21. рд╕рдиреНрддрд┐ рдЬреНрд╡рд░
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рд╕рдиреНрддрддреНрдпрд╛ рдпреЛрд╜рддрд╡рд╕рдЧреА рд╕реНрдпрд╛рддреНрд╕рдиреНрддрд┐рдГ рд╕ рддрдирдЧрджреНрдпрд┐реЗ ||рд╕реБ.рдЙ.39/ремреп||
Spreads through out the body by Rasavahi dhamani
рд╡рд╛рд┐-7 days
рддрдкрддреНрддреН -10 days
рдХрдл- 12 days
If Doshas are alpa will subside or else will kill the patient
Has 12 Ashrayas- рддрддреНрд░рджреЛрд╖рд╛, рд╕рд┐рд┐рд╛рд┐реБ, рдорд┐ and рдореВрддреНрд░
94. Dengue Fever
тАв Break-bone fever
тАв 4 serotypes:
тАв DEN-1
тАв DEN-2
тАв DEN-3
тАв DEN-4
тАв DEN-2: Produces DHF,DSS
тАв Seasonality of July to November
тАв Dengue virus is a positive-stranded encapsulated RNA virus
тАв Belongs to the flavivirus genus of the Flaviviridae family
95.
96. тАв After an acute phase of infection by a particular serotype there is
lifelong immunity to the infecting serotype but only temporary and
partial protection against the other three serotypes and secondary or
sequential infections are possible after variable time period
98. тАв High concentrations of this antigen can be detected in patients with
primary and secondary dengue infections up to 9 days after the onset
of illness with the newer kits
тАв Antigen detection in the acute stage of secondary infections can be
compromised by pre-existing virusтАУIgG immune-complexes.
99. тАв Symptomatic dengue infection is a systemic and dynamic disease having
wide clinical spectrum that includes both severe and no severe clinical
manifestations.
тАв The incubation period lasts for 5 to 7 days and the onset of the illness is
abrupt.
тАв Common presenting symptoms include high-grade fever, headache, retro-
orbital pain, myalgia, arthralgia, nausea, vomiting and rash. The symptoms
usually last for 2-7 days.
тАв Three phases: febrile, critical and recovery.
тАв The severity of the disease becomes apparent during defervescence
(transition from the febrile to the afebrile phase).
тАв Increased capillary permeability, that lasts approximately for 24 to 48
hours, is more common in secondary dengue infections.
101. Course of Dengue Illness
Febrile or Viremic Phase Critical Phase Recovery Phase
тАв Lasts for 2 to 7 days.
тАв Symptoms: Headache, Myalgia,
Arthralgia, Retro-orbital pain
тАв Children: anorexia, N/V
тАв Progressive decrease in WBC
(TC<5000/ cumm) & mild Thrombo-
cytopenia +/- mild hemorrhage
тАв Positive Tourniquet Test
тАв Warning signs between days 3
and 7 of illness.
тАв Increased capillary permeability
causing plasma leakage.
тАвA Rising Hematocrit is the earliest
sign of plasma leakage.
тАв Gradual re-absorption of extra-
vascular compartment fluid takes
place in following 48 to 72 hours.
тАв General well-being improves
тАв Isles of white in the sea of red
тАв Fluid Overload may happen
Dehydration, High fever
яГаneurological disturbances &
febrile seizure
Shock from plasma leakage: severe
hemorrhage and organ impairment
Hypervolemia and acute
pulmonary oedema
102.
103. Immunopathogenesis of DHF / DSS тАУ Cytokine
overproduction
тАв Serotype cross-reactive antibodies from the previous infection bind to
virions without neutralization and enhance the entry of virus into
monocytes
тАв The number of virus-infected monocytes increases
тАв As a result, the level of T-cell activation is markedly increased,
reflecting the increased antigen presentation
тАв Increased frequency of dengue-virus-specific T cells in secondary
infectionThese T cells produce cytokines such as IFN-╞┤, IL-2, and TNF┬╖,
and lyse dengue-virus-infected monocytes
104. Immunopathogenesis тАУ Complement
activation
тАв The risk of DHF/DSS is higher in secondary infections with dengue virus of
serotype 2 compared to the other serotypes.
тАв Apparently, viral load is also a contributing factor in the development of
DHF/DSS
тАв The complement cascade is activated by a virus-antibody complex as well
as by several cytokines to release C3a and C5a that also have direct effects
on vascular permeability.
тАв The synergistic effects of IFN-╞┤, TNF┬╖, and activated complement proteins
trigger plasma leakage from capillaries in secondary dengue
тАв DHF develops rapidly, usually over a period of hours, and resolves within 1тАУ
2 days in patients who receive appropriate fluid resuscitation.
105. Grading of DF/ DHF
тАв DF: Fever of 2-7 days with two or more of following- Headache, Retro
orbital pain, Myalgia, Arthralgia with or without leukopenia,
thrombocytopenia and no evidence of plasma leakage.
тАв DHF I: Above criteria plus positive tourniquet test and evidence of plasma
leakage. Thrombocytopenia with platelet count less than 1,00,000/ mm3 and
Hct rise more than 20% over baseline or Fall in Hct by 20% after Fluid
replacement.
тАв DHF II: Above plus some evidence of spontaneous bleeding in skin or other
organs (black tarry stool, epistaxis, gum bleeds) and abdominal pain.
тАв DHF III (DSS): Above plus circulatory failure (weak rapid pulse, narrow pulse
pressure < 20 mm Hg, Hypotension, cold clammy skin, restlessness).
тАв DHF IV (DSS): Profound shock with undetectable blood pressure or pulse.
106. Warning and danger signs and symptoms of
dengue fever
тАвBleeding: epistaxis, scanty haemoptysis, hematemesis, gum bleeding, black
coloured stools, excessive menstrual bleeding, dark-coloured urine or haematuria.
тАвLethargy and/or restlessness
тАвSudden behavioural changes
тАвConvulsions.
тАвDifficulty in breathing or palpitation or breathlessness.
тАвPersistent vomiting >3 times a day.
тАвSevere abdominal pain
тАвPostural hypotension - dizziness.
тАвPale, cold clammy extremities.
тАвNot able to drink and no urine output for 4-6 h or urine output less than 0.5
ml/kg/h.
107. Warning and danger signs and symptoms of
dengue fever
яГШAdditional danger signs for clinicians
тАвEnlarged and/or tender liver
тАвRising haematocrit together with rapid fall in platelet count. тАвMetabolic
acidosis.
тАвDerangement of liver/ kidney function tests.
тАвPleural effusion/ ascites/ gall bladder oedema clinically or by imaging.
яГШKEY POINTS:
тАвWarning signs between days 3 and 7 of illness.
тАвIncreased capillary permeability causing plasma leakage is the main
pathophysiology.
тАвA rising haematocrits the earliest sign of plasma leakage
108. Laboratory Diagnosis of Dengue Virus
яГШNS1 Antigen Detection
яГШ Serology: The study of the diagnosis of disease by measuring
antibody levels in serum is referred to as serology.
яГШ IgM-captured enzyme-linked immunosorbent assay (MAC ELISA)
яГШ RT-PCR and Real time RT PCR
яГШ Virus Isolation and Culture
From onset of Illness to 5 days of
feverяГаVirus detected in serum, Plasma,
circulating blood cells and tissues
яГаVirus isolation Nucleic Acid Detection
NS1 Antigen Detection
From 6th Day onwardsяГа Antibody
Detection First antibody to appear тАУIgM
Secondary Antibody тАУ IgG
Any one of the NS1Ag and IgM assays is confirmatory for diagnosis of Dengue if done
through ELISA method
109. Distinct clinical and initial parameters to
differentiate from other viral aetiologies
1. Positive Tourniquet Test
2. Relative bradycardia
3. Leucopenia with Relative lymphocytosis
4. Specific Aspartate Aminotransferase [AST] elevation and Serum
Lipase elevation
110. Clinical Management
General management of Dengue Fever (DF):
тАв Management of dengue fever is symptomatic and supportive
тАв Bed rest is advisable during the acute phase.
тАв Use cold/ tepid sponging to keep temperature below 38.5 ┬░ C.
тАвParacetamol as Antipyretic to lower body temperature is preferable in the
recommended doses [Note: In children the dose of oral and IV paracetamol is
calculated as per 15 mg/Kg body weight and 10 mg/Kg body weight respectively
per dose at an interval of 6 hrs depending upon fever and body ache ]
тАв Encourage oral intake of at least 5 glasses of other fluids (with electrolytes) in
addition to normal daily intake of plain fluid. Small frequent sips for those with
nausea and anorexia.
тАв Patients should be monitored for development of complications till 24 to 48
hours after they become afebrile.
111. When to start and stop intravenous fluid
therapy
Febrile phase
тАв Limit IV fluids.
тАв Early IV therapy may lead to fluid overload especially with nonisotonic IV
fluid
Critical phase
тАв IV fluids are usually required for 24тАУ48 hours
NOTE: For patients who present with shock, IV therapy should be
Recovery phase
тАв IV fluids should be stopped so that extravasated fluids can be reabsorbed
112. Management of Severe Bleeding
тАв Platelet Transfusion
тАв Blood Transfusion-Loss of blood (overt blood)тАФ10% or more of total
blood volume
113. Ayurvedic Co relation
тАв Its been corelated to Dandaka Jwara
тАв Mentioned in Parishishta Chap of Madhava Nidhana
тАв Where the basic cause is due to bite of a particular species of
mosquito
тАв Features of Dandaka Jwara is very similar to Vatolbana Sannipataj
Jwara
114. Typhoid Fever/Enteric Fever
тАв Typhoid fever is a life-threatening infection caused by the bacterium
Salmonella Typhi.
тАв It is usually spread through contaminated food or water. Once
Salmonella Typhi bacteria are ingested, they multiply and spread into
the bloodstream.
тАв Urbanization and climate change have the potential to increase the
global burden of typhoid.
тАв In addition, increasing resistance to antibiotic treatment is making it
easier for typhoid to spread in communities that lack access to safe
drinking water or adequate sanitation.
115. Symptoms
тАв Salmonella Typhi lives only in humans.
тАв Persons with typhoid fever carry the bacteria in their bloodstream
and intestinal tract.
тАв Symptoms include prolonged high fever, fatigue, headache, nausea,
abdominal pain, and constipation or diarrhoea.
тАв Some patients may have a rash.
тАв Severe cases may lead to serious complications or even death.
тАв Typhoid fever can be confirmed through blood testing.
116. тАв Untreated typhoid fever may progress to delirium, obtundation,
intestinal haemorrhage, bowel perforation, and death within 1 month
of onset.
тАв Survivors may be left with long-term or permanent neuropsychiatric
complications.
тАв The term typhoid derived from the ancient Greek word for cloud, was
chosen to emphasize the severity and long lasting neuropsychiatric
effects among the untreated.
117. Characteristics
тАв Clinically characterized by typical continuous fever for 3-4 weeks,
relatively bradycardia with involvement of intestinal lymphoid tissue,
reticuloendothelial system and gall bladder.
118. Causative agent
тАв Salmonella typhi
тАв A gram negative, facultative aerobic, non spore forming bacteria that
is motile due to its peritrichous flagella
тАв Grows best in 37 C
тАв Has two sets of antigens for detection
тАв 1 Somatic or O antigen
тАв 2 Flagellar or H antigen: strong immunogenic induces antibody formation and
present in high titters following infection or immunization
119. Cases Carriers
A case in infectious as long as bacilli appears in stool
or urine
Temporary/Incubatory- excrete bacilli for 6 -8 weeks
Chronic- excrete bacilli for more than a year, organ
persists in gall bladder/biliary tract
120. Pathopysiology
тАв Ingestion of contaminated food or water
тАв Invade small intestine and enter bloodstream
тАв Carried by white blood cells in the liver, spleen, and bone marrow
тАв Multiply and re-enter the blood stream
тАв Bacteria invade gall bladder, biliary system and lymphatic tissue of the
bowel and multiply in high number
тАв Then pass into the intestinal tract and can be identified for diagnosis
in culture from the stool tested in lab
121. Course of Disease
тАв S typhi and paratyphi are clinically indistinguishable from each other.
тАв Symptoms of disease develop 7-14 days after ingestion of the organism.
тАв Over the course of the first week of illness, a wide variety gastrointestinal
symptoms of the disease develop. These include diffuse abdominal pain
and tenderness and, in some cases, fierce colicky right upper quadrant
pain.
тАв Inflamed Peyer patches narrow the bowel lumen to the point of causing
significant constipation that may persist for the duration of the illness.
тАв If untreated the individual may develop a dry cough, dull frontal headache,
delirium, and severe malaise associated with marked stupor.
122. тАв Seven to 10 days into the illness, the fever plateaus at 103-104┬░F (39-
40┬░C).
тАв The patient develop Rose Spots, salmon-colored, blanching, truncal,
maculopapules that are 1-4 cm wide and fewer than 5 in number.
These generally resolve within 2-5 days. They are caused by bacterial
emboli to the dermis Occasionally , they may be seen in cases of
Shigellosis or nontyphoidal Salmonellosis.
123. тАв During the second week, the signs and symptoms listed above
progress.
тАв The abdomen becomes distended, and soft splenomegaly is common.
Relative bradycardia and dicrotic pulse (double beat, the second beat
weaker than the first) may develop.
124. тАв In the third week, the still febrile individual grows more toxic and
anorexic with significant weight loss.
тАв The conjunctivae are infected, and the patient is tachypneic with a
thready pulse and crackles over the lung bases.
тАв Abdominal distension is severe. Some patients experience foul, green-
yellow, liquid diarrhea (pea soup diarrhea).
тАв The individual may descend into the typhoid state, which is
characterized by apathy, confusion, and even psychosis.
тАв Necrotic Peyer patches may lead to bowel perforation and peritonitis.
This complication is often unheralded and may be masked by
corticosteroids. At this point, overwhelming toxemia, myocarditis, or
intestinal hemorrhage may cause death.
125.
126. тАв If the individual survives to the fourth week, the fever, mental state,
and abdominal distension slowly improve over a few days.
тАв Intestinal and neurologic complications may still occur in surviving
untreated individuals.
тАв Weight loss and debilitating weakness last months.
тАв Some survivors become asymptomatic S typhi carriers and have the
potential to transmit the bacteria indefinitely.
127. Investigation
1. Blood Culture: Blood cultures are positive
1st week-90%
2nd week-75%
3rd week-60%
4th week and later-25%
2. Felix-Widal Test
3. New Tests: IDL Tubex, Typhidot Test, Typhidot-M, Typhidot rapid, IgM Dip
Test.
128. Cases
1. Early Diagnosis by culture of blood or stool
2. Notification done where its mandatory
3. Isolation till 3 negative test
4. Treatment by appropriate antibiotics
5. Follow up examination of stools and urine after 3-4 months and 12
months after infection
129. Management
General:
тАв Mantenance of hyderation
тАв Antipyretics
тАв Appropriate nutrition
Specific: Antibiotics
Ampicillin, Amoxicillin, Trimethoprim& Sulphamethoxazole, Fluroquinolones
In Quinolone resistance- Azythromycin, 3rd gen cephalosporins- Ceftriaxone
130. Optimal Therapy
Susceptibility Antibiotic Daily dosage (mg/kg) Days
Fully sensitive Fluoroquinilove-
Ciplox/Oflox
15 5-7
Multi drug resistant Fluoroquinilone/Cefixime 15/15-20 5-7/7-14
Quinilone resistant Azithromycin/Ceftriaxone 8-10/75 7/10-14
Alternative effective Therapy
Susceptibility Antibiotic Daily dosage (mg/kg) Days
Fully sensitive Amoxicillin 75-100 14
Multi drug resistant Azithromycin/Cefixime 8-10/15-20 7/7-14
Quinilone resistant Cefixime 20 7-14
132. Carriers
тАв Treatment my intensive course of Ampicillin/Amoxicillin with
probenecid for 6 weeks
тАв Cholecystectomy if needed
133. Prevention
тАв Typhoid fever is common in places with poor sanitation and a lack of
safe drinking water.
тАв Access to safe water and adequate sanitation, hygiene among food
handlers and typhoid vaccination are all effective in preventing
typhoid fever.
тАв Typhoid conjugate vaccine, consisting of the purified Vi antigen linked
to a carrier protein, is given as a single injectable dose in children
from 6 months of age and in adults up to 45 years or 65 years
(depending on the vaccine).
134. Chikungunya
Chikungunya is a mosquito-borne viral disease caused by the
chikungunya virus (CHIKV), an RNA virus in the alphavirus genus of the
family Togaviridae. The name chikungunya derives from a word in the
Kimakonde language, meaning тАЬto become contortedтАЭ.
135. Distribution and transmission
тАв CHIKV was first identified in the United Republic of Tanzania in 1952
and subsequently in other countries Africa and Asia.
тАв Urban outbreaks were first recorded in Thailand in 1967 and in India
in the 1970s (2).
тАв CHIKV has now been identified in over 110 countries in Asia, Africa,
Europe and the Americas.
тАв All regions with established populations of Aedes aegypti or Aedes
albopictus mosquitoes have now experienced local mosquito-borne
transmission.
136. Symptoms
тАв In symptomatic patients, CHIKV disease onset is typically 4тАУ8 days (range
2тАУ12 days) after the bite of an infected mosquito.
тАв It is characterized by an abrupt onset of fever, frequently accompanied by
severe joint pain. The joint pain is often debilitating and usually lasts for a
few days but may be prolonged, lasting for weeks, months or even years.
тАв Other common signs and symptoms include chills, arthralgia orarthritis,
rash, nausea, vomiting, headache, conjunctival suffusion, mild
photophobia
тАв In the absence of significant joint pain, symptoms in infected individuals
are usually mild and the infection may go unrecognized.
тАв Once an individual is recovered, available evidence suggests they are likely
to be immune from future infections
137. Complications
тАв Most patients recover fully from the infection; however, occasional
cases of eye, heart, and neurological complications have been
reported with CHIKV infections.
тАв Patients at extremes of the age spectrum are at higher risk for severe
disease. Newborns infected during delivery and older people with
underlying medical conditions may become severely ill and CHIKV
infection can increase the risk of death.
тАв The joints of the extremities are swollen and tender. Some patients
may have incapacitating arthralgia or arthritis, which may last for
weeks to months.
138. Diagnosis
тАв Blood samples collected during the first week of illness using tests
such as reverse transcriptaseтАУpolymerase chain reaction (RTтАУPCR).
тАв IgM capture ELISA
139. Treatment
тАв The clinical management includes addressing fever and joint pain
with anti-pyretics and optimal analgesics, drinking plenty of fluids and
general rest. There is no specific antiviral drug treatment for CHIKV
infections.
тАв In Ayurveda its being co related to Sandhigata Sannipataja
Jwara(Bhavaprakasha), Vatapitta Jwara, Vatakapha Jwara, Sharad
Jwara(Bhela)