AIDS

AIDS

The acquired immunodeficiency syndrome (or AIDS) was first recognised in USA, and the association of human immunodeficiency virus (HIV) as the cause of development of AIDS was established later on in 1984.

Initially, some cases of severe opportunistic infections e.g

Pneumocystis carinii pneumonia and unusual neoplasms, such as kaposi’s sarcoma, which can only be seen in severely immunocompromised patients i.e in defective

Cell-mediated immunity-were found in some previously healthy homosexual individuals

In the absence of any know cause of underlying immune defects this condition was then eventually recognised as the ‘acquird immunodeficiency syndrome’ or AIDS.

Aetiology:

AIDS is caused by infection with human retroviruses known as human immunodeficiency virus (or HIV or HIV-1).

Besides classic AIDS virus, a group of related viruses designated as HIV-2 -  found in some west African patients having same genetic organization as HIV-1, but significantly different glycoprotein contents, manifested AIDS-like illnesses in some patients, but most cases found asymptomatic.

Mode of transmission:

1. Sexual contact is the major mode of transmission of HIV. About 60% are homosexual bisexual.

2. Intravenous route- about 20% of patients are heterosexual men and women intravenous drug users, and is related to the sharing of needles.

About 7% are homosexual or bisexual men, who are also using intravenous drugs.

Transfusion of contaminated blood and blood products, if not screened or treated may be a significant way of AIDS transmission.

3. Infected mothers are efficiently (30-40%) transmit the virus to their infants parentally during the first and second trimester. Virus can also be transmitted from mother to infant via breast feeding.

Incubation period:

  Incubation period is about 2-4 weeks following infection.

Diagnosis:

1. ELISA test-diagnosis is confirmed by detection of antibodies to  HIV by ELISA test. Blood specimen should be handled carefully. It becomes positive with 5months of infection.

2.  Detection of virus-by circulating viral protein assays.

3.  complete blood count (CBC)-usually anemia; neutropenia and thrombocytopenia are found in advanced HIV infection.

4.  Absolute CD4 lymphocyte count and percentage- a person with a positive HIV serology and a CD4 lymphocyte count below 200 cells/     or a CD4 lymphocyte percentage below 14% is to be considered as a patient of AIDS.

 Antiretroviral treatment-

The antiretroviral agents that are in clinical use now a day, play their role by suppression of HIV replication. A considerable suppression of HIV replica-tion may cause partial immunologic reconstitution &improvement of immunosuppression. as a result, the patient get stabilization and improvement of clinical course of the disease.

Initiation of antiretroviral therapy depends on different clinical situations. Such as, an adult patient should be initiated therapy only when any of the following indications is present-

-symptomatic HIV disease

-CD4 counts <350 cells/ul

-very rapidly falling CD4 count

-high viral load (> log 4)3

There are several guidelines and treatment frameworks developed (e.g PACT framework, BHIVA guidelines) for retroviral therapy is to be given must be individualized depending on the clinical condition of the particular patient.

The antiretroviral drugs available now-a-day, are classified into three main categories-

1. Nucleoside and nucleotide reverse transcriptase inhibitors-

(a)  Zidovdine

(b)  Didanosine

(c)  Zalcitabine

(d)  Stavudine

(e)  Lamivudine

(f)  Abacavir

(g)  Adefovir

2. Nonncleoside reverse transeriptase inhibitors-

(a)  Nevirapine

(b)  Delavirdine

3. Protease inhibitors

(a)  Indinavir

(b)  Nelfinavir

(c)  Ritonavir

(d)  Saquinavir

WHOOPING COUGH

  

Whooping cough

 This is due to respiratory droplet infection caused by bordetella pertussis. The disease most commonly affects infants, fifty percent cases occurring before the age of two years . Incubation period is 7-17 days. Classically there are three stages.

Catarrhal stage:

This is chracterised by anorexia, malaise, lacrimation and cough more at night, followed by paroxysmal stage. The infectivity is greatest during this stage..

Paroxysmal stage:

This appears 10-14 days later characterized by bouts of cough ending in a whoop. Vomiting is common during paroxysmal attacks. Paroxysms may vary from 1-2 to 40-50 per day. The cojunctiva are deeply engorged. Epistaxis is common. Subconjunctival haemorrhage and periorbital oedema may develop. Infants may be cyanotic.

Physical signs of bronchitis may be found in the chest .

Stage of convalescence:

One to several weeks later cough becomes less frequent and sputum less tenacious.

Complications include bronchopneumonia, segmental or lobar collapse, bronchiectasis, subconjunctival or periorbital haemorrhage, prolapse of the rectum.

Bordetella pertussis may be isoloated by culture of nasal swabs or cough plates in 50% cases nasopharyngeal swabs yield higher result.

Treatment

1. Nursing is best carried out by mother.

2. During spasm:

           (a)  Lift the child immediately from the cot.

           (b) Hold the baby in head down position.

           (c) Put the back till the spasm is over.

3. Feed should be small and frequent preferably immediately after the spasm. This should mainly consist of milk. Sticky food should be avoided.

4. Drugs:

   (a) Tr. belladonna and syr. Codeine phos may be given in       
        appropriate doses for the control of spasm.

          

   (b) Erythromycin or ampicillin, 50mg/kg daily orally for 14

         days. Erythromycin is preferable.

         

    (c) Azithromycin 500 mg 1^st day then 250 mg/d for 5 days

    (d) Clarithromycin 250 mg/d for 5 days or

          

    (e) Dirythromycin 500 mg single dose.

          

    (f) For complications like bron chopneumonia,erythromycin

         ampicillin should be given or the drug should be decided
         apon bacterial sensitivity report.

         

    (g) For penicillin resistant staphylococcus use cloxacillin,
         50mg/kg in 6 hourly divided  doses.

5. Postural drain age and physiotherapy for atelectasis .

Hypertension

Hypertension is directly or indirectly responsible for 10-15 of all deaths. This is uncommon below 20 years.

Hypertension is said to be present when diastolic  pressure is consistently above 90 mm Hg in persons bellow 50 years and above 100 mm of Hg in this above 50 and above 105 mm of hg in this above 70.

Types of hypertension:

1. Benign hypertension: Hypertension without features of malignant       hypertension.

2. Malignant hypertension: A very high diastolic pressure usually more than 130 mm. of hg.

3. Paroxysmal hypertension: The blood pressure remains normal in between

paroxysmal rise.

4. Systolic hypertension: Diastolic pressure is normal and systolic pressure is raised.

Factors unfavourably influencing prognosis:  

(1) Male

(2) Early age of onset

(3) High diastolic and systolic pressure

(4) Positive family history

(5) Level of blood lipids

(6) Glucose intolerance and

(7) Smoking.

Precipitating factor

1. Obesity: This associated with increased intralasenlar  volum and high output.                                                                                                                                                                    

2. Smoking

3. Polycy thaemia

4. NSAIDs

Retinal changes in hypertension:

These are graded as follows.

1. Arterial narrowing with irregularity.

2. More marked narrowing and arteriovenous nicking.

3. Flame shaped (Superficial haemorrhage) or circuler haemorrege and cotton wool exudates.

4. This above and papilloedema.

The indications are:  

1. Hypertension under 30 yrs of age.

2. Accelerated hypertension.

3. Rapidly deteriorating renal function.

4. History of renal pain or renal trauma.

5.Presence of renal bruit.

Malignant hypertension:

Both primary and secondary hypertension may become malignant. Symptoms are almost always present. These are headache, dyspnoea, blurring of vision .

Usually over 40 . Most cases of malignant hypertension below the age of 30 are due to renal parenchymal disease.

This may be lower in children. Without treatment mortality during first year 80% and during second year 100% .

Indication for treatment:

1. Al patients with diastolic pressure above 100 mm Hg.

2. Patients below the age of 65 with diastolic pressure between 90-100 mm

Hg if associated with obesity , smoking .  diabetes , blood lipid abnormality.

3. Patients in category 2 having no risk factor should be kept under observation.

 Treatment:

1. Adequate rest and physical a activity in moderation.

2. Restrict salt, Stop smoking, reduce weihght. Treat associated diseases. Remove removable causes wherever possible. Withdraw oral pills.

3. Drug treatment for the rest of the patients .About half the patient can be controlled with one drug, one phird with two and the rest may require three or more.

MALARIA

Malaria

Malaria is caused by the protozoa of the genus plasmodium, transmitted to man almost always by the infected female anopheles mosquito.

Depending on the period of invasion. Multiplication and finally rupture of the red cell. Febrile episodes occur at varying intervals.

This cycle in the red cells takes 48 hours for P. vivax and P. ovale resulting in tertian periodicity. P. malariae takes 72 hours resulting quartan fever. P. falciparum takes shorter period and produces more constant fever.

The incubation  period is 10-15 days. Clinical manifestations vary according to different species of plasmodium.

Malaria should be considered as one of the causes of   P. U.O.

A typical paroxysm may be divided into 3 stages:

 

    1. A cold stages

    2. The hot stages

    3. Sweating stages

Tertian malaria

Paroxysm occur on alternate days. Spleen becomes palpable during the second week.

Quartan malaria :

   

    (a). paroxysm occur at an interval of 2 days.

    (b). clinical features simulating acute nephritis namely scanty urine.

    (c). albuminuria and haematuria may occur.

    (d). chronic form of the disease may be associated nephrosis.   

       

Falciparum malaria:

    (a) The onset may be insidious and the fever continuous, remittent or irregular.

     (b) Typical paroxysms are unusual.

     (c) Splenomegaly occurs of few days.

     (d) Serious complications may suddenly develop producing malignant symptoms. and more Doctor here

                                                              

The pernicious manifestations include:

1. Cerebral malaria

2. Hyperpyrexia

3. Gastro-intestinal type.

4. Algid malaria

5. Pulmonary oedema

6. Renal failure

7. Hypoglycemia

8. Spontaneous bleeding and disseminated intravascular Coagulation (DIC)

9. Black water fever

Treatment

*Acute attack of al forms of malaria:

   The initaial treatment of acute malaria is the same irrespective of its rype.

1. In uncomplicated cases:

    (a). Chloroquine diphosphate  or chloroquine sulphate, 600mg of base initially; 300mg of base after 6 hours; then 300mg of base daily for 3-6 days, or,

   

    (b) Amodiaquine-600mg base followed 6 hours later by 400mg – 1^st then 400mg base        daily for 3-6 days

   

2.In special circumstances:

    (a) Quinine dihydrochloride : This is available as ampoules containing 600 mg in 2 ml (300mg/ml).One ampoule (60 mg) is to be diluted with 500 ml of 5 percent dextrose in normal saline and administered slowly by intravenous drip in 4 hours. It may be repeated, if necessary, after 8 hours.

   (b) Comatosed patient should also receive: Dextran75 , one unit every 12 hours by drip to reduce intravascular sludging.