Mark Corson

By V. Cruz. Webb Institute.

Identification—A chronic and progressively destructive cheap endep 25mg mastercard, but poorly communicable bacterial disease of the skin and mucous mem- branes of the external genitalia cheap endep 50 mg without a prescription, inguinal and anal regions cheap endep 25mg with amex. One or more indurated nodules or papules lead to a slowly spreading, nontender, exuberant, granulomatous, ulcerative or cicatricial lesions. The lesions are characteristically nonfriable beefy red granulomas that extend peripherally with characteristic rolled edges and eventually form fibrous tissue. Lesions occur most commonly in warm, moist surfaces such as the folds between the thighs, the perianal area, the scrotum, or the vulvar labia and vagina. The genitalia are involved in close to 90% of cases, the inguinal region in close to 10%, the anal region in 5%–10% and distant sites in 1%–5%. If neglected, the process may result in extensive destruction of genital organs and spread by autoinoculation to other parts of the body. Laboratory diagnosis is based on demonstration of intracytoplasmic rod shaped organisms (Donovan bodies) in Wright- or Giemsa-stained smears of granulation tissue or on histological examination of biopsy specimens; the presence of large infected mononuclear cells filled with deeply staining Donovan bodies is pathognomonic. Haemophi- lus ducreyi should be excluded by culture on appropriate selective media. Infectious agent—Klebsiella granulomatis (Donovania granulo- matis, Calymmatobacterium granulomatis), a Gram-negative bacillus, is the presumed causal agent; this is not certain. Occurrence—Rare in industrialized countries, but cluster outbreaks occasionally occur. Endemic in tropical and subtropical areas, such as central and northern Australia, southern India, Papua New Guinea, Viet Nam; occasionally in Latin America, the Caribbean islands and central, eastern and southern Africa. It is more frequently seen among males than females and among people of lower socioeconomic status; it may occur in children aged 1–4 years but is predominantly seen at ages 20–40. Mode of transmission—Presumably by direct contact with lesions during sexual activity, but in various studies only 20%–65% of sexual partners were infected, thus not quite fulfilling the criteria for sexual transmission. Donovanosis occurs in sexually inactive individuals and the very young, suggesting that some cases are transmitted nonsexually. Period of communicability—Unknown; probably for the duration of open lesions on the skin or mucous membranes. Susceptibility and resistance—Susceptibility is variable; immu- nity apparently does not follow attack. Preventive measures: Except for those measures applicable only to syphilis, preventive measures are those for Syphilis, 9A. Educational programs in endemic areas should stress the impor- tance of early diagnosis and treatment. Control of patient, contacts and the immediate environment: 1) Report to local health authority: A reportable disease in most states and countries, Class 3 (see Reporting). Erythromycin, trimethoprim-sufamethox- azole and doxycycline have been reported to be effective but drug-resistant strains of the organism occur. Treatment is continued for 3 weeks or until the lesions have resolved; recurrence is not rare but usually responds to a repeat course unless malignancy is present. Many of these agents have been isolated from rodents but are not associated with human cases. Because they are caused by related causal organisms and have similar features of epidemiology and pathology (febrile prodrome, thrombocyto- penia, leukocytosis and capillary leakage), both the renal and the pulmo- nary syndrome are presented under Hantaviral diseases. Identification—Acute zoonotic viral disease with abrupt onset of fever, lower back pain, varying degrees of hemorrhagic manifestations and renal involvement. Severe illness is associated with Hantaan (primarily in Asia) and Dobrava viruses (in the Balkans). Disease is characterized by 5 clinical phases which frequently overlap: febrile, hypotensive, oliguric, diuretic and convalescent. High fever, headache, malaise and anorexia, followed by severe abdominal or lower back pain, often accompanied by nausea and vomiting, facial flushing, petechiae and conjunctival injection characterize the febrile phase, which lasts 3–7 days. The hypotensive phase lasts from several hours to 3 days and is characterized by deferves- cence and abrupt onset of hypotension, which may progress to shock and more apparent hemorrhagic manifestations. Blood pressure returns to normal or is high in the oliguric phase (3–7 days); nausea and vomiting may persist, severe hemorrhage may occur and urinary output falls dramatically. The majority of deaths (the case-fatality rate ranges from 5% to 15%) occur during the hypotensive and oliguric phases. Diuresis heralds the onset of recovery in most cases, with polyuria of 3–6 liters per day. A less severe illness (case-fatality rate 1%) caused by Puumala virus and referred to as nephropathia epidemica is predominant in Europe. Infec- tions caused by Seoul virus, carried by brown or Norway rats, are clinically milder, although severe disease may occur with this strain. Hantavi- ruses can be propagated in a limited range of cell cultures and laboratory rats and mice, mainly for research purposes. Leptospirosis and rickettsio- ses must be considered in the differential diagnosis. More than 25 antigenically distinguishable viral species exist, each associ- ated primarily with a single rodent species. Seoul virus is found world- wide, Puumala virus in Europe, Hantaan virus principally in Asia, less often in Europe, Dobrava (Belgrade) virus in Serbia and Montenegro (formerly the Federal Republic of Yugoslavia). In 1951, it was recognized among United Nations troops in Asia and later in both military personnel and civilians—the virus was first isolated from a field rodent (Apodemus agrarius) in 1977 near the Hantaan river. The disease is considered a major public health problem in China and the Republic of Korea. Occurrence is seasonal, most cases occurring in late autumn and early winter, primarily among rural populations.

Aural symptoms: The tumour presents in the Type A Tumour confined to the middle ear buy 25 mg endep with visa. Neurological symptoms: The tumour which infralabyrinthine part of the tempo- primarily arises from the jugular bulb ral bone cheap 25 mg endep overnight delivery. The thine part of the temporal bone and seventh and eighth cranial nerve involve- destruction of the petrous apex generic endep 75mg fast delivery. Staging of Glomus Jugular Tumour Pain is not the usual feature unless infection is present. Hearing tests may show conductive or external auditory canal by the Siegle’s sensorineural loss. X-ray examination of the mastoids is of prominent and red, with increased pulsations. Erosion of jugular plate Once the tumour perforates the drum-head is diagnostic(Phelp’s sign) it presents as a bleeding vascular polypoidal 4. Carotid angiography is helpful is diagnos- eighth, ninth, tenth and eleventh cranial ing the extent of the tumour as this tumour nerves are involved. Biopsy from the tumour mass is confir- Oldring and Fisch’s (1979) matory but should be done very carefully Classification of the glomus jugular tumour as the tumour is very vascular and bleeds is as follows: profusely. Larger lesions Examination reveals the friable bleeding may be treated by radiotherapy followed by mass in the external meatus and biopsy surgery. Antitumour drugs like per cent of all tumours of the cerebellopontine cyclophosphamide combined with radio- angle and 8 per cent of the brain tumours. Acoustic neuroma is a benign tumour and Eosinophilic granuloma Eosinophilic granuloma may be associated with multiple neuro- is a disease of unknown origin which may fibromatosis (von Recklinghausen’s disease) affect the temporal bone chiefly in children in which case it may be bilateral. Osteolytic lesions occur and involvement of the temporal bone may Origin present as a polypoid mass in the posterior These tumours arise from the distal neuri- canal wall followed by pain and infection. The tumour represents neo- surgery with steroids and radiotherapy has plasia of the Schwann cells and is correctly proved useful in such patients. Epithelial Tumours Spread The disease commonly affects elderly males In most cases, the tumour arises in the distal and squamous cell carcinoma is the common neurilemmal portion of the vestibular division variety of malignancy involving this region. The adjacent nerve malignancy, the discharge becomes blood roots in the cerebellopontine angle get stret- stained and may be profuse. Extratemporal spread in the posterior becomes progressive and more marked and fossa leads to increased intracranial pressure. Tumours of the Ear 99 Histopathology Neurological Evaluation The tumour consists of interlacing bundles of 1. A typical feature of these nystagmus, signs of papilloedema and tumours is that spindle shaped nuclei of corneal reflex. Corneal reflex reflects on the integrity of forming ribbon-like fasciculated structures the trigeminal nerve. Facial nerve examination: The posterior nuclei are seen scattered in connective tissue aspect of the external auditory canal fibrils (Antoni type B). Clinical Features As the tumour grows larger, there may be evidence of involvement of the cerebellum, The tumour is common in the 4th to 6th adjacent brainstem and other cranial nerves. Although the tumour most commonly arises from the vesti- Investigations bular nerve, the earliest symptoms are usually 1. Radiological investigation: To demonstrate nerves, and in late cases symptoms of the erosion or widening of the internal increased intracranial pressure may occur. Once the may show marked erosion of the internal tumour involves the cerebellum, cerebellar auditory meatus. It can pick up lesions as cranial fossa approach are carried out for the small as 2 mm with a positive predictive tumour limited to the meatus. The suboccipital approach latency difference of wave V of more than is adopted for the large tumours. Although this procedure is controversial in cases of Bell’s palsy and herpes zoster oticus but it has a definitive role in primary facial tumours and in cases of trauma where the nerve is disrupted and it is necessary to find the proximal and distal ends for repair. Pathology of Facial Nerve Injury Sunderland (1978) has described five possible degrees of injury facial nerve can undergo. It also supplies 4th degree Disruption of endoneurium and sensory twigs to concha and retroauricular perineurium regions. Intracranial—from pons to internal than the previous classification of neuro- acoustic meatus. Extratemporal—from stylomastoid paralysis in patients with Bell’s palsy or herpes foramen to its peripheral branches. Neuroma of middle ear anteriorly from the processus facial nerve cochleariformis, above the promontory and 7. Malignancy of the oval window to the pyramidal process middle ear cleft where it takes a bend, to start its vertical 9. Ramsay Hunt portion and comes out of the temporal bone syndrome through the stylomastoid foramen. The of the mastoid process the standard treatment is of the infective process, and postaural incision damages the nerve, so facial palsy recovery occurs with the the incision is placed more horizontally to control of the infection. During mastoidectomy, one should iden- Hunt’s syndrome): Herpetic infection of the tify the plane of the lateral semicircular geniculate ganglion is often associated canal, and avoid working at any level more with facial palsy accompanying auditory medial than this to avoid nerve damage. The compact bone of the digastric ridge eruptions usually occur on the concha, gives the plane of the stylomastoid antihelix, antitragus and external auditory foramen. The treatment in such cases is while working on the mastoid tip, other- symptomatic. The gouge and drill work should be otitis media (atticoantral variety), the parallel and in the line of the facial nerve.

It is a common heart bacterium buy endep 10mg with mastercard, causing much of our heart ailments endep 25 mg on line, particularly mitral valve disease and irregularity problems order endep 50 mg. After wisdom teeth are extracted, the hole left in the jaw frequently does not heal, it picks up Staphylococcus aureus from the mouth and a chronic infection is started. Pain and body damage will return unless you do the proper re- pair and cleanup work. Throat Pain Recurring sore throats are always improved by removing dental metal and root canals, and by cleaning up hidden tooth infections. Bacteria and viruses that cause sore throats are thriving in hiding places under and around dental metal. It is quite difficult to reach the center of such places (abscesses) with electric currents. Even if you could, you would reinfect the very next time you ate non- sterile food! The eye is a favorite location for many para- sites, including Giardia, amoebas, hookworm, schistosomes, Toxoplasma, and innu- merable others. The eye has two large bodies of watery fluid: the aqueous humor and vitreous humor, where no blood Light travels through the cornea, through traverses to bring in extra the aqueous liquid, the lens, and then the white blood cells when vast vitreous humor, finally striking the the need arises. It has its super sensitive spot on the retina, called own protective devices, the macula. Toxoplasma infection could be the beginning of a lifetime of eye disease due to weakening of the eyes at an early age. Toxoplasma also invades the brain, frequently causing a dull ache or pressure at the back of the head. By killing all the large parasites plus a few bacteria (Staphylococci, Chlamydias, Neisserias) the eye can become pain free in a few days. No indoor pets should be kept by a person of low immunity, since infecting yourself daily and then killing parasites daily is not a solution. Tapeworm stages should be killed with an herbal preparation, Rascal, or with a zapper. Only a zapper can kill all the segments and eggs at once, leaving nothing alive to wander about and find a new tissue to invade. Even her eyes had a dull ache around and behind them, some- times reaching to the back of the head. She was full of Ascaris, amoebas and pin- worms which kept her legs twitching and jerking in bed at night, even waking her up. She was so much better after the kidney cleanse and parasite program she was eager to cleanse her liver. Jessie Healy, middle aged and in good health otherwise, had carried the anxiety of having inherited retinitis pigmentosa for forty years. She had eight parasites in the retina including Toxoplasma from association with cats years ago. Macular Degeneration Dolores Bollapragada, 50ish, had suffered from clinical ergot poison- ing in the past which put her in a coma for several weeks. It no longer detoxified solvents for her, allowing them to accumulate in her retina. There she had propyl alcohol, benzene, carbon tetrachloride acetone, butyl nitrite, styrene, gasoline, wood alcohol, paradichlorobenzene (moth balls), pentane, methylene chloride and decane. Although there are common headaches, sinus headaches, migraines, and others, the causes of all overlap a great deal. Tooth infection, urinary tract infection, bowel problems, and a wormlet, Strongyloides are the common causes. There are also allergic connections which include milk, eggs, citrus and salty foods. Possibly the parasite wormlet comes first, since even young children can suffer with migraines. Strongyloides is a micro- scopically small threadworm that horses are plagued with, but humans and our pets pick it up easily. Perhaps it is really the special bacteria it brings with it that cause the blood vessels to seep or to spasm in the brain, causing pain. Bacteria hidden under a tooth filling or root canal or in a space where once a tooth was pulled can be the cause. Staphylo- coccus aureus is a favorite, but various Clostridia, Streps and others are often seen, too. Find an alternative dentist with experience cleaning cavitations and finding small hidden abscesses. If you get immediate relief from dental work, only to lose ground again later, the abscess may have formed again (they are notorious for forming again). Irrigate the dental wound site with white iodine (potassium iodide, 12 drops) or Lugol’s (6 drops) to ¼ cup water using a curved-tip syringe. Use the simple herb, Cascara sagrada, senna tea, or magnesium oxide tablets (2 to 3 a day) to help you eliminate frequently if your own regularity is lacking. Is it the toxins made by bacteria or the inflammation from the bacteria or wormlets themselves that produces the headache? Certainly, one can eat the toxins by themselves in foods like yogurt, cheese, wine, sour cream and develop “royal” headaches. Boil all your dairy foods to prevent Salmonellas and Shigellas from swimming into your beleaguered brain.

Health staff should be aware of the should only be used where absolutely necessary and importance of audit and always be involved 75 mg endep with amex. The risk of areas where audits may be useful include: infection is greatly increased in such units discount 50mg endep, due in • handwashing; part to the presence of various pieces of invasive • environmental cleanliness; equipment buy endep 50mg line. All • decontamination procedures; and methods of • patient outcomes, for example, postoperative decontamination wound infections. The measures taken to prevent and control spread of number of visitors may need to be limited and infection are essential in everyday practice. Such they must be advised on the precautions to be documentation will alert healthcare workers to the followed. Thorough, correct handwashing is the recommended precautions and in turn help to most important measure that can be carried out to control nosocomial infections. Occupational health staff and infection control Other considerations staff often work closely together to provide It is recommended that infection control teams protection to staff from infectious diseases. These teams, Immunizations which should be made available consisting of an infection control doctor and include hepatitis B. In addition, occupational infection control nurse, should be consulted on all exposures to patient blood or body fluids should infection-related matters. The team should always be reported, as steps must be taken to protect regularly conduct surveillance, and audit and and reassure exposed healthcare workers. This can recommend best practice to prevent or control be done swiftly and effectively by trained nosocomial infections. Page 24 Module 1 Summary of key points The health status of the staff is clearly an important • The principles of infection control and prevention factor in limiting cross infection to susceptible are essential in the everyday care of patients within patients, particularly in high-risk areas such as healthcare settings. Illnesses (coughs and colds) as well as conditions • We continually share our environment with many (eczema and psoriasis) among healthcare staff must different microorganisms. Occupational health and infection and their pathogenicity is extremely important for control officers should work closely together when healthcare workers. More detailed information about individual diseases, including definitions, epidemiology within Europe, modes of transmission, methods of prevention, treatment options, and practical nursing care can be found in Modules 3 – 6 of this manual. A suspension of dead, attenuated, or otherwise modified microorganisms for inoculation to produce immunity to a disease by stimulation of antibodies 2. A preparation of the virus cowpox Page 41 Module 2 Page 41 Basic principles of immunization It is widely acknowledged that the two most Immunization occurs when a specific resistance to important public health interventions, which have an infectious disease is induced by the had the greatest impact on the world’s health, are administration of a vaccine. In addition, immunization has been shown to be one of the safest and most cost- Active immunization involves the stimulation of effective interventions known. This can be achieved by the Edward Jenner administration of: produced the very • live attenuated organisms: the organism’s first vaccine over two pathogenicity is reduced by sequential subculturing hundred years ago. He took some material from a cowpox • toxoid: the inactivated products of an organism pustule and scratched it into the arm of a young (for example, diphtheria, tetanus); boy. The boy developed a cowpox pustule and mild • components of organisms: such as capsular fever but remained well when subsequently polysaccharides (for example, meningococcal, inoculated with smallpox. The first vaccine had pneumococcal); and been discovered and indeed, as a consequence, the • genetically engineered viral products (for example, original meaning of “vaccine” was “protection hepatitis B). One hundred and seventy years later, following a targeted global vaccination Passive immunization does not induce an antibody programme, smallpox had been completely response; rather it involves the direct transfer of eradicated. It was to be almost one hundred years later before Immunity is gained immediately but is short-lived. A child to be prepared by taking blood from actively who had been bitten by a rabid dog was inoculated immunized donors (e. Active immunization is preferred to passive The discoveries of Jenner and Pasteur formed the immunization for the following reasons: basis for vaccine production. Now there are many • it confers long term immunity, and different types of vaccine. Page 42 Module 2 Administration of vaccines Passive immunization is generally reserved for Consent (written or implied) must be obtained situations where: from parents or guardians of small children before • rapid immunity is needed (for example, for post- any vaccine is given. It is important to understand exposure treatment of a tetanus-prone wound), and local policy on informed consent. Doctors and nurses who administer vaccines must have suitable training in the appropriate techniques. A primary course of immunization may consist of Training for anaphylaxis should be undertaken and one or more doses of vaccine depending upon the suitable drugs and equipment should be available individual vaccine. A All vaccines vary full course of immunization may consist of a slightly, but all come primary course of vaccine followed by one or more packaged with a boosters. Boosters of vaccine are given at varying manufacturer’s data intervals depending upon the individual vaccine. Vaccines needing to be reconstituted with diluent should be used within the manufacturer’s time recommendations. Generally vaccines are administered via the oral, intramuscular, subcutaneous or intradermal routes. Vaccines that are not administered via the correct route may be sub-optimal or cause harm. If the skin is cleaned with alcohol prior to the administration of a vaccine, the alcohol should be allowed to dry first. Correct vaccine administration techniques hepatitis B can be administered if appropriate. If immunization is delayed because of be disposed of safely, usually in a sharps bin for mild illness, there is a risk that the child may not incineration. Throughout the world, lost opportunity Administration of more than one vaccine because of false contraindications is a major cause When more than one live attenuated vaccine is to of delay in completing the immunization schedule. All other vaccines can be given malignant disease, therapy with immuno- within any time schedule. This is especially A severe adverse event following a dose of vaccine important in areas where vaccine uptake is poor.