific antiviral treatment for mumps. Management focuses on supportive care:

Complete bed rest: Encourage rest to facilitate recovery.
Fever control: Antipyretics (e.g., acetaminophen) as needed.
Communication and feeding: Devise strategies to ensure effective communication and comfortable feeding, especially for those with difficulty swallowing.
Steroids (if prescribed): Corticosteroids (e.g., hydrocortisone 100-200 mg initially, followed by prednisolone 10-15 mg twice daily for 5-7 days) may be used to reduce inflammation in severe cases, but this is at the doctor’s prescription..
Anti-inflammatory medications: (In severe cases, corticosteroids are sometimes considered, but mainly if there’s severe complications)
Supportive care: Focuses on adequate rest, hydration, and pain management.
Hydration: Ensure adequate fluid intake to prevent dehydration. Offer fluids the patient can tolerate.
Pain relief: Acetaminophen (paracetamol) can be used to manage fever and pain and cold compresses. Avoid NSAIDs (like ibuprofen or aspirin) as these may increase the risk of bleeding.
Soft diet: Provide soft foods that are easy to swallow and minimize discomfort.
Oral hygiene: Encourage frequent rinsing of the mouth with warm salt water to soothe inflammation.

Prevention:

Vaccination: A live attenuated mumps vaccine ( part of the MMR vaccine) is highly effective in preventing mumps. It’s usually given subcutaneously in two doses, starting at 9 months or first contact, and at 18 months of age in Uganda.
Hygiene: Avoid sharing eating and drinking utensils with infected individuals.

Complications

Meningitis (inflammation of the meninges): The virus can spread to the brain, causing meningitis, with symptoms such as severe headache, stiff neck, fever, and altered mental status.
Encephalitis (inflammation of the brain): A rare but serious complication characterized by inflammation of the brain tissue.Symptoms can include seizures, coma, and lasting neurological deficits.
Orchitis (inflammation of the testicles): Common in post-pubertal males, causing testicular pain, swelling, and tenderness. While it can cause temporary discomfort and potentially impact fertility in severe cases, it usually resolves without long-term effects.
Oophoritis (inflammation of the ovaries): Rare complication in females, causing similar symptoms to orchitis, though usually less severe.
Deafness: Rare complication of mumps.
Pancreatitis (inflammation of the pancreas): Can lead to severe abdominal pain, nausea, and vomiting.
Myocarditis (inflammation of the heart muscle): Rare but potentially life-threatening complication.
Nephritis (inflammation of the kidneys): Rare and typically mild.

Mumps (Parotitis) Read More »

YELLOW FEVER

Yellow fever is an acute viral hemorrhagic disease transmitted by infected mosquitoes.

Yellow fever is an acute, contagious, notifiable viral hemorrhagic fever endemic in central and South America and Africa.

The name derives from the jaundice (yellowing of the skin and eyes) that affects some patients.

Aetiology:

Yellow fever is caused by the yellow fever virus (YFV), an arbovirus belonging to the Flavivirus genus of the Flaviviridae family. The virus is approximately 25-65 nm in size and can survive at 40°C for a month and in a freeze-dried state for many years.

Forms and Routes of Transmission:

The primary mode of transmission is through the bite of infected Aedes mosquitoes (primarily Aedes aegypti in urban areas and Aedes africanus in sylvatic/jungle cycles). These mosquitoes become infected when they feed on the blood of infected primates (monkeys, apes) or humans.

There are two main transmission cycles:

Sylvatic (Jungle) Cycle: This cycle involves transmission between monkeys and mosquitoes in forested areas. Humans can become infected through contact with this sylvatic cycle if they venture into these areas.
Urban Cycle: This cycle occurs in urban areas where Aedes aegypti mosquitoes are abundant and feed on both infected humans and other humans. This cycle is responsible for larger outbreaks.

Incubation Period:

The incubation period for yellow fever is typically 3 to 6 days, but can range from 2 to 15 days. This is the time between the bite of an infected mosquito and the onset of symptoms.

Pathology:

After entering the body through a mosquito bite, the virus multiplies in lymph nodes and organs (liver, kidneys, heart, lungs, spleen, brain, digestive tract). The virus primarily affects specialized epithelial or myocardial cells. Cellular changes range from cloudy swelling to generalized fatty changes, coagulation, and necrosis.

Liver: Destruction of epithelial cells in liver lobes.
Kidneys: Necrosis of tubular epithelium.
GIT: Hemorrhage due to damage of blood vessels.

Death can result from liver or kidney failure (or both). Damage to the sino-atrial node, bundle of His, and myocardial cells can also contribute.

Clinical Features

Yellow fever presents in two phases:

Phase 1 (Acute Phase): This phase usually lasts 3-4 days and includes:

Sudden onset of fever (often high, 38.3°C to 40°C or higher)
Severe headache
Muscle aches (particularly back pain)
Shivering
Nausea and vomiting
Loss of appetite
Fatigue
Malaise

Phase 2 (Toxic Phase): This phase doesn’t always occur and only develops in severe cases. It’s characterized by:

Jaundice (yellowing of the skin and whites of the eyes)
Bleeding (from the nose, mouth, or gums – hemorrhage)
Abdominal pain
Dark urine
Low blood pressure (hypotension)
Impaired kidney function
Delirium
Shock
Seizures

A short period of recovery may occur, followed by a return of fever and rapid deterioration with liver and kidney failure.

Continuous abdominal pain with vomiting of altered blood (“coffee ground” or fresh blood) or black vomit (melena), and potentially diarrhoea.
Bleeding from eyes, nose, mouth, bladder, rectum, and other organs.
Heavy proteinuria (protein in the urine) with oliguria (decreased urine output) and granular casts, red blood cells (RBCs), and haemoglobin (Hb) in the urine.
Death occurs with increasing proteinuria, haemorrhage, rising pulse, hypotension, and oliguria.

Diagnosis and Investigations:

Diagnosis is based on:

Clinical presentation: Symptoms are highly suggestive.
Serological tests: Detection of IgM antibodies in the blood using ELISA (enzyme-linked immunosorbent assay) or other methods indicates recent infection. LFT’s and RFT’s
Virus isolation: This can be performed from blood samples during the acute phase of illness, but is less commonly used due to the availability of serological testing.
PCR (Polymerase Chain Reaction): Detection of viral RNA in blood samples. This is a more sensitive technique for confirming diagnosis.

Management:

Aims:

The primary aims of management are:

To provide supportive care to manage symptoms.
To prevent complications.
To reduce mortality.

Medical Management:

No specific antiviral treatment is available for yellow fever. Management focuses on supportive care, including:

Fluid and electrolyte balance: Careful monitoring and replacement are crucial.
Respiratory support: Oxygen therapy as needed.
Blood pressure management: Vasopressors if needed.
Seizure control: Anticonvulsants as needed.
Monitoring for organ dysfunction: Close monitoring of kidney function, liver function and other organ systems is critical.
Nutritional support: Enteral or parenteral nutrition as necessary.

Nursing Care:

Nursing care is essential and focuses on:

Monitoring vital signs: Frequent monitoring of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation.
Fluid balance management: Careful monitoring of fluid intake and output.
Neurological assessment: Regular neurological checks for signs of encephalopathy.
Skin assessment: Monitoring for jaundice and signs of bleeding.
Hygiene: Maintaining personal hygiene to prevent skin breakdown.
Pain management: Providing analgesics as needed.
Emotional support: Providing emotional support to the patient and their family.

Prevention:

Vaccination: The most effective preventive measure is vaccination. A single dose of the yellow fever vaccine provides lifelong protection.
Mosquito Control: Reducing mosquito breeding sites through eliminating standing water, using insecticides and using mosquito nets.
Personal Protective Measures: Wearing protective clothing (long sleeves, long pants) and using insect repellent containing DEET or other EPA-approved repellents when in endemic areas.

Complications:

Hepatitis: Liver inflammation can lead to liver failure.
Renal failure: Kidney damage can result in acute kidney injury or failure.
Encephalitis: Brain inflammation can lead to neurological deficits.
Myocarditis: Heart muscle inflammation.
Hemorrhagic manifestations: Severe bleeding can be life threatening.
Shock: This can be fatal if not promptly managed.
Death: Yellow fever can be fatal in a significant proportion of severe cases.

YELLOW FEVER Read More »

HAEMORRHAGIC FEVERS

Ebola and Marburg

Ebola and Marburg are severe zoonotic multisystem febrile diseases caused by RNA viruses. They are notifiable diseases.

Ebola Virus:

Morphology: The Ebola virus is filamentous, often resembling a “U” or “S” shape. It measures approximately 2 μm (micrometers) in length and 70-80 nm (nanometers) in diameter. It has an internal structure (nucleoprotein core) enclosed within an external envelope studded with numerous glycoprotein spikes.
Multiplication: The virus replicates by budding from its internal structures.

Types of Ebola Viruses:

Ebola Virus (EBOV): This is the species most commonly associated with severe outbreaks in humans.

EBO-Zaire (EBO-Z): This subtype has a high fatality rate, averaging around 89%.
EBO-Sudan (EBO-S): This subtype has a fatality rate of 41.65%, although this can vary depending on factors like treatment and location.

Vectors:

Mosquitoes and Termites: While there have been theories suggesting these insects could play a role in transmission, there is no definitive evidence to support their role as vectors for Ebola.
Bats: The most likely primary reservoir for Ebola viruses. They can harbor the virus without showing symptoms and transmit it to other animals or humans.
Dogs: While some sources mention dogs, there is no clear evidence to suggest they are a significant reservoir for Ebola.

Transmission:

Human-to-Human:

Direct contact with infected bodily fluids, such as blood, vomit, feces, urine, and saliva.
Contact with contaminated materials like clothing, bedding, needles, and medical equipment.
Sexual contact with a survivor who is still shedding the virus in semen (this can last for months after recovery).

Animal-to-Human: Contact with infected animals (particularly primates like chimpanzees and gorillas) or their bodily fluids.

Mosquitoes: As mentioned above, mosquitoes are not considered reliable vectors for Ebola virus transmission.

Pathology:

The Ebola virus affects multiple tissues throughout the body, not just a specific organ. It causes widespread damage, including:

Necrotic Lesions: The virus leads to cell death (necrosis) in various organs, affecting their functionality.
Immune System Suppression: Ebola weakens the immune system, making individuals vulnerable to other infections.

Incubation Period:

Primary Infection: The incubation period typically ranges from 2 to 21 days after exposure.
Secondary Infection: For transmission from human to human, the incubation period is the same, 2 to 21 days.

Causes:

Ebola Virus: The causative agent is the Ebola virus, a member of the Filoviridae family. There are five known species of Ebola virus:

Zaire ebolavirus (responsible for the most severe outbreaks)
Sudan ebolavirus
Reston ebolavirus (not known to cause disease in humans)
Taï Forest ebolavirus
Bundibugyo ebolavirus

Marburg: Marburg virus

Risk Factors:

Communities Around Game Parks: Proximity to wildlife increases the risk of exposure.
Endemic Areas: Regions with a history of EVD outbreaks.
Cultural Practices: Burial rituals involving close contact with the deceased can facilitate transmission.
Poor Infection Control: Inadequate sanitation and hygiene practices in healthcare settings can increase the spread.
History of Exposure: Contact with infected individuals within 2-21 days prior to symptom onset (e.g., sexual partners, breastfeeding mothers).
Contact with Infected Animals: Handling infected animals (like monkeys, bats, and infected game meat).

Clinical Features:

Early Signs (Non-Specific):

Sudden Fever: A rapid onset of high fever (often exceeding 101.5 °F / 38.6 °C).
Weakness: General feeling of weakness and exhaustion.
Headache: Intense headache.
Muscle Pain: Pain in muscles and joints.
Loss of Appetite: Decreased appetite or inability to eat.
Conjunctivitis: Inflammation of the conjunctiva (white part of the eye).

Late Signs:

Diarrhea: Profuse diarrhea, sometimes with blood.
Vomiting: Severe vomiting.
Mucosal and Gastrointestinal Bleeding: Bleeding from the nose, gums, eyes, and rectum.
Chest Pain: Pain in the chest area.
Respiratory Distress: Difficulty breathing.
Circulatory Shock: Low blood pressure and impaired blood flow.
CNS Dysfunction: Confusion, seizures, and coma.
Miscarriage in Pregnancy: EVD can cause miscarriage or stillbirth in pregnant women.
Elevated AST and ALT: Elevated levels of liver enzymes, indicating liver damage.
Kidney Injury: Damage to the kidneys, potentially leading to kidney failure.
Electrolyte Abnormalities: Imbalances in electrolytes (minerals like potassium and sodium) in the body.

Differential Diagnosis:

Malaria: A parasitic disease that also causes fever, headache, and muscle aches.
Meningitis: Inflammation of the membranes surrounding the brain and spinal cord.
Shigellosis: A bacterial infection causing diarrhea, abdominal cramps, and fever.
Typhoid Fever: A bacterial infection causing high fever, headache, and constipation.
Anthrax: A bacterial infection causing skin lesions, fever, and respiratory problems.
Sepsis: A serious bacterial infection causing fever, chills, and rapid heart rate.
Viral Hepatitis: Inflammation of the liver caused by viruses like hepatitis A, B, or C.
Dengue Fever: A viral infection transmitted by mosquitoes, causing fever, headache, and muscle pain.

Investigations:

Blood Sample for Specific Testing: Blood samples from suspected EVD cases should be collected by trained healthcare professionals wearing proper PPE.

Laboratory Testing: The blood sample needs to be sent to a reference laboratory for specific tests to identify the Ebola virus.
Real-Time PCR: This is the preferred method for detecting Ebola virus.
Antigen and Antibody Detection: ELISA (enzyme-linked immunosorbent assay) and other antibody tests can identify Ebola virus antigens and antibodies.

Postmortem: If an individual dies from EVD, postmortem examination is critical for confirmation and to prevent further spread.

Notification: Immediately notify the district surveillance focal person if you suspect a case of EVD.

Management

Management Aims:

Fluid Replacement: Maintain adequate hydration to compensate for fluid loss.
Prevention of Spread: Isolate the patient and implement strict infection control measures.
Conservation of Energy: Provide rest and supportive care to conserve energy.
Symptom Relief: Administer medications to manage symptoms like fever, pain, and vomiting.

Specific Management:

1. Admission: Admit the patient to an isolated room in a medical ward, providing complete bed rest.

Bed Preparation: Use a freshly prepared bed, with a comfortable position for the patient (supine or semi-recumbent depending on their condition).

2. Protection:

Handwashing: Strict handwashing before and after attending to the patient.
Isolation: Isolate the patient in a designated room, and implement barrier nursing techniques. Healthcare workers and patient attendants should wear gowns, gloves, goggles, and gumboots to prevent contact with bodily fluids.
Identification Tag: Place an “INFECTIOUS” tag on the door to alert others about the infectious nature of the room.

3. Fluid Replacement: Administer intravenous fluids (N/S, RL, and Dextrose 5%) according to the doctor’s prescription.

4. Hygiene:

Patient Hygiene: Maintain cleanliness of the patient’s skin, secretions, and stool. Disinfect with bleach solutions before disposal.
Bed Pans: Scrub bed pans thoroughly with strong detergent, rinse, and dry.
Patient’s Orifices: Wash and dry the patient’s orifices. Apply perineal pads if needed for profuse diarrhea.
Linens: Disinfect linens in a bleach solution for at least 6 hours. Label and transport them in “infected linen” bags to be sluiced, boiled, dried, and ironed.
Room Disinfection: Mop the room, scrub the floors and walls, disinfect lockers, and wash and boil patient utensils for at least 10 minutes.
Refuse Disposal: Place food and hospital refuse in polythene bags and incinerate.

5. Diet: Provide a fluid diet in the acute stage, primarily through IV fluids and oral fluids as much as possible.

6. Terminal Disinfection: Thoroughly disinfect the room and all contaminated materials after the patient is discharged.

7. Notification: Report the case to health authorities to inform the public health system about the outbreak.

Health Education:

Patient Attendants: Educate patient attendants about the infection, its mode of transmission, and prevention measures.
General Public: Inform the general public about the disease, its signs and symptoms, and preventative measures.
Patient Care: Ensure the patient feels supported and understood, preventing isolation and stigma.

Prevention:

Avoid Contact: Minimize contact with the patient’s blood and secretions.
Personal Protective Equipment: Wear proper PPE (gowns, gloves, masks, eye protection) when providing care.
Safe Burial Practices: Use safe burial practices to prevent transmission during funerals.
Vaccination: The Ebola vaccine is available and should be considered for high-risk individuals.
Isolation: Isolate infected individuals in designated Ebola treatment centers.
Contact Tracing: Identify and monitor individuals who have come into contact with infected persons.

Prevention Complications:

Shock: Monitor for signs of shock (low blood pressure, rapid heart rate, weakness, and cool, clammy skin).
Organ Failure: Monitor for signs of organ failure (e.g., jaundice for liver failure, decreased urine output for kidney failure).
Disseminated Intravascular Coagulation (DIC): Be aware of the signs of DIC (bleeding from multiple sites, bruising, and difficulty controlling bleeding).
Meningitis: Monitor for signs of meningitis (stiff neck, headache, fever).
Encephalitis: Monitor for signs of encephalitis (confusion, seizures).
Secondary Infections: Monitor for signs of secondary infections (fever, cough, difficulty breathing).
Psychological Trauma: Provide psychological support to patients and their families to address potential psychological trauma.

EBOLA: HAEMORRHAGIC FEVERS Read More »

Brucellosis (Undulant Fever, Malta Fever, Abortus Fever)

Brucellosis is a zoonotic bacterial infection of acute onset, commonly known as undulant fever, Malta fever, or abortus fever.

It’s primarily an occupational disease among people working with infected livestock or associated fresh animal products. This includes butchers, farmers, abattoir workers, and vendors of contaminated roasted meat (muchomo).

Incubation Period:

The incubation period for brucellosis is typically 2-4 weeks, but can range from 1 to 8 weeks.

Forms of Transmission:

Direct Contact: Contact with infected animals, particularly during handling, slaughtering, or birthing, can lead to transmission.
Ingestion: Consuming unpasteurized milk, cheese, or other dairy products from infected animals is a common route of transmission.
Inhalation: Inhaling contaminated aerosols, particularly in settings where animal products are processed or handled, can lead to infection.
Accidental Exposure: Laboratory workers or those handling animal products in agricultural settings may be at risk of accidental exposure.

Routes of Transmission:

Occupational Exposure: Farmers, veterinarians, slaughterhouse workers, and laboratory workers are at increased risk of exposure due to their close contact with infected animals.
Consumption of Contaminated Products: Consuming unpasteurized milk, cheese, or other dairy products from infected animals is a common route of transmission.
Accidental Exposure: Accidental exposure to contaminated materials or aerosols, particularly in laboratory settings, can lead to infection.

Causes/Aetiology:

Brucella Species: The most common species of Brucella that infect humans are:

Brucella abortus (cattle)
Brucella melitensis (goats and sheep)
Brucella suis (pigs)
Brucella canis (dogs)

Clinical Features:

Brucellosis is known for its diverse range of symptoms, which can appear anywhere from a few days to several weeks after infection. Common features include:

Fever: High-grade fever, often accompanied by chills and sweats.
Fatigue and Weakness: Profound fatigue, lethargy, and muscle aches.
Headache and Stiff Neck: Persistent headache, often accompanied by neck stiffness.
Arthritis and Muscle Pain: Pain and inflammation in joints, particularly in the spine and large joints.
Sweating: Excessive sweating, particularly at night.
Weight Loss: Unintentional weight loss due to poor appetite and decreased food intake.
Depression: Emotional disturbances, including depression, anxiety, and irritability.
Splenomegaly and Hepatomegaly: Enlargement of the spleen and liver.
Orchitis: Inflammation of the testicles in men.
Endocarditis: Infection of the heart valves.
Meningitis: Inflammation of the meninges (membranes surrounding the brain and spinal cord).

Differential Diagnosis:

Typhoid fever: Similar symptoms, including high fever, headache, and muscle aches.
Malaria: Fever episodes that coincide with mosquito bites.
Tuberculosis: Chronic cough, night sweats, and weight loss.
Trypanosomiasis (sleeping sickness): Fever, headache, and fatigue, often accompanied by neurological symptoms.
Other causes of prolonged fever: Other infections, autoimmune disorders, and certain cancers can also cause prolonged fever.

Definitive Diagnosis and Investigations:

Blood Culture: A positive blood culture for Brucella is considered the definitive diagnosis.
Serological Tests: Serological tests, such as the agglutination test and the enzyme-linked immunosorbent assay (ELISA), can detect antibodies against Brucella bacteria.
Other Tests: Additional tests, such as bone marrow culture, urine culture, or biopsy, may be necessary depending on the clinical presentation.
Blood: Complement fixation test or agglutination test (where possible).
Isolation of the infectious agent from blood, bone marrow, or other tissues by culture.

Management:

Treatment:

Adults and children > 8 years:

Doxycycline 100 mg every 12 hours for 6 weeks
Plus gentamicin 5-7 mg/kg IV daily for 2 weeks
Or ciprofloxacin 500 mg twice daily for 2 weeks

Children < 8 years:

Cotrimoxazole 24 mg/kg every 12 hours for 6 weeks
Plus gentamicin 5-7 mg/kg IV in single or divided doses for 2 weeks

Caution:

Treatment duration must be adhered to at all times.
Ciprofloxacin is contraindicated in children <12 years.
Doxycycline and gentamicin are contraindicated in pregnancy.

Prevention:

Public health education:

Drinking only pasteurized or boiled milk.
Careful handling of pigs, goats, dogs, and cattle, especially if a person has wounds or cuts.

Veterinary services: Provide veterinary services for domestic animals to prevent the spread of infection.
Safe handling practices: Use proper hygiene practices when handling animals and wear protective clothing.
Occupational safety: Implement safety protocols and use PPE in occupational settings where exposure to infected animals or their products is likely.
Food safety: Consume only pasteurized milk, cheese, and other dairy products. Avoid eating raw or undercooked meat from animals suspected of being infected with Brucella.
Travel precautions: Advise travelers to countries where brucellosis is endemic to be aware of the risks and take necessary precautions.

Complications:

Endocarditis: Infection of the heart valves, which can be life-threatening.
Meningitis: Inflammation of the meninges, which can lead to neurological complications.
Arthritis: Inflammation of joints, particularly in the spine and large joints.
Osteomyelitis: Infection of the bone, which can lead to bone damage and disability.
Hepatitis: Inflammation of the liver.
Orchitis: Inflammation of the testicles in men.
Chronic Fatigue Syndrome: Persistent fatigue and other symptoms, which can significantly impact quality of life.
Neurological complications: Neurological complications can occur in severe cases and may include encephalitis, seizures, and coma.

Brucellosis Read More »