Mark Corson

By B. Deckard. Flagler College.

Until the second half of the 1990s clarinex 5mg with amex, only concentrate of poppy straw containing morphine as the 250 main alkaloid was manufactured order 5mg clarinex overnight delivery. Since then cheap clarinex 5 mg fast delivery, concentrate of poppy straw containing mainly thebaine or oripavine 200 has started to be manufactured. Concentrate of poppy straw may contain a mixture of alkaloids, and more 150 alkaloids than just the principal alkaloid may be extracted in industrial processes. The different types of concentrate 100 of poppy straw are referred to by the main alkaloid contained in them. Since the actual content of alkaloids in concentrate 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 of poppy straw may vary significantly, for purposes of Year comparison and for statistical purposes, all data referring Utilization Stocks Manufacture to concentrate of poppy straw are expressed in terms of the a Stocks as at 31 December of a given year. The totals of all the individual countries in the period 1988-2007 are presented in alkaloids contained in concentrate of poppy straw are figure 7. Throughout the two decades prior to 2007, examined below, expressed in terms of 100 per cent of the Australia has been the leading manufacturer. Figure 6 shows the trends in 2006, and Hungary, which had manufactured between its manufacture, stocks and utilization during the 20-year 9. In 2007, they 14Currently the following types are traded: (a) concentrate of poppy amounted to 218 tons. Turkey was the main exporter straw containing morphine as the main alkaloid; (b) concentrate of in 2007 (with 119 tons, it accounted for 55 per cent of poppy straw containing thebaine as the main alkaloid; and (c) concen- trate of poppy straw containing oripavine as the main alkaloid global exports), followed by Spain (59 tons or 27 per cent 15The comments on concentrate of poppy straw in this publication of global exports) and Australia (35 tons or 16 per cent are not directly comparable with comments on concentrate of poppy of global exports). Anhydrous morphine alkaloid contained in concentrate of poppy straw: manufacture in the main concentrate of poppy straw: utilization for the manufacturing countries, 1988-2007 manufacture of opiates in Australia, France, the United Kingdom and the United States Tons and total world utilization, 1988-2007 140 Tons 360 120 320 100 280 80 240 200 60 160 40 120 20 80 40 0 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 0 Year 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Australia Turkey France Spain United States France Australia United Kingdom World total total in 2007. It is also used in continuous Tons manufacturing processes for the manufacture of codeine. Utilization levelled off in the period 140 2004-2006 but increased to a record level of 351 tons in 2007. Anhydrous thebaine alkaloid contained in thebaine and the substances that may be obtained from it. Australia, Spain and France, in descending order, have been the main manufacturers, accounting for 74 per cent, 13 per cent and 12 per cent, respectively, of the Anhydrous codeine alkaloid contained in concentrate global total in 2007. Opioids are used mostly for their analgesic properties drugs derived from opium and their chemically related to treat severe pain (fentanyl, hydromorphone, methadone, derivatives, such as the semi-synthetic alkaloids, while morphine and pethidine), moderate to severe pain “opioid” is a more general term for both natural and (buprenorphine17 and oxycodone) and mild to moderate synthetic drugs with morphine-like actions, although the pain (codeine, dihydrocodeine and dextropropoxyphene), chemical structure may differ from that of morphine. M orphine: global manufacture, stocks,a They are also used as cough suppressants (codeine, consumption and utilization, 1988-2007 dihydrocodeine and, to a lesser extent, pholcodine and ethylmorphine), to treat gastrointestinal disorders, mainly Tons diarrhoea (codeine and diphenoxylate) and to treat addiction 450 to opioids (buprenorphine and methadone). Certain 400 analgesic opioids, such as hydrocodone or oxycodone, are compounded in mixtures with non-opiate drugs to provide 350 analgesic action (analgesic-antipyretic preparations). Morphine, codeine, thebaine, noscapine, oripavine, papaverine and narceine are alkaloids contained in opium or 150 poppy straw. Morphine and codeine are under international 100 control because of their potential for abuse, while thebaine and oripavine are under such control because of their 50 convertibility into opioids subject to abuse. Noscapine, papaverine and narceine are not under international 0 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 control. Morphine is the prototype of natural opiates and Year many opioids and, because of its strong analgesic potency, Consumption Utilization is used as a reference parameter for comparative purposes. Figure 11 presents manufacture, stocks, consump- tion and utilization of morphine in the period 1988-2007. Percentage Global manufacture of morphine followed an increasing 100 trend during that 20-year period. After having averaged 90 about 200 tons per year in the period 1987-1991, global manufacture grew steadily reaching a record level of 440 tons 80 in 2007. Almost 90 per cent of the morphine manufactured 70 globally is converted into other narcotic drugs and substances 60 not covered by the 1961 Convention (see paras. United Kingdom France Netherlands Together, those five countries accounted for more than Denmark Germany Australia three quarters of global manufacture. Seven other countries Belgium Others reported the manufacture of morphine in 2007 in quantities of more than 5 tons: China (21. As can be seen in figure 12, the leading exporter remained the United Kingdom (36 per cent19 of global 18In Australia, Brazil, China, Iran (Islamic Republic of), the Neth- exports), followed by Australia (29 per cent of global erlands, Norway, Portugal, Turkey and the United Kingdom, concen- trate of poppy straw is used in continuous industrial processes for the exports), Denmark and France (7 per cent of global exports manufacture of other narcotic drugs, without first separating morphine. In some countries, morphine is used for the increased more than threefold, from less than 5. The differences in consumption levels among for that purpose were Italy (497 kg), the United Kingdom countries continue to be very significant, the increase in (166 kg), Australia (49 kg), Switzerland (less than 4 kg), consumption taking place mainly in developed countries Panama (3 kg) and South Africa (less than 2 kg). The amounts utilized for that purpose, which had fluctuated at around 200 tons per year until the beginning of the 1990s, increased steadily since then, Figure 13. Other countries reporting conversion of morphine into other drugs in significant quantities in 2007 were China (13. Morphine is also used for the manufacture of substances not controlled under the 1961 Convention, such as noroxymorphone, nalorphine and naloxone. The use of a significant quantity of morphine for the manufacture of substances not controlled under the 1961 Convention was reported in 2007 by Brazil (7. Ranked alkaloid contained in concentrate of poppy straw for the manufacture of other alkaloids in continuous manufacturing processes. Codeine manufacture: world total, the United States (41 tons or 33 per cent of global stocks) Australia, France, Iran (Islamic Republic of), Japan, and the United Kingdom, which became the second largest the United Kingdom and the United States, 1988-2007 stockholder in 2007 (23. The other countries holding large stocks of morphine in 2007 Tons were Hungary (18. Codeine is a natural alkaloid of the opium poppy plant, but most (90-95 per cent) of the codeine currently 150 being manufactured is obtained from morphine through a semi-synthetic process.

Cheese washer’s lung Penicillium casei Moldy cheese Chemical worker’s lungb Isocyanates Polyurethane foam cheap 5 mg clarinex with visa, varnishes buy 5mg clarinex free shipping, lacquer Coffee worker’s lung Coffee bean dust Coffee beans Compost lung Aspergillus spp purchase 5mg clarinex visa. Contaminated metalworking fluid Miller’s lung Sitophilus granarius (wheat weevil) Infested wheat flour Miscellaneous medications Amiodarone, bleomycin, efavirenz, Medication gemcitabine, hydralazine, hydroxyurea, isoniazid, methotrexate, paclitaxel, penicillin, procarbazine, propranolol, riluzole, sirolimus, sulfasalazine Mushroom worker’s lung Thermophilic actinomycetes,a Hypsizigus Mushroom compost; mushrooms marmoreus, Bunashimeji spp. Contaminated tap water Thatched roof disease Sacchoromonospora viridis Dried grasses and leaves Tobacco worker’s disease Aspergillus spp. Mold on tobacco Winegrower’s lung Botrytis cinerea Mold on grapes Wood trimmer’s disease Rhizopus spp. Oak and maple trees Woodworker’s lung Wood dust, Alternaria Oak, cedar, pine, and mahogany dusts aThermophilic actinomycetes species include Micropolyspora faeni, Thermoactinomyces vulgaris, T. In some patients, a subacute form of the 81 leukocytes in the alveoli and small airways. This early disease may persist after an acute presentation of the dis- lesion is followed by an influx of mononuclear cells into order, especially if there is continued exposure to antigen. This source includes both alveolar macrophages and T lym- stage may progressively worsen, resulting in dependence phocytes in the lung. Such a gradual onset frequently occurs ing mechanisms: induction of the adhesion molecules with low-dose exposure to the antigen. Increased levels of Fas protein and FasL in All forms of the disease may be associated with elevations the lung (which would be expected to suppress inflam- in erythrocyte sedimentation rate, C-reactive protein, mation by induction of T cell apoptosis) is counterbalanced rheumatoid factor, and serum immunoglobulins. After by increased expression of the inducible antiapoptotic acute exposure to antigen, neutrophilia and lymphopenia gene Bcl-xL, resulting in a lower overall level of pulmonary are frequently present. If found, precipitins recent or continual exposure to antigen may have an indicate sufficient exposure to the causative agent for increase in polymorphonuclear leukocytes in lavage generation of an immunologic response. It can be normal even in symptomatic which varies from patient to patient and seems related to patients. The acute or subacute phases may be associated the frequency and intensity of exposure to the causative with poorly defined, patchy, or diffuse infiltrates or with antigen and perhaps other host factors. In the acute form, chest x-ray usually shows a diffuse reticulonodular infil- symptoms such as cough, fever, chills, malaise, and dysp- trate. Honeycombing may eventually develop as the con- nea may occur 6–8 h after exposure to the antigen and dition progresses. Apical sparing is common, suggesting usually clear within a few days if there is no further expo- that disease severity correlates with inhaled antigen load, sure to antigen. When the biopsy predominate in the lower lobes, and expiratory views is taken during the active phase of disease, typical find- may demonstrate air trapping; this pattern is more com- ings include an interstitial alveolar infiltrate consisting of mon in individuals whose exposure to antigen continues plasma cells, lymphocytes, and occasional eosinophils rather than those in whom removal from antigen expo- and neutrophils, usually accompanied by loose, non- sure has occurred. Interstitial fibrosis seen more often than interstitial fibrosis; subpleural may be present but most often is mild in earlier stages of linear opacities and honeycombing are common, and the disease. Some degree of bronchiolitis is found in these changes may be found throughout the lung. Alveolar neutrophilia is also only a subset of the criteria are fulfilled, the diagnosis is prominent acutely but tends to fade in the absence of less clearly established. No previous 83 (2) a history of exposure to a recognized antigen; and (3) sensitization is required, and precipitins are absent to ideally, identification of an antibody to that antigen. This is usually possible if the negative history for use of relevant drugs and no evi- physician takes a careful environmental and occupa- dence of a systemic disorder usually exclude the pres- tional history or, if necessary, visits the patient’s envi- ence of drug-induced lung disease or a collagen vascular ronment. This recommendation cannot be taken lightly paratracheal lymphadenopathy or evidence of multisys- when it completely changes the lifestyle or livelihood tem involvement also favors the diagnosis of sarcoidosis. In many cases, however, the source of In some patients, a lung biopsy may be required to dif- exposure (birds, humidifiers) can easily be removed. If symptoms recur or physiologic abnormalities including the allergic bronchopulmonary mycoses and progress despite these measures, then more effective other eosinophilic pneumonias. After initial ized by transient fever and muscle aches with or without prednisone therapy (1 mg/kg per day for 2–4 weeks), dyspnea and cough. Serum precipitins are absent, and the drug is tapered to the lowest dosage that will the chest x-ray is usually normal. Massive exposure to moldy silage may glucocorticoid therapy on long-term prognosis of result in a syndrome termed pulmonary mycotoxicosis, with patients with farmer’s lung. Since Loeffler’s Peripheral eosinophilia (>1000/μL) Immediate wheal-and-flare response to initial description of a transient, benign syndrome of Aspergillus fumigatus migratory pulmonary infiltrates and peripheral blood Serum precipitins to A. Elevated IgE (and IgG) class antibodies specific When an eosinophilic pneumonia is associated with for A. These are exemplified by acute reactions bronchiectasis associated with this disorder is thought to to nitrofurantoin, which may begin 2 h to 10 days after result from a deposition of immune complexes in proxi- nitrofurantoin is started, with symptoms of dry cough, mal airways. Adequate treatment usually requires the fever, chills, and dyspnea; an eosinophilic pleural effusion long-term use of systemic glucocorticoids. Other drugs associated with eosinophilic should prompt the consideration of parasite-associated pneumonias include sulfonamides, penicillin, chlor- disorders. Tropical eosinophilia is usually caused by filarial propamide, thiazides, tricyclic antidepressants, hydralazine, infection; however, eosinophilic pneumonias also occur gold salts, isoniazid, indomethacin, and others. Treat- ment consists of withdrawal of the incriminated drugs and the use of glucocorticoids, if necessary. Loeffler’s syndrome Etiology Known was originally reported as a benign, acute eosinophilic Allergic bronchopulmonary mycoses pneumonia of unknown cause characterized by migrat- Parasitic infestations ing pulmonary infiltrates and minimal clinical manifes- Drug reactions tations. In some patients, these clinical characteristics Eosinophilia-myalgia syndrome may prove to be secondary to parasites or drugs. Acute Idiopathic eosinophilic pneumonia is an idiopathic acute febrile illness Loeffler’s syndrome of less than 7 days’ duration with severe hypoxemia, pul- Acute eosinophilic pneumonia Chronic eosinophilic pneumonia monary infiltrates, and no history of asthma. Chronic Allergic granulomatosis of Churg and Strauss eosinophilic pneumonia presents with significant systemic Hypereosinophilic syndrome symptoms, including fever, chills, night sweats, cough, anorexia, and weight loss of several weeks’ to months’ duration. The chest x-ray classically shows peripheral metalworking fluids; the prevalence of these environmen- 85 infiltrates. Some patients also have bronchial asthma of tal contaminants greatly depends on workplace hygiene the intrinsic or nonallergic type.

I can here limit myself only to this latter case order clarinex 5 mg with amex, as the other cases cannot be arranged in tabular form for the weak and negligent clarinex 5 mg without a prescription, but must be left to the accuracy discount 5 mg clarinex mastercard, the industry and the intelligence of able men, who are masters of their art. Experience has shown me, as it has no doubt also shown to most of my followers, that it is most useful in diseases of any magnitude (no excepting even the most acute, and still more so in the half-acute, in the tedious and most tedious) to give to the patient the powerful homœopathic pellet or pellets only in solution, and this solution in divided doses. In this way we give the medicine, dissolved in seven to twenty tablespoonfuls of water without any addition, in acute and very acute diseases every six, four or two hours ; where the danger is urgent, even every hour or every half-hour, a tablespoonful at a time ; with weak persons or children, only a small part of a tablespoonful (one or two teaspoonfuls or coffeespoonfuls) may be given as a dose. But since water (even distilled water) commences after a few days to be spoil, whereby the power of the small quantity of medicine contained is destroyed, the addition of a little alcohol is necessary, or where this is not practicable, or if the patient cannot bear it, I add a few small pieces of hard charcoal to the watery solution. This answers the purpose, except that in the latter case the fluid in a few days receives a blackish tint. This is caused by shaking the liquid, as is necessary every time before giving a dose of medicine, as may be seen below. Before proceeding, it is important to observe, that our vital principle cannot well bear that the same unchanged dose of medicine be given even twice in succession, much less more frequently to a patient. For by this the good effect of the former dose of medicine is either neutralized in part, or new symptoms proper to the medicine, symptoms which have not before been present in the disease, appear, impeding the cure. Thus even a well selected homœopathic medicine produces ill effects and attains its purpose imperfectly or not at all. Thence come the many contradictions of homœopathic physicians with respect to the repetition of doses. But in taking one and the same medicine repeatedly (which is indispensable to secure the cure of a serious, chronic disease), if the dose is in every case varied and modified only a little in its degree of dynamization, then the vital force of the patient will calmly, and as it were willingly receive the same medicine even at brief intervals very many times in succession with the best results, every time increasing the well-being of the patient. This slight change in the degree of dynamization is even effected, if the bottle which contains the solution of one or more pellets is merely well shaken five or six times, every time before taking it. Now when the physician has in this way used up the solution of the medicine that had been prepared, if the medicine continues useful, he will take one or two pellets of the same medicine in a lower potency (e. This last solution may then be taken in the same manner, or at longer intervals, perhaps also less of the solution at a time ; but every time the solution must be shaken up five or six times. This will be continued so long as the remedy still produces improvement and until new ailments (such as have never yet occurred with other patients in this disease), appear ; for in such a case a new remedy will have to be used. On any day when the remedy has produced too strong an action, the dose should be omitted for a day. If the symptoms of the disease alone appear, but are considerably aggravated even during the more moderate use of the medicine, then the time has come to break off in the use of the medicine for one or two weeks, and to await a considerable improvement. He will dissolve one (two) pellet of the highly potentized, well selected medicine in seven, ten or fifteen tablespoonfuls of water (without addition) by shaking the bottle. He will then, according as the disease is more or less acute, and more or less dangerous, give the patient every half hour, or every hour, every two, three, four, six hours (after again well shaking the bottle) a whole or a half tablespoonful of the solution, or, in the case of a child, even less. If the physician sees no new symptoms develop, he will continue at these intervals, until the symptoms present at first begin to be aggravated ; then he will give it at longer intervals and less at a time. As is well know, in cholera the suitable medicine has often to be given at far shorter intervals. Children are always given these solutions from their usual drinking vessels ; a teaspoon for drinking is to them unusual and suspicious, and they will refuse the tasteless liquid at once on that account. When the medicine has been consumed and it is found necessary to continue the same remedy, if the physician should desire to prepare a new portion of medicine from the same degree of potency, it will be necessary to give to the new solution as many shakes, as the number of shakes given to the last portion amount to when summed up together, and then a few more, before the patient is given the first dose ; but after that, with the subsequent doses, the solution is to be shaken up only five or six times. In this manner the homœopathic physician will derive all the benefit from a well selected remedy, which can be obtained in any special case of chronic disease by doses given through the mouth. But if the diseased organism is affected by the physician through this same appropriate remedy at the same time in sensitive spots other than the nerves of the mouth and the alimentary canal, i. The limbs which are thus rubbed with the solution may also be varied, first one, then another. Thus the physician will receive a greater action from the medicine homœopathically suitable to the chronic patient, and can cure him more quickly, than by merely internally administering the remedy. This mode of procedure has been frequently proved by myself and found extraordinarily curative ; yea, attended by the most startling good effects ; the medicine taken internally being at the same time rubbed on the skin externally. This procedure will also explain the wonderful cures, of rare occurrence indeed, where chronic crippled patients with sound skin recovered quickly and permanently by a few baths in a mineral water, the medicinal constituents of which were to a great degree homœopathic to their chronic disease. Therefore the homœopathic remedy given internally must never be rubbed in on parts which suffer from external ailments. The limb, therefore, on which the solution is to be rubbed in, must be free from cutaneous ailments. In order to introduce also here change and variation, when several of the limbs are free from cutaneous ailments, one limb after the other should be used, in alternation, on different days, (best on days when the medicine is not taken internally). A small quantity of the solution should be rubbed in with the hand, until the limb is dry. Convenient as the mode of administering the medicine above described may be, and much as it surely advances the cure of chronic diseases, nevertheless, the greater quantity of alcohol or whiskey or the several lumps of charcoal which have to be added in warmer weather to preserve the watery solution were still objectionable to me with many patients. I have, therefore, lately found the following mode of administration preferable with careful patients. From a mixture of about five tablespoonfuls of pure water and five tablespoonfuls of French brandy -which is kept on hand in a bottle, 200, 300 or 400 drops (according as the solution is to be weaker or stronger) are dropped into a little vial, which may be half-filled with it, and in which the medicinal powder or the pellet or pellets of the medicine have been placed. From this solution one, two, three or several drops, according to the irritability and the vital force of the patient, are dropped into a cup, containing a spoonful of water ; this is then well stirred and given to the patient, and where more especial care is necessary, only the half of it may be given ; half a spoonful of this mixture may also well be used for the above mentioned external rubbing. On days, when only the latter is administered, as also when it is taken internally, the little vial containing the drops must every time be briskly shaken five or six times ; so also the drop or drops of medicine with the tablespoonful of water must be well stirred in the cup. It would be still better if instead of the cup a vial should be used, into which a tablespoonful of water is put, which can then be shaken five or six times and then wholly or half emptied for a dose. Frequently it is useful in treating chronic diseases to take the medicine, or to rub it in in the evening, shortly before going to sleep, because we have then less disturbance to fear from without, than when it is done earlier. When I was still giving the medicines in undivided portions, each with some water at a time, I often found that the potentizing in the attenuating glasses effected by ten shakes was too strong (i.

This pattern forms the primary r Inthelung buy cheap clarinex 5mg on line,thebacteriahaveapreferencefortheapices complex with infection at the periphery of the lung (higher pO2) discount clarinex 5 mg fast delivery, and form an apical lung lesion known and enlarged peribronchial lymph nodes generic 5mg clarinex. It begins as a small caseating r The outcome of the primary infection depends on the tuberculous granuloma, histologically similar to the balance between the virulence of the organism and Ghon focus, with destruction of lung tissue and cavi- the strength of the host response (see Table 3. T cells are re-induced by the secondary infec- the host can mount an active cell mediated immune tion, with activation of macrophages, and exactly as response the infection may be completely cleared. Collagen is healing of the apical region with collagen de- is deposited around these, often becoming calcified. This is called a ‘progres- tissue, thinning of the collagen wall and increasing sive primary infection’. Coughing disperses these bacilli into the at- Poor immune system eg Good immune response, e. Without malnutrition, extremes of healthy immunised treatment, extensive caseating lesions develop rapidly, age, intercurrent disease individual leading to a high mortality. This disease is sometimes Use of appropriate antibiotics called ‘galloping consumption’. By that time there may be no evidence of tu- comesinfectedbymiliarydisseminationwithmultiple berculosis elsewhere. If a lesion erodes a pulmonary vein, there may be systemic miliary dissemination, for ex- Clinical features ample to the meninges, spleen, liver, the choroid and 1 Primary tuberculosis is usually asymptomatic, occa- the bone marrow. The hypersensitivity reaction may produce patient mounts a good immune response, organisms atransient pleural effusion or erythema nodosum. The outstanding Chapter 3: Respiratory infections 105 features are fever (drenching night sweats are rare) be normal, as tubercles are not visible until they are and cough productive of mucoid, purulent or blood 1–2 mm. Microscopy Formal culture of material is the only way of accu- The characteristic lesion, the tubercle (granuloma) con- rately determining virulence and antibiotic sensitivity sists of a central area of caseous tissue necrosis within and should be attempted in every case, results may which are viable mycobacteria. It relies on the hypersensitivity reaction, usually heals spontaneously but occasionally may per- and is rarely helpful in the diagnosis of tuberculosis: sist giving rise to bronchiectasis particularly of the i The Tine test and Heaf test are for screening: 4/6 middle lobe (Brock’s Syndrome). If the spots are confluent, logicalfractures,particularlyofthespinetogetherwith the test is positive, indicating exposure. The reaction is read at Investigations 48–72 hours and is said to be positive if the indura- r An abnormal chest X-ray is often found incidentally tion is 10 mm or more in diameter, negative if less in the absence of symptoms, but it is very rare for a than 5 mm. The X-ray shows purified protein derivative this can indicate active patchy or nodular shadowing in the upper zone with infection requiring treatment. In an immunocom- fibrosis and loss of volume; calcification and cavita- promised host (such as chronic renal failure, lym- tion may also be present. Human immunity depends largely on the haemag- niazid, ethambutol and pyrazinamide, and a further glutinin (H) antigen and the neuraminidase (N) antigen 4months of rifampicin and isoniazid alone. Major shifts in these antigenic re- taken 30 minutes before breakfast to aid absorption. Thesecancauseapandemic,whereasantigenicdrift organism is sensitive for a full 6 months to avoid de- causes the milder annual epidemics. Other upper and lower respiratory symptoms to6weeks after birth (without prior skin testing) in ar- may develop. Individuals are infective for 1 day prior to eas with a high incidence of tuberculosis. Less commonly, secondary Five per cent of patients do not respond to therapy, only Staph. Influenza A causes worldwide annual epidemics and is Retrospective diagnosis can be made by a rise in spe- infamous for the much rarer pandemics, the most seri- cificcomplement-fixingantibodyorhaemagglutininan- ous of which occurred in 1918 when ∼40 million people tibody measured 2 weeks apart, but this is usually un- died worldwide. Spread is by respiratory r Bed rest, antipyretics such as paracetamol for symp- droplets. Chapter 3: Respiratory infections 107 r The neuraminidase inhibitors zanamivir and os- emboli, e. Clinical features They are particularly indicated in the elderly, those Patients present with worsening features of pneumonia, with underlying respiratory disease such as chronic usually with a swinging pyrexia, and can be severely ill. Some are manufactured in strates one or more round opacities often with a fluid chickembryosandtheseshouldnotbegiventoanyone level. Routine vaccination is reserved for bronchoscopy may be necessary to exclude obstruction, susceptible people with chronic heart, lung or renal to look for underlying carcinoma, and to obtain biopsies disease,diabetes,immunosuppressionandtheelderly. Echocardiogram should be considered to look for infec- These predications depend on global surveillance or- tive endocarditis. This surveillance depends on viruses being cultured Complication and therefore on nose/throat swabs being taken and Breach of the pleura results in an empyema. Management Lung abscess Posturaldrainage,physiotherapyandaprolongedcourse of appropriate antibiotics to cover both aerobic and Definition anaerobic organisms will resolve most smaller ab- Localisedinfectionanddestructionoflungtissueleading scesses. Largerabscessesmayrequirerepeatedaspiration, to acollection of pus within the lung. Organismswhichcausecav- Definition itation and hence lung abscess include Staphylococcus Thereareessentiallythreepatternsof lungdiseasecaused and Klebsiella. Pathophysiology Aetiology The abscess may form during the course of an acute It is a filamentous fungus, the spores (5 µmindiame- pneumonia, or chronically in partially treated pneu- ter) are ubiquitously present in the atmosphere. The pattern of disease that arises depends 108 Chapter 3: Respiratory system on the degree of tissue invasiveness, the dose inhaled and Aspergilloma the level of the host’s defence. This results from Aspergillus growing within an area of previously damaged lung such as an old tuberculous Allergic bronchopulmonary aspergillosis cavity (sometimes called a mycetoma). Seen on X-ray as a round lesion with an air ‘halo’ above i Initially it causes bronchospasm which commonly it.