Mark Corson

By M. Kerth. Spring Arbor College. 2018.

Identification—This prototype disease of the spotted fever group rickettsiae is characterized by sudden onset of moderate to high fever buy 100 pills aspirin with mastercard, which ordinarily persists for 2–3 weeks in untreated cases aspirin 100pills on line, significant malaise cheap 100 pills aspirin with amex, deep muscle pain, severe headache, chills and conjunctival injection. A maculopapular rash generally appears on the extremities on the 3rd to 5th day; this soon includes the palms and soles and spreads rapidly to much of the body. A petechial exanthem occurs in 40% to 60% of patients, generally on or after the 6th day. Risk factors associated with more severe disease and death include delayed antibio- therapy and patient age over 40. Absence or delayed appearance of the typical rash or failure to recognize it, especially in dark-skinned individu- als, contribute to delay in diagnosis and increased fatality. Reservoir—Maintained in nature among ticks by transovarial and transstadial passage. The rickettsiae can be transmitted to dogs, various rodents and other animals; animal infections are usually subclinical, but disease in rodents and dogs has been observed. At least 4–6 hours of attachment and feeding on blood by the tick are required before the rickettsiae become reactivated and infectious for people. Contamination of breaks in the skin or mucous membranes with crushed tissues or feces of the tick may also lead to infection. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Case report obligatory in most countries, Class 2 (see Reporting). Chloramphenicol may also be used, but only when there is an absolute contraindication for using tetracyclines. Treatment should be initiated on clinical and epidemiological considerations without waiting for laboratory confirmation of the diagnosis. Identification—A mild to severe febrile illness of a few days to 2 weeks; there may be a primary lesion or eschar at the site of a tick bite. This eschar (tache noire), often evident at the onset of fever, is a small ulcer 2–5 mm in diameter with a black center and red areola; regional lymph nodes are often enlarged. A generalized maculopapular erythema- tous rash usually involving palms and soles appears about the 4thto 5thday and persists for 6–7 days; with antibiotherapy, fever lasts no more than 2 days. Occurrence—Widely distributed throughout the African continent, in India and in those parts of Europe and the Middle East adjacent to the Mediterranean and the Black and Caspian seas. Expansion of the European endemic zone to the north occurs because tourists often carry their dogs with them; the dogs acquire infected ticks, which establish colonies when the dogs return home, with subsequent transmission. In more temperate areas, the highest incidence is during warmer months when ticks are numerous; in tropical areas, disease occurs throughout the year. Mode of transmission—In the Mediterranean area, bite of infected Rhipicephalus sanguineus, the brown dog tick. Clinically similar to Boutonneuse fever (see above), but fever less com- mon, rash noticed in only half the cases and may be vesicular. Multiple eschars, lymphangitis, lymphadenopathy, and oedema localized to the eschar site are seen more commonly than with Boutonneuse fever. Outbreaks of disease may occur when groups of travellers (such as persons on safari in Africa) are bitten by ticks. Occurrence—Sub-Saharan Africa, including Botswana, South Af- rica, Swaziland and Zimbabwe, 4. Occurrence—Queensland, New South Wales, Tasmania and coastal areas of eastern Victoria, Australia. Ixodes holocyclus, which infests small marsupials and wild rodents, is probably the major vector. Mode of transmission—Through the bite of ticks in the genera Dermacentor and Haemaphysalis, which infest certain wild rodents. An initial skin lesion at the site of a mite bite, often associated with lymphadenopathy, is followed by fever; a disseminated vesicular skin rash appears, which generally does not involve the palms and soles and lasts only a few days. The disease, caused by Rickettsia akari, a member of the spotted fever group of rickettsiae, is transmitted to humans from mice (Mus musculus) by a mite (Liponyssoides sanguineus). Incidence has been markedly reduced by changes in management of garbage in tenement housing, so that few cases have been diagnosed in recent years. Identification—Rubella is a mild febrile viral disease with a diffuse punctate and maculopapular rash. Clinically, this is usually indistinguish- able from febrile rash illness due to measles, dengue, parvovirus B19, human herpesvirus 6, Coxsackie virus, Echovirus, adenovirus or scarlet fever. Children usually present few or no constitutional symptoms, but adults may experience a 1–5 day prodrome of low grade fever, headache, malaise, mild coryza and conjunctivitis. Postauricular, occipital and poste- rior cervical lymphadenopathy is the most characteristic clinical feature and precedes the rash by 5–10 days. Leukopenia is common and throm- bocytopenia can occur, but hemorrhagic manifestations are rare. Arthral- gia and, less commonly, arthritis complicate a substantial proportion of infections, particularly among adult females. Encephalitis is a more common complication than generally appreciated, and occurs with a higher frequency in adults. Laboratory diagnosis of rubella is required, since clinical diagnosis is often inaccurate. An epidemiologically confirmed rubella case is a patient with suspected rubella with an epidemiological link to a laboratory- confirmed case. Rubella is important because of its ability to produce anomalies in the developing fetus. Congenital malforma- tions and fetal death may occur following inapparent maternal rubella. Fetuses infected early are at greatest risk of intrauterine death, sponta- neous abortion and congenital malformations of major organ systems.

Periodic Abstinence (Natural Family Planning) Avoidance of sexual intercourse during ovulation and for a safety margin before and after ovulation cheap aspirin 100 pills with amex. Various methods may be used to determine the fertile period: cervical mucus best aspirin 100pills, basal body temperature discount aspirin 100pills, rhythm. Benefits • No physical side effects it is cheap • No need for prescriptions by medical person • Improved knowledge of reproductive system and possible closer relationship between couples. Client Education • Requires high motivation • Has a high failure rate • Assumes a regular, perfect menstrual cycle • Requires proper record−keeping • Has no health risks, except for pregnancy. Consult a surgeon for drainage of pointing liver abscesses, bowel perforations (peritonitis), amoebomas and large bowel strictures • Amoebiasis and "vague" abdominal complaints: − where amoebiasis is common, there is a tendency to blame any abdominal complaints on amoeba. Usually these patients have cysts in stool but no 109 evidence of invasive disease e. Exclude other causes of abdominal pain • Asymptomatic cyst carriers: − only treat cyst carrier if patient is a food handler. Do not waste metronidazole: use it for appropriate indications Prevention • Provision of safe drinking water and sanitary disposal of faeces are important preventive measures • Regular examination of food handlers and appropriate treatment when necessary. Diarrhoeal Diseases Diarrhoea is defined as occurrence of at least 3 loose or watery stools in a day. Clinical Features − Dehydration The major cause of death from diarrhoea is dehydration, especially in infants and young children. Management is aimed primarily at evaluation, prevention, and treatment of dehydration. Diarrhoeal illness is classified for dehydration, dysentery and persistent diarrhoea. Management − Pharmacologic • that 50−60 % of acute gastroenteritis is viral • Other anti−diarrhoea drugs (e. If still breastfeeding, allow it more and for longer − give as much of these fluids as child will take − continue fluids until diarrhoea stops • Give the child plenty of food to prevent malnutrition: 114 − continue to breast−feed frequently or give usual milk (if not breast−fed) − encourage eating and offer food at least 6 times a day or one extra meal per day. Take−home messages: − Breastfeeding exclusively up to age 6 months and continue with other foods up to age 2 years − Solid foods ("complementary foods") should be introduced from about age 6 months − Proper sanitation: Provision of safe drinking water in sufficient quantities and disposal of faeces. Gastritis An acute ulceration of the stomach, usually multiple, non−recurrent and self−limiting. Peptic Ulcer Disease Ulceration of gastroduodenal mucosa that has tendency to be chronic and recurrent. Clinical Features Duodenal Ulcer • Epigastric pain, typically at night and when hungry • May present for the first time with complications [see later in this section] • Wide individual variation in symptoms and food that give pain • 95% of duodenal ulcers are caused by Helicobacter pylori (H. Gastric Ulcer • Epigastric pain, worse with food • Other features as in duodenal ulcer above. Admit For • All of the above • Indications for surgery in peptic ulcer disease: − intractable haemorrhage more than 5 units of blood in 24 hrs − recurrent bleeding after non surgical management during same hospitalisation − perforation − penetration to the pancreas − intractable ulcer pain − suspicion of malignancy especially in gastric ulcers. Aetiology • Oesophageal varies • Gastritis and gastric ulcers • Duodenal ulcers • A−V malformation 118 • Malignancies − stomach and oesophagus • Mallory −Weiss syndrome • Polyps. Clinical Features Vomiting of fresh bright blood or coffee−ground vomitus (haematemesis). Forceful vomiting followed by haematemesis suggests gastroesophageal junction tear. Excessive alcohol intake or ingestion of anti−inflammatory drugs may suggest erosive gastritis, previous epigastric pain suggests peptic ulcer. Lower Git Bleeding This may be frank bleeding (haematochezia) or occult bleeding depending on the cause. Management • Group and cross match if necessary • Treat the cause • Refer suspicious rectal bleeding. Cross infection: • Contamination of fingers with objects, clothing, toilet seats, etc. In general: • Safe water provision 122 • Hand washing and trimming of fingernails • Frequent changing of innerwear and sheets • Use of latrines. A critically ill child needing hospital admission must be given the appropriate vaccines upon recovery. Remember: • That a slight fever and/or other minor illness should not prevent you from immunizing a child • To inform mothers/child−caretakers about possible side effects of each of the given vaccines • To record all vaccinations on tally sheets and on the Child−Health immunization cards and instruct the mothers always to bring the cards along with them when taking children to a health facility • To instruct mothers to return the child for the next immunization date as indicated on the card • That vaccines are easily destroyed by heat and rendered ineffective • To handle the disposal of used sharp syringes appropriately • To ensure appropriate cold storage of the vaccines and follow the recommended cold− chain instructions for each of the vaccines carefully. Symptoms include severe cough followed by a whoop and vomiting, leads to malnutrition, can cause death, severe under 1 year old. Tetanus: [see tetanus] A clinical syndrome involving primarily the central nervous system and resulting from the tetanus toxins. Symptoms include rash, fever, cough, red eyes; is associated with blindness, malnutrition, deafness, pneumonia and death. Symptoms include pain and flaccid paralysis in limbs, fever, vomiting; can lead to permanent deformity and can cause death. Transmitted mainly by parenteral route, also from person to person by close contact through exchange of body fluids such as saliva, secretions from open wounds, blood, vaginal secretions and semen. Transmission between children is common, since they are often more infectious than adults. Infection may be transmitted either vertically (transplacentally from mother to unborn baby) or horizontally by close contact. Haemophilus Influenzae b: is a bacteria recognised as one of the commonest agents causing pneumonia and meningitis in children (see 21. If no reaction develops, the vaccination should be Child over 1 year, full repeated after 3 months.

The process is often followed by gravity separation (sedimentation or flotation) and is always followed by filtration generic 100pills aspirin amex. A chemical coagulant buy aspirin 100 pills with visa, such as iron salts buy aspirin 100pills fast delivery, aluminum salts, or polymers, is added to source water to facilitate bonding among particulates. Coagulants work by creating a chemical reaction and eliminating the negative charges that cause particles to repel each other. The coagulant-source water mixture is then slowly stirred in a process known as flocculation. This water churning induces particles to collide and clump together into larger and more easily removable clots, or “flocs. The ultimate effectiveness of coagulation/flocculation is also determined by the efficiency of the filtering process with which it is paired. This chemical must not be overfed due to a possible exposure to a high concentration of the chemical. The most important safety considerations to know about fluoride chemicals are that all fluoride chemicals are extremely corrosive. These are the substances most commonly used to furnish fluoride ions to water: Sodium fluoride, Sodium silicofluoride and Hydrofluosilicic acid. When the water flux decreases through a semipermeable membrane, it means that the mineral concentration of the water is increasing. Formation: A series of layers, deposits, or bodies of rock, which are geologically similar and related in depositional environment or origin. A formation can be clearly distinguished relative to bounding deposits or formations due to its particular characteristics and composition. The reason for chlorinating past the breakpoint is to provide protection in case of backflow. A functional group contributes somewhat predictable properties to the molecules which possess them. Lovelock in 1979, which suggests that the biosphere of the earth exists as a "superorganism" which exhibits homeostatic self- regulation of the environment-biota global system. In gel electrophoresis, the porous medium through which the macromolecules move is a gel. Viruses possess various natural biochemical methods for achieving gene delivery; artificial gene delivery is one of the essential problems of "genetic engineering". The most important Waterborne Diseases ©6/1/2018 565 (866) 557-1746 barrier is apparently the outer cell membrane, which is essentially a lipid barrier, and introduction of any large complex into the cell requires a fusion of one kind or another with this membrane. Identical alleles may have different effects on offspring depending on whether they arrive in the zygote via the ovum or via the sperm. The giardia parasite attaches to the epithelium by a ventral adhesive disc, and reproduces via binary fission. Giardiasis does not spread via the bloodstream, nor does it spread to other parts of the gastro-intestinal tract, but remains confined to the lumen of the small intestine. Giardia trophozoites absorb their nutrients from the lumen of the small intestine, and are anaerobes. The giardia parasite attaches to the epithelium by a ventral adhesive disc, and reproduces via binary fission. Giardiasis does not spread via the bloodstream, nor does it spread to other parts of the gastro-intestinal tract, but remains confined to the lumen of the small intestine. Giardia trophozoites absorb their nutrients from the lumen of the small intestine, and are anaerobes. Plays a role in the production and release of secretory materials such as the digestive enzymes manufactured in the pancreas. A single grab sample should be taken over a period of time not to exceed 15 minutes. A single water or wastewater sample taken at a time and place representative of total discharge. A halide ion is a halogen atom bearing a negative Waterborne Diseases ©6/1/2018 567 (866) 557-1746 charge. The halide anions are fluoride (F), chloride (Cl), bromide (Br), iodide (I) and astatide (At). Hard water is a type of water that has high mineral content (in contrast with soft water). Hard water primarily consists of calcium (Ca2+), and magnesium (Mg2+) metal cations, and sometimes other dissolved compounds such as bicarbonates and sulfates. The simplest way to determine the hardness of water is the lather/froth test: soap or toothpaste, when agitated, lathers easily in soft water but not in hard water. Although water hardness usually only measures the total concentrations of calcium and magnesium (the two most prevalent, divalent metal ions), iron, aluminum, and manganese may also be present at elevated levels in some geographical locations. The term "hardness" comes from the fact that it is hard to get soap suds from soap or detergents in hard water. This happens because calcium and magnesium react strongly with negatively-charged chemicals like soap to form insoluble compounds. Water absorbs approximately 580 calories per gram when it changes from liquid water to water vapor. Such cells give rise to erythrocytes and a variety of types of lymphocytes and leucocytes. Such an organism requires carbon ("food") from its environment in an organic form. The association is due to the charged regions of the polar water molecules themselves. Although this ion does not exist except in extraordinary conditions, the term hydride is widely applied to describe compounds of hydrogen with other elements, particularly those of groups 1–16. The variety of compounds formed by hydrogen is vast, arguably greater than that of any other element.

The exfoliative toxins are also known as epidermolytic toxins purchase aspirin 100 pills on-line, epidermolysins 100pills aspirin sale, and exfoliatins aspirin 100 pills discount. Bullous impetigo (also known as bullous varicella or measles pemphigoid) presents with a few localized, fragile, superficial blisters that are filled with colorless, purulent fluid (118). The lesions are located in the area of the umbilicus and perineum in infants and over the extremities in older children (119). Risk factors for development in adults include renal dysfunction, lymphoma, and immunosup- pression (112,119,120). Patients with pemphigus neonatorum present with fever, erythema, malaise, and irritability. They then develop large superficial blisters that rupture easily because of friction (112). A positive Nikolsky sign refers to dislodgement of the superficial epidermis when gently rubbing the skin (121). If untreated, the epidermis will slough off leaving extensive areas of denuded skin that are painful and susceptible to infection. Potentially fatal complications in infants and young children occur because of the loss of protective epidermis. A thorough exam looking for foci of infection (pneumonia, abscess, arthritis, endocarditis, sinusitis, etc. Blood cultures are usually negative because toxins are produced at a distant site (119,124). The biopsy typically reveals mid-epidermal splitting at the level of the zona granulosa without cytolysis, necrosis, or inflammation (126). Staphylococci may be seen in bullous lesions of localized disease, but are rarely seen in the bullous lesions of generalized disease (120). Scarlet Fever Scarlet fever is the result of infection with a Streptococcus pyogenes strain (i. There are three different toxins, types A, B, and C, which are produced by 90% of these strains. The rash of scarlet fever starts on the head and neck, followed by progression to the trunk and then extremities (8,127). There are numerous papular areas in the rash that produce a sandpaper-type quality. On the antecubital fossa and axillary folds, the rash has a linear petechial character referred to as Pastia’s lines (127). Confirmation of the diagnosis is supported by isolation of group A streptococci from the pharynx and serologies (111). The signs and symptoms evolve over the first 10 days of illness and then gradually resolve spontaneously in most children. Fever for five days or more that does not remit with antibiotics and is often resistant to antipyretics. Changes in the lips and mouth: reddened, dry, or cracked lips; strawberry tongue; diffuse erythema of oral or pharyngeal mucosa 36 Engel et al. Changes in the extremities: erythema of the palms or soles; indurative edema of the hands or feet; desquamation of the skin of the hands, feet, and perineum during convalescence e. Other clinical features include intense irritability (possibly due to cerebral vasculitis), sterile pyuria, and upper respiratory symptoms (130). Treatment with aspirin and intravenous immune globulin has reduced the development and severity of coronary artery aneurysms. Other Causes of Diffuse Erythematous Rashes Streptococcus viridans bacteremia can cause generalized erythema. Enteroviral infections, graft versus host disease, and erythroderma may all present with diffuse erythema (8). The causes of vesiculobullous rashes associated with fever include primary varicella infection, herpes zoster, herpes simplex, small pox, S. Other causes that will not be discussed include folliculitis due to staphylococci, Pseudomonas aeruginosa, and Candida, but these manifestations would not result in admission to a critical care unit. Varicella Zoster Primary infection with varicella (chicken pox) is usually more severe in adults and immunocompromised patients. Although it can be seen year-round, the highest incidence of infection occurs in the winter and spring. The disease presents with a prodrome of fever and malaise one to two days prior to the outbreak of the rash. A characteristic of primary varicella is that lesions in all stages may be present at one time (8). Patients often have a prodrome of fever, malaise, headaches, and dysesthesias that precede the vesicular eruption by several days (139). The characteristic rash usually affects a single dermatome and begins as an erythematous maculopapular eruption that quickly evolves into a vesicular rash (Fig. The lesions then dry and crust over in 7 to 10 days, with resolution in 14 to 21 days (112). Both immunocompetent and immunocompromised patients can have complications from herpes zoster; however, the risk is greater for immunocompromised patients (147). Complications of herpes zoster include herpes zoster ophthalmicus (140,148), acute retinal Fever and Rash in Critical Care 37 Figure 8 Lower abdomen of a patient with a herpes zoster outbreak due to varicella zoster virus. The diagnosis of primary varicella infection and herpes zoster is often made clinically. The World Health Organization declared that smallpox had been eradicated from the world in 1980 as a result of global vaccination (156,157).