3. 3
Fever
Temperature elevation >38oc
Characteristics
Incubation period
Pattern
Duration
Associated symptoms and signs
According to studies of healthy individuals 18–40 years of age, the mean
oral temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F), with low levels at 6 A.M.
and higher levels at 4–6 P.M
Rectal temperatures are generally 0.4°C (0.7°F) higher than oral readings
It then rises by ~0.6°C (1°F) with ovulation and remains at that level until
menses occur. Body temperature can be elevated in the postprandial state.
4. 4
Fever continued
Incubation period
Short <10 days
Bacillary dysentry, Ricketsial infections, RF,
Plague
Intermediate: 10-21 days
Typhoid, Malaria, Typhus, HIV, Brucellosis
Long: >21 days
Viral hepatitis, Malaria, Amebic liver abscess,VL
5. 5
Pattern
Periodic fever: Malaria
Biphasic or saddle back: (short afebrile
period)- Dengue, leptospirosis
Undulant fever: (waxes and wanes over
days)- Brucellosis, VL, lymphoma
Relapsing fever: settles spontaneously with
recurrence after intervals of few days or
weeks.
Hectic fever--- abscess
10. 10
Contd.
Three major groups:
Typhus group
R. prowazeki-(epidemic typhus)
Transmision by human body louse
R. typhi-(endemic murine typhus)
Transmision by Rat flea
Spotted fever group
R. rickettsi
Transmision by ticks from Rodents
Scrub typhus
Orientia tsutsugamushi ( Mite borne)
11. 11
Epidemic typhus
(louse borne)
“Fever with stupor or smoke”
First recognized in 430 BC-great plague of
Athens.
1685 body louse involvement in the spread of
the disease.
In 1916 da Rocha Lima identified the etiologic
agent- Rickettsia prowazekii.
12. 12
Contd.
Transmission:
Peduculus humanus corporis
Air borne
Blood transfusion
Accidental lab. Exposure.
Risk factors
Poor hygiene
Over crowding-’jail fever’
Cold areas
poverty, war, disaster
13. 13
Contd.
mechanism:
Ingestion of blood from rickettsimic patient
R. prowazekii multiply in mid gut epithelia Cells
Defecates during its meal
Auto inoculation by scratching
Lice dies after 1-2 weeks- red louse syndrome
14. 14
Pathogenesis
Proliferation in the small blood vessel endothelial
surface- early febrile illness
Toxins damages the endothelial cell integrity
Leakage of fluid
Occlusive endangiitis
Micro infarction
Venous thrombosis and gangrene
Immune complex deposition- late febrile episode
15. 15
Clinical presentation
Incubation period: 12 days
fever
Abrupt onset ,high grade (39-40)
Resolves by second week
Myalgia: severe -crouching disease
Prostration, nausea and vomiting
Dry cough, epistaxis
16. 16
Contd.
Congested face
Depression, delirium,
meningoencephalitis
Skin rash 2-4 day of fever
Spottles epidemic typhus
17. 17
Complications
TM, hemiparesis, peripheral neuropathy
Psychiatric disturbance
Secondary infection
Pneumonia, otitis media
Myocarditis
Peripheral vessel occlusion
Recrudescent: (Brill-zinsser disease)
Due to immuno-supression and old age
18. 18
Diagnosis
Clinical:
Epidemic situation and rapid response to treatment
Serology:
Heterophile Ab to proteus mirabilis Ox19 and Ox2 strains (weil-felix
test)
Microaglutination-IFA titer of >1:128
Isolation by inoculation to guinea pigs or fertile duck eggs.
PCR
19. 19
Treatment
General:
Delousing-1% malathion
Fluid balance
Nursing care
Analgesics, Sedation
Antibiotics to secondary infection
Specific:
Doxycycline stat or till afebrile for 24hr.
TTC, CAF, Quinolone, Rifampine
Predensolone??-severe cases ; renal failure.
20. 20
Prevention
Delousing
Personal and environmental hygiene
Contact treatment with Doxycycline.
Out come
Rapid defervescence in 48 hrs
If untreated mortality 7-40%
22. 22
Introduction
A systemic disease characterized by fever and
abdominal pain.
Exclusively human disease caused by an organism of
genus salmonella, family of enerobacterisae.
First report as separate clinical entity in 1578.
Pathological difference confirmed in 1832 by
Gerhard.
24. 24
Contd.
Transmission:
S. typhi and S. paratyphi acquired through
contaminated food and water with faeces
and urine.
Human faeces as a fertilizer
Contaminated water
S. paratyphi is less often water borne-
needs higher infective dose.
25. 25
Risk factors
1. Dose of the organism
2. State of gastric acidity
1. Use of antiacids & H2 blockers
2. Hypoacidity
3. Acquisition through contaminated food
3. Possession of Vi antigen.
26. 26
H.Pylori and typhoid fever
Positivity increases the risk
Others
Illiteracy
Non use of soap
Ice cream
27. 27
Pathogenesis
Multiplication in the SI lumen.
First 4 days-stool culture could be positive.
Proliferation in the mesenteric LN
Through thoracic duct reaches the blood stream–
primary bacteremia.
Dissemination to liver and spleen
Massive multiplication- secondary bacteremia.
Invasion of most organs
Gall bladder-chronic carriers
Peyer’s patches-hyperplasia and necrosis, perforation
28. 28
Clinical presentation
IP:10-20 days (1-10 days for paratyphi)
First week
Rising remittent fever
Malaise , Head ache
Mild non productive cough
Constipation
29. 29
Contd.
Second week:
Sustained high grade fever
Toxic and apathetic
Slight abdominal distension
Relative bradycardia
Splenomegaly
Rose spots-pink papules on the upper abdomen
and lower chest -result of bacterial embolization
30. 30
Contd.
Third week
More toxic, delirious & confusional state( typhoid
state)
Abdominal distension worsen
Diarrhea-foul, green-yellow, watery
Feeble pulse, rapid breathing
Lung base crackles
Death due to toxemia, myocarditis, intestinal
haemorrhage &/ perforation
31. 31
Contd.
Fourth week:
Fever, mental state and abdominal distension improves
Intestinal complication may still occur
Chronic or recurrent fever with bacteremia- some
times associated with schistosomiasis.
Relapse
A week after stoppage of antibiotic
Seen in 10-20%
Rose spots may appear, blood culture could be positive
Milder and shorter duration
32. 32
Complications
Intestinal haemorrhage and perforation
Late second and early third week
Bleeding per rectum
Sharp fall in body temp. and BP
Sudden tachycardia
For perforation:
Difficult to recognize because of ileus and distension
Worsening of pain and tenderness
Free fluid in the abdomen and gas under the diaphragm
36. 36
Laboratory
CBC-mild leukocytosis
Later neutropenia, mild anemia, thrombocytopenia
Culture:
Definitive Dx-blood or BM culture
Presumptive evidence-stool or urine culture and clinical picture
Blood culture:
Yield -1st WK 90% and 3rd wk 50%
BM culture positive-90% despite treatment
Duodenal string test
Combined yield is >90%
Stool culture: positive in 30-40% only by 1st wk increases by 3rd wk
In 90% clear bacteremia by 8th wk
False positive in chronic carriage
37. 37
Contd.
Serology:
Ab against flagellar (H) and somatic (O) Ag –widal
test
False positive
Immunization, early infection-serology scar, anamnestic
reaction
Chronic carrier state:
Stool culture positive by 3rd month (3%)
Remained positive >1 year (1-3%)
Common in women and elderly and those infected
with S.hematobium
38. 38
Treatment
First line
Fluoroquinolones-cipro and oflo x 10 days
Fewer Rx failures and rapid resolution
3rd generation cephalosporine-ceftriaxone
2nd line-Azithromycine 1gm/d x 5days
Alternatives- CAF, Ampicillin, Tmp-Smx
Severe forms: Fever, delirium, coma, septic shock
and positive culture
Dexa-3mg/kg loading then 1mg/kg 6hrly x 2 days
Decreases mortality from 56% to 10%
39. 39
Rx contd.
Blood transfusion and supportive care for
haemorrhage
Surgical intervention for perforation
Chronic carriage state:
Amox, TMP-SMX, cipro, norfloxacine for 6 weeks
Surgical correction of defects
Out come:
Duration of fever 3-5 days
Mortality <1%
40. 40
Prevention
Personal and environmental hygiene
Vaccine
Whole cell killed vaccine, Ty21a attuenated, Vicps
polysaccharide
Indication:
Contacts with chronic carriers
Lab workers
Travellers
Monitoring of food handlers
41. 41
Pregnancy and typhoid fever
In adult females bacteremic typhoid
disease is pregnancy related (47%)
Treatment
Ampicillin/Amoxacillin/Cephalosporin
Complication is less
It doesn't affect the pregnancy
outcomes
43. 43
Introduction
Recurrent acute episodes of spirochetemia
and fever alternate with spontaneous
spirochetal clearance and apyrexia.
Two forms:
TBRF-a zoonosis transmited from rodents to
humans by tick bite
LBRF-disease of humans transmited by body louse
44. 44
Etiology
Borrelia spp
B. dutoni agent of TBRF
B. recurrentis-LBRF
B. burgdorferi-Lyme disease
Vector:
Body louse- transmission is by crashing of
pruritic louse bites
45. 45
Risk factors
Overcrowding, impoverishment,
unhygienic condition
Prisoners, war, famine
Cool, rainy season
Close contacts
Accidental needle prick
46. 46
Pathogenesis
Multiplication in blood- (febrile period)
Sequestration at liver, spleen, BM &
CNS- (remission)
Activation of mediators of inflammation
Hageman factor, complement system
Cytokines: IL-6, IL-8, CRP, TNF-responsible
for JHR
47. 47
Contd.
Edema and swelling of organs
Histocytic inflamation of myocardium
Petechial haemorrhage
Haemorrhagic infarction of the spleen, heart,
liver and brain
48. 48
Clinical presentation
IP: 7 days
Sudden high grade fever(>40 )
Chills, rigor, sweats, myalgia, arthralgia
Dellirium, prostration, photophobia,cough
Tachycardia, tachypnea
Meningismus
Icterus, petechia in 1/3 of patients
Tender Hepatosplenomegaly
Symptoms subside after 5 days with spontaneous
crisis
51. 51
Contd.
Jarisch-Herxheimer Reaction (JHR)
Caused by release of mediators-TNF
Two phases
Chill phase:
Toxic T>41, rigors, hyper metabolism
Increase PVR & decrease in Pul. arterial pressure
Lasts 10-30 min
Flush phase:
Decrease in PVR & increase in Pul. Arterial pressure
Decrease in T, diaphoresis, decreased effective circulatory volume
Lasts<8 hrs
Sleep, exhaustion, recovery with disappearance of spirochetes
Mortality reaches 20% in malnourished & stressed
population.
52. 52
Dx.
Demonstration of spirochetes in blood also in
BM & CSF
Giemsa, wright or acridine-orange staining
Dark field microscopy : yield >70%
Serology-IFA, western immunoblotting
Insenstive, cross react with B. burgdorferi and T.
pallidum
CBC: low platelet
Coagulation profile: PT, PTT, BT-prolonged
53. 53
Treatment
Delousing: permethrine dust or liquid
Suportive: Rehydration, transfussion
Antibiotic:
Procaine penicilline
TTC
Monitor for JHR in 1-4 hrs of therapy
54. 54
Treatment of Complications
JHR
Supportive, cold sponging
Monitoring of fluid balance, arterial and venous pressure,
myocardial function
Pretreatment with Ab to TNF
Steroid, acetaminophen-no value
Myocarditis:
Caution with fluid balance
Ionotropics
Digoxin
Postural hypotention-during recovery
55. 55
Out come
Fatality rate with Rx is < 5%
Prevention:
Personal and environment hygiene
Living standard
Early case detection & treatment
Mass delousing
Doxy in out breaks of fever
57. 57
Bacterial Meningitis
Acute purulent infection with in the
sub-arachinoid space
Most common of suppurative CNS
infection (Empyema, Encephalitis)
61. 61
Contd.
Transmission via respiratory secretion
Gram negative diplococcic with
polysaccharide capsule –antigenecity
Nine sub groups
A, B, C, Y, W-135, D, 29E, X, Z
Epidemic-group A & C
Sporadic-group B
Group Y= older, chronic underlying illness,
African-American
Gp Y & W-135=in patient with pneumonia
62. 62
Contd.
300,000-500,000 cases/year
Annual incidence:
1-2cases/100,000-sporadic
5-10/100,000-hypersporadic
10 to >100/100,000-pandemic & epidemic
Peak incidence-winter ,respiratory viral illness
During epidemic peak among teenagers and
young adults.
63. 63
Cntd.
Secondary attack rate:
The risk is 1245x greater than general
population
Incubation period : 2-3 days
70% occurs in the 1st week
13% in 2nd week, 6% in the 3rd week
11% occurs from 4th -6th week
400-1000/100,000 in close contacts
64. 64
Contd.
Meningococci first isolated in 1896
In Sub-Saharan Africa it occurs every
8-14 years-Meningitis belt—extends 16
and 4 degree north (Senegal-Ethiopia)
Mean annual rainfall—300-1100mm
Incidence 400/100,000/yr during
epidemics, between epidemics 40 cases
per 100,000/yr.
66. 66
Contd.
Outbreak: case definition
Three or more cases in <3 months
Common affiliate or reside in the same
area but not close contacts
Primary attack rate>10cases/100,000
Strain isolate-N. meningitides of same
type.
67. 67
Pathogenesis contd.
Bacteria colonizes the nasopharynx
A defect in the barrier by URTI or
dryness
Transmigration to blood and reaches
the Pia and Arachnoids matters
Inflammatory response
Increased permeability of BBB
69. Meningitis can present as either an acute fulminant illness that
progresses rapidly in a few hours or as a subacute infection that
progressively worsens over several days.
The classic clinical triad of meningitis is fever, headache, and
nuchal rigidity.
A decreased level of consciousness occurs in >75% of patients
and can vary from lethargy to coma.
Nausea, vomiting, and photophobia are also common
complaints.
69
70. Seizure occur as part of the initial presentation of
bacterial meningitis or during the course of the illness
in 20–40% of patients.
Focal seizures are usually due to focal arterial
ischemia or infarction, cortical venous thrombosis
with hemorrhage, or focal edema.
Generalized seizure activity and status epilepticus
may be due to hyponatremia, cerebral anoxia, or,
less commonly, the toxic effects of antimicrobial
agents such as high-dose penicillin.
70
71. Raised ICP is an expected complication of bacterial meningitis
and the major cause of obtundation and coma in this disease.
More than 90% of patients will have a CSF opening pressure
>180 mmH2O, and 20% have opening pressures >400 mmH2O.
Signs of increased ICP include a deteriorating or reduced level
of consciousness, papilledema, dilated poorly reactive pupils,
sixth nerve palsies, decerebrate posturing, and the Cushing
reflex (bradycardia, hypertension, and irregular respirations).
The most disastrous complication of increased ICP is cerebral
herniation.
The incidence of herniation in patients with bacterial meningitis
has been reported to occur in as few as 1% to as many as 8%
of cases.
71
72. Specific clinical features may provide clues to the diagnosis of
individual organisms.
The most important of these clues is the rash of
meningococcemia, which begins as a diffuse erythematous
maculopapular rash resembling a viral exanthem; however, the
skin lesions of meningococcemia rapidly become petechial.
Petechiae are found on the trunk and lower extremities, in the
mucous membranes and conjunctiva, and occasionally on the
palms and soles.
72
73. 73
Clinical presentation
Nausea and vomiting, head ache & fever
Neck stiffness, photophobia
Lethargy and confusion
Petechia, purpura
Fever, HA, nuchial rigidity in >90%
Altered mental state >75%
Seizure-(due to infarction, ischemia,
hemorrhage, edema, toxicity).
Signs of increased ICP.
76. 76
Treatment
Emperic therapy
Penicilline
Third generation cephalosporine and vancomycine
Oily CAF
Specific Rx after culture result
Dexamethasone -10mg 20min before antibiotic
administration then every 6hrly for 4 days.
Decreases production of TNF
Contact Rx:
Rifampicine, cipro, ceftriaxone, azithromycine
77. 77
Contd.
Out break:
Oily CAF, Penicillin
Mass vaccination
Chemoprophylaxis of close contacts
78. 78
Out come
Mortality:
Meningococcal meningitis , H. influenza and GBS=3-7%
Pneumococcal meningitis=20%
In general, the risk of death from bacterial meningitis increases with (1) decreased level of
consciousness on admission, (2) onset of seizures within 24 h of admission, (3) signs of
increased ICP, (4) young age (infancy) and age >50, (5) the presence of comorbid
conditions including shock and/or the need for mechanical ventilation, and (6) delay in the
initiation of treatment. Decreased CSF glucose concentration [<2.2 mmol/L (<40 mg/dL)]
and markedly increased CSF protein concentration [>3 g/L (>300 mg/dL)] have been
predictive of increased mortality and poorer outcomes in some series.
Poor prognosis
Age
State of consciousness
Seizure
CSF glucose, protein
Delay treatment
79. 79
Acute viral meningitis
Etiology:
Enterovirus, coxasackie,echo, polio,HIV and HSV-2
Manifestation:
Fever, frontal head ache-retroorbital
Malaise, anorexia, nausea, vomiting
Lethargy or drowsiness
Mild nuchial rigidity
Absent kernig’s and Brudzinskis sign
80. 80
Contd.
CSF:
Lymphocytic pleocytosis (25-500/ul)
Protein and glucose slightly increased
Normal opening pressure
CSF PCR
90. 90
Introduction
“Bad air”-believed to be caused by bad
air.
Recognized long time ago
Treatment precedes exact pathogenesis
Early 20th century etiology recognized
92. 92
Etiology :
Plasmodium species
It is a haemoparasite affecting all stages of
RBC depend on the type of species.
P. falciparum-all stages of RBC
P. Vivax-affects young RBC up to 14 days old
and reticulocytes
P. ovale- affects reticulocytes
P. malariae- affects older RBCs
94. 94
Life cycle
Asexual reproduction
Sporozoites
Hepatic parenchyma cell asexual multiplication
Merozoites (10,000- >30,000)
Invades the RBC to become trophozoites
Schizonts---schizogony in 48hrs
Dougther merozoites released after rupture of RBC
invasion of other RBC and clinical manifestation
95. 95
Sexual multiplication
Schizonts developed to gametocytes
Taken by anopheles mosquito during its meal
Mid gut multipication
Zygote
Ookinete
To saivary gland of the mosquito
Inoculation with sporozoites
97. 97
Epidemiology
Palpable spleen and parasitic rate in children
2-9 years of age.
Hypoendemic <10%
Mesoendemic 11-50%
Hyperendomic 51-75%
Holoendemic >75%
Holoendemic and hyperendemic characterized
by:
>1 bites/day
High morbity and mortality during child hood
In Adults most infection are asymptomatic
99. 99
Contd.
Stable transmission
Year round transmission
Un stable transmission
Erratic focal low transmission
Protective immunity not acquired
Seen in hypo endemic area
100. 100
Pathogenesis
RBC becomes irregular in shape, less
deformable, more antigenic
Agglutination
Rosette formation (infected-uninfected)
Cytoadherence
Sequestration
Toxic Hemoglobin polymerizes to innert
hemozoin
101. 101
Clinical presentation
Fever, Head ache, myalgia, fatigue
Classical paroxysm of fever, chills, rigor
followed by a drenching sweating recurring
every 48 hrs in tertian and every 72 hrs in
quartan malaria
Irregular in P. falciparum
Mild anemia, palpable spleen
Mild jaundice, palpable liver
Resolution in 1-3 weeks
Mortality 0.1% if untreated
102. 102
Severe and complicated
malaria
1.Cerebral malaria
Def.
Unarousable coma lasting > 30min with
positive asexual forms of P. falciparum
Diffuse symmetrical encephalopathy
The onset can be gradual or sudden ff
convulsion
Mortality -20% in adults , sequele <3%
103. Corneal reflex is preserved except in
deep coma
Abdominal and cremasteric reflexes are
absent
15% retinal hemorrhage
103
104. 104
2. Hypoglycemia
Blood glucose < 40mg/dl
Causes:
Abnormal hepatic gluconeogenesis
Increased consumption mainly the host and to
lesser extent by the parasite
Effect of drugs:
Quinine increases pancreatic insulin secretion
Common seen with pregnancy and in children.
Clinical dx is difficult bc physical signs of … are
absent( the neurologic impairment caused by hypoglycemia confuses with that caused by
malaria)
105. 105
3. Anemia
Haematocrit <15% (Hgb <5gm/dl with
parasite density of <10,000/ul.
Cause:
Increased RBC dstruction
Hypersplenism
Coagulopathy
Bleeding due to stress ulcer
106. 106
4. Acute renal failure
Urine output < 400ml/24 hrs and no
change with rehaydration
Serum creatinine > 3mg/dl.
Cause:
RBC sequestration in the microcirculation
Manifested as ATN
In survivors, urine flow resumes in a median of 4 days, and serum creatinine
levels return to normal in a mean of 17 days. Early dialysis or hemofiltration
considerably enhances the likelihood of a patient's survival, particularly in acute
hypercatabolic renal failure
107. 107
5. ARDS (non cardiogenic PE)
Manifested with progressive worsening
of shortness of breathing
Can occur after several days treatment
Pathology is unclear
Mortality >80%
Careful with hydration
can also develop in otherwise uncomplicated vivax malaria, where recovery is
usual
108. 108
6. Lactic acidosis
Labored deep breathing
Dx:
Venous lactate level >5mmol/L
Bicarbonate <15 mmol/L
pH < 7.25
Lactic acidosis is caused by the combination of anaerobic glycolysis in tissues where sequestered parasites
interfere with microcirculatory flow, hypovolemia, lactate production by the parasites, and a failure of
hepatic and renal lactate clearance. The prognosis of severe acidosis is poor
110. 110
Contd.
10. Hemoglobinuria
Black water fever
Can cause renal failure
Septicemia may complicate malaria and Salmonella bacteremia has been associated specifically with P.
falciparum infections
Others-included in the 2000 WHO
Obtundation:
Prostration
Hyperparacytemia: > 10% in any population and
> 5% in non immune.
Jaundice with other vital organ dysfunction
(hemolytic, hepatic injury and cholestatic)
112. 112
Diagnosis
1.Peripheral blood smear:
Thin film
Number of parasitized RBC per ul=
Parasitized RBC/1000 RBC or 200 WBC
Numbers > 105 severe with increased risk of
dying
Poor prognosis:>20% of parasites identified as pigment-containing trophozoites and
schizonts
>20% of parasites with visible pigment
Phagositised malarial pigment in > 5% neutrophiles
113. 113
Contd.
Thick film:
To concentrate the parasite by 20-40 x
Increases sensitivity
Count parasites and WBC (200)
Up to 100-200 field should be examined
before declaring negative
114. 114
Contd.
2. Antibody based tests/sticks
Histidine rich protein 2 (pfHRP 2)
LDH Ag in finger prick blood
In patients who taken antimalarial and
cleared peripheral pasitemia
3. CBC:
Anemia, leukocytosis, thrombocytopenia
115. 115
Contd.
Prolonged PT and PTT
RFT
Serum creatinine
BUN
Serum glucose
Serum Na, HCO3
LFT, Bilirubine
116. 116
Treatment
Principles:
Document positivity
Grade the severity
Clinical signs
Parasitic load
Type of malaria
Benign human malarias-vivax, ovale and malarae Vs P. falcip
Classify –complicated Vs uncomplicated
Asses co morbidity
Pregnancy
Children
Preexisting cardiac and renal failure
117. 117
Drugs
Three broad groups:
1.Aryl amino alcohols- quinolone related or like
Quinine, Quinidine, Chloroquine, Amodoqune, Mefloquine,
Lumefantrine, Primaquine
2. Antifols:
Pyrematamine, Proguanil, Chlorproguanil, Trimetoprim
3. Artemisinin compounds:
Artemisinin, Dihydroartemesnin, Artemether, Artesunate
Broadest action against asexual parasites-medium sized rings to
early schizonts
It has a rapid therapeutic response
Antibacterial- Sulphonamides, TTC, Macrolides, CAF-slow action
118. 118
Contd.
Quinine acts in the middle third of life
cycle when there is greatest increase in
parasitic synthesis and metabolic
activity
Antifols acts a little later
Both donot act once schizont has formed
also not active against young rings –
artemisnin is preferable
119. 119
Benign human malarias
P. vivax, P. ovale, p. malarae
Chloroquine:
Sensitive
Dose-10mg/kg base, same after 24hrs, 5mg/kg at
48hrs.(4+4+2)
Primaquine:
For radical cure-prevents recrudescence.
Relapse is seen in 50% of those infected.
Primaquine eradicates hypnozoites in 80% of patients.
Dose-15mg/day for 14 days.
Monitor for vomiting with in 1 hr
Supportive-antipyretics
120. 120
Contd.
P. vivax and pregnancy
Increased anemia
Decreases birth weight by 100gm
Affects multigravida than primigravida
121. 121
Uncomplicated P. falciparum
Sulfadoxine- pyremetamine(SP)
Three tab. Stat
Resistance is increasing-40%
Artemisnin(20mg)+lumefantrine(120gm for 3
days.
Quinine-po
Mefloqine
Artemether(4mg/kg)+Mefloquine x 3d
Atavaquone+proguanil(malarone)-x 3d
122. In summary, the options now recommended for
treatment of uncomplicated falciparum malaria in
alphabetical order are:
■ Artemether plus lumefantrine,
■ Artesunate plus amodiaquine,
■ Artesunate plus mefloquine,
■ Artesunate plus sulfadoxine-pyrimethamine,
■ Dihydroartemisinin plus piperaquine
122
123. 123
Contd.
Follow up:
Daily BF till negative
At 48 hrs parasite decrease by 75%
Cleared by 7th day
If both requirement is not mate and adherence
is good suspect drug resistance- use alternate
drugs
SP Artesunate+mefloquine
Mefloquine quinine+doxy/clindam or
artesunate+ doxy
124. 124
Drug resistance-WHO def.
R1 resistance (low grade)
Recrudescence b/n 7-28 days after completion of Rx
following initial resolution of symptoms and parasitic
clearance
R2 resistance (high grade):
Decrease parasitic load by >75% at 48hrs but failed to clear
in 7 days.
R3 resistance
Parasitemia does not fall by >75% with in 48hrs.
125. 125
Complicated P. falciparum
A medical emergency
ABC
Resuscitate with IV fluids
Look for existing complication
Immediate blood glucose, Hct, parasitic
load, renal function, ABG
144. 144
Life cycle
Ova hatch in water to miracidia
Inside a Snail changed to Cercaria
Ceracaria attach to the skin
In the SC tissue transforms to schistosomula
Migration through venous or lymphatic to reach lung
and liver
Adults descend down to intestinal veins or visceral
veins
Ova penetrates the wall by enzymatic secretion and
reaches the intestinal lumen or urinary tract
145. 145
Epidemiology
Infection starts at the age of 3-4 yrs.
Peaks at 15-20 yrs.
Decreases after the age of 40 yrs.
S. mansoni endemic
Nile valley- Sudan, Egypt
Arabian peninsula
Latin America-Brazil
S. hematobium
Middle east, Africa, Indian
S. japonicum
China, Indonesia, Phillipines
148. 148
Clinical presentation
Depends on
Intensity of infection
Host factors-age, genetics
Three stages:
1. Swimmers itch
2-3 days after invassion
Itchy maculopapular rash at the affected site
Commonly seen with S. mansoni & S. japonicum
Self limiting
149. 149
2. Acute Schistosomiasis
“Katayama fever”
Occurs 4-8 weeks after skin invassion
Fever, generalized LAP
Hepatosplenomegaly
Peripheral blood eosinophilia
Occurs during worm maturation and at the
beginning of oviposition
Benign,Death reported with heavy exposure
151. 151
Contd.
Hepato-splenic phase
Hepatomegaly-granulomatous
Pre-sinusoidal portal fibrosis leads to portal
hypertension and splenomegaly.
Esophageal varices-bleeding is tolerable
because of normal liver function.
Cirrhosis- if it is associated with viral
hepatitis and malnutrition
152. 152
S. hematobium
Dysurea, frequency, hematuria
U/A:
Blood, albumine, bacteria, sediments,
cellular metaplasia
Urinary bladder granulomas leads to
obstructive uropathy, Squamous cell
Ca-hence it is a human carcinogen.
153. 153
Contd.
Pulmonary:
Cough, fever, dyspnea
Cor-pulmonale due to pul. Hypertension
CNS-granulomatous depossion
Epilepsy in S. japonicum
TM in S. mansoni & S. hematobium
154. 154
Dx.
Travel hx and exposure to fresh water bodies
For Katayama
Peripheral eosinophilia
High Ab for schistosoma-FAST-ELISA
Immuno electrotransfer blot(IETB)
Stool or urine for ova
Stool:
kato thick smear –quantifcation
Concentration method
Rectal biopsy
Ultrasound of the abdomen.
155. 155
Treatment
Phase 1.
Topical to relief itching
Phase 2.(Katayama fever)
Anti schistosomal chemotherapy
Immunosuppressant-steroid
Supportive
Phase 3.
Chronic form- supportive and treatment of
complication
Hepatic failure & varices
156. 156
Contd.
Chemotherapy
Praziquantel 40-60mg/kg divided in 2-3
doses for 1 day
Parasitological cure rate-85%
Decreases egg counts by >90%
Early hepatomegaly and bladder lesion
resolve after chemotherapy, fibrosis
remained the same
157. Patients with both HIV infection and schistosomiasis
excrete far fewer eggs in their stools than those
infected with S. mansoni alone; the mechanism
underlying this difference is unknown.
Treatment with praziquantel may result in reduced
HIV replication and increased CD4+ T lymphocyte
counts.
157
158. 158
Prevention
Endemic areas:
Sewage disposal, sanitation
Health education
Chemotherapy
For travelers
Avoid contact with fresh water bodies
If exposed follow up visits
159. 159
Filariasis
Nematodes that dwell in SC tissue and lymphatics
Eight filarial species of these, four—Wuchereria bancrofti, Brugia malayi,
Onchocerca volvulus, and Loa loa—are responsible for most serious filarial
infections
Lymphatic filariasis
W. bancrofti, B. malayi, B. timori
SC dwellers
Onchocerca volvulus, Loa loa
160. 160
Life cycle
Transmission by mosquitoes or arthropodes
Inoculates infective larvae
Develops to Adults that circulate in the circulation or
SC tissue.
Microfilaria formed –(stays for 3-36 months)
Ingested by arthropode vector and develop to new
infective larva in 1-2 wks
162. 162
Lymphatic Filariasis
Reside in lymphatic channels or LN. It
remained viable for > 2 decades.
W. bancrofti widely distributed , affects
> 115 million people.
Found in the tropics and sub topics
Common in Africa
Human- the only definitive host.
163. 163
Contd.
Vector:
Culex fatigans mosquitoes-urban
Anapheline or aedean in rural
W. bancrofti is nocturnally periodic. (Nocturnally periodic forms of
microfilariae are scarce in peripheral blood by day and increase at night,
whereas subperiodic forms are present in peripheral blood at all times and
reach maximal levels in the afternoon.)
B. malayi found in China, India, Indonessia, Korea, Japan, Malaysia, Phillipin.
164. 164
Pathology
Inflammatory damage to the lymphatics by
adult worms (not by microfilaria)
Lymphatic dilatation and thickening of vessel
wall.
Incompetence of lymphatic valves
Lymphedema and chronic stasis changes
Granulomatous reaction following death of
worms with fibrosis
Complete lymphatic obstruction
165. 165
Clinical presentation
The most common manifestation:
Asymptomatic microfilaremia, hydrocele,
acuteadenolymphangitis(ADL) and chronic
lymphatic disease.
Early manifestations
Microscopic hematuria or proteinuria
Dilated, totuous lymphatics – by imaging
Scrotal lymphangiectasia by ultrasound
166. 166
Contd.
ADL (acuteadenolymphangitis)
Fever – high grade
Lymphatic inflammation
Transient local edema
Inflammation is retrograde – extending
from the LN draining the area
In B. Malayi forms a local abscess –
raptures to the surface
167. 167
Cont.
Both involves the upper and lower
extremities
Genital involvement is exclusively with
W. bancrofti infection
Epididmitis
Scrotal pain and tenderness
168. 168
Cont.
Dermatolymphangioadenities (DLA)-another
type of acute disease other than ADL.
High grade fever, chills, myalgia and head
ache
Edematous inflammatory plaques
Vesicles, ulcers, hyper pigmentation
History of trauma precedes
Mimics cellulites
169. 169
Cotnd.
Chronic changes
Brawny edema follows early pitting edema, and thickening
of the subcutaneous tissues and hyperkeratosis occur.
Early pitting
Thickening of SC tissue and hyperkeratosis
Fissuring and hyperplastic changes with super infection
Hydrocele- scrotal elephantiasis
Furthermore, if there is obstruction of the retroperitoneal
lymphatics, the increased renal lymphatic pressure leads to
rupture of the renal lymphatics and the development of
chyluria, which is usually intermittent and most prominent in
the morning.
170. 170
Dx.
Demonstration of micrifilaria in blood, body fluids, hydrocele
Direct staining
by the centrifugation of fluid fixed in 2% formalin (knott’s technique)
Adult worms are not accessible
Serology- Ag of W. bancrofti
ELISA
rapid-format immunochromatographic card test
Sensitivity =96-100%
Specificity= 100%
PCR for DNA
High frequency U/S with Doppler
Visualizes worms in the scrotum or female breast. Worms may be visualized
in the lymphatics of the spermatic cord in up to 80% of infected men. Live
adult worms have a distinctive pattern of movement within the lymphatic
vessels (termed the filaria dance sign).
Eosinophilia
Increased IgE and antifilarial anti body They only
support
the dx
172. 172
Contd.
Difference from bacterial lymphangitis
Assending infection
Filarial infection a retrograde extension.
Active disease
Microfilaremia
Antigen positivity
Detection of adult worms on ultrasound
173. 173
Treatment
Active infection
DEC (Diethylcarbamazine)
Has both micro and macro filacidal properties
Dose-6mg/kg/d x 12days
Albendazole – macro filaricidal efficacy
Does – 400mg bid x 21days
An 8-week course of daily doxycycline (targeting the intracellular
Wolbachia endosymbiont) has significant macrofilaricidal activity
Adult worm carriers without microfilaria- need
DEC
Chronic complication
Surgical correction of hydrocele
It recurs
174. Side effects of DEC treatment include fever, chills, arthralgias, headaches,
nausea, and vomiting.
Both the development and the severity of these reactions are directly related to
the number of microfilariae circulating in the bloodstream.
The adverse reactions may represent either an acute hypersensitivity reaction to
the antigens being released by dead and dying parasites or an inflammatory
reaction induced by lipopolysaccharides from the intracellular Wolbachia
endosymbionts freed from their intracellular niche.
Ivermectin has a side effect profile similar to that of DEC when used in
lymphatic filariasis.
In patients infected with L. loa, who have high levels of Loa microfilaremia,
DEC—like ivermectin —can elicit severe encephalopathic complications.
When used in single-dose regimens for the treatment of lymphatic filariasis,
albendazole is associated with relatively few side effects
174
175. 175
Prevention
Impregnated bed nets.
DEC – prophylaxis
Mass distribution of chemotherapy
annually
Albendazole + DEC/Ivermectine
183. Onchocericasis ( River blindness)
Transmitted by blackfly vector that breeds along free-flowing
rivers and streams (particularly in rapids)
Onchocerciasis primarily affects the skin, eyes, and lymph
nodes.
In contrast to the pathology in lymphatic filariasis, the damage
in onchocerciasis is elicited by microfilariae and not by adult
parasites.
In the eye, neovascularization and corneal scarring lead to
corneal opacities and blindness. Inflammation in the anterior
and posterior chambers frequently results in anterior uveitis,
chorioretinitis, and optic atrophy.
183
184. Clinical feature:
Skin- Pruritus and rash are the most frequent manifestations of
onchocerciasis.
Onchocercomata– These are subcutaneous nodules, which can be
palpable and/or visible, contain the adult worm. In African patients, they
are common over the coccyx and sacrum, the trochanter of the femur,
the lateral anterior crest, and other bony prominences.
Ocular tissue-Lesions may develop in all parts of the eye. The most
common early finding is conjunctivitis with photophobia. Punctate
keratitis—acute inflammatory reactions surrounding dying microfilariae
and manifested as "snowflake" opacities—is common among younger
patients and resolves without apparent complications. Anterior uveitis
and iridocyclitis develop in ~5% of infected persons in Africa
184
185. Lymph node-- Mild to moderate lymphadenopathy is common,
particularly in the inguinal and femoral areas, where the enlarged
nodes may hang down in response to gravity ("hanging groin")
DX detection of an adult worm in an excised nodule or, more
commonly, of microfilariae in a skin snip.
Eosinophilia and elevated serum IgE levels are common .
The Mazzotti test is a provocative technique that can be used in cases
where the diagnosis of onchocerciasis is still in doubt (i.e., when skin
snips and ocular examination reveal no microfilariae). A small dose of
DEC (0.5–1.0 mg/kg) is given orally; the ensuing death of any dermal
microfilariae elicits the development or exacerbation of pruritus or
dermatitis within hours—an event that strongly suggests onchocerciasis
185
186. DEC (300 mg weekly) is an effective
prophylactic regimen for loiasis. But no
drug has proved successful prophylaxis
for onchocerciasis.
186
187. 187
Trypanosomiasis
Trypanosoma Cruzi Chagas desease
In America
A zoonosis
T.brucei gamiense and T.brucei rhodesiense
African trypanosmiasis
Human disease
Chagas disease
Mild febrile illness
Chronic chagas’ disease-manifested with
Rhythm disturbance
Dilated CMP
Thromboembolism
RBBB
188. 188
Sleeping sickness-HAT
Etiology: T. brucei complex
East Africa- Rhodesiense
West Africa- gambiense
Vector: Tsetse fly-blood sucking genus
Glossina.
After inoculation multiply in the blood and
other extracellular spaces
Under goes antigenic variation to evade
the immune system.
189. 189
Pathogenesis
At the site of inoculation : inflammatory
lesion called chancre-painful.
Occurs 1 week after the bite.
Dissemination through blood and lymphatics
to induce a febrile illness-Stage I disease.
Invasion of the CNS with perivascular
infiltration with mononuclear cells-Stage II
disease.
190. 190
Clinical presentation
Skin –tender lesion
Stage I:
AFI-relapsing type
LAP-discrete, rubery, non tender located on the
posterior cervical triangle called Winterbottom’s
sign.
Pruritic maculopapular rash
Malaise, fatigue, Wt loss
Hepatosplenomegaly, edema, tachycardia
191. 191
Contd.
Stage II- CNS invasion
Progressive day time somnolence alternate
with restlessness and insomnia at night
Speech- halting and indistinct
Extrapyramidal signs
Choreiform movement, tremor, fasciculations
Ataxia, hypertonia,
Shuffling gait
Progress to coma and death
192. 192
Contd.
West African- Insidious course
East African- Acute course
Symptoms appear early-persistent
tachycardia which is unrelated with fever
Death could be due to: arrhythmias & CHF
before CNS disease occurs
Takes weeks to months
193. Table 206-1 Comparison of West African and East African
Trypanosomiases
Point of Comparison West African
(Gambiense)
East African
(Rhodesiense)
Organism T. b. gambiense T. b. rhodesiense
Vectors Tsetse flies (palpalis
group)
Tsetse flies (morsitans
group)
Primary reservoir Humans Antelope and cattle
Human illness Chronic (late CNS
disease)
Acute (early CNS
disease)
Duration of illness Months to years <9 months
Lymphadenopathy Prominent Minimal
Parasitemia Low High
Diagnosis by rodent
inoculation
No Yes
Epidemiology Rural populations Workers in wild areas,
rural populations,
tourists in game parks
193
194. 194
Diagnosis
Demonstration of the parasite in:
Body fluids
Chancre, LN aspiration, BM, blood samples
Positivity is high in stage I than stage II, in T.b.
rhodesiense than T.b. gambiense
CSF examination
Increased pressure, mononuclear cells, protein
and IgM
Trypanosomiasis in centrifuged CSF
PCR
195. 195
Treatment
Depends on:
Type of the organism
Stage of the disease
T.b. gambiense
Stage I :
Suramine-1gm iv on 1,3,7,14 & 21 day through infusion
Toxic-renal failure
Eflornithine-400mg/kg/day x 2 weeks
Pentamidine
Stage II
Eflornithine
196. 196
Contd.
T.b. rhodosiense
Stage I:
Suramine
Alternate-pentamidine
Stage II:
Melarsoprol 2-3.6mg/kg/day iv 3 dosex 3d
Toxicity with reactive encephalopathy
Melarsoprol cures both stages of the disease and therefore is also
indicated for the treatment of stage I disease in patients who fail to
respond to or cannot tolerate suramin or pentamidine. However,
because of its relatively high toxicity, melarsoprol is never the first
choice for the treatment of stage I disease
197. Melarsoprol is highly toxic and should be administered with great care.
To reduce the likelihood of drug-induced encephalopathy, all patients receiving
melarsoprol should be given prednisolone at a dose of 1 mg/kg (up to 40 mg) per
day, beginning 1–2 days before the first dose of melarsoprol and continuing
through the last dose.
Without prednisolone prophylaxis, the incidence of reactive encephalopathy has
been reported to be as high as 18% in some series.
Clinical manifestations of reactive encephalopathy include high fever, headache,
tremor, impaired speech, seizures, and even coma and death.
Treatment with melarsoprol should be discontinued at the first sign of
encephalopathy but may be restarted cautiously at lower doses a few days after
signs have resolved.
Extravasation of the drug results in intense local reactions. Vomiting, abdominal
pain, nephrotoxicity, and myocardial damage can occur
197
198. 198
Prevention
Avoid insect bite
Protective clothing
Insect repellent
Vaccine not available
Chemoprophylaxis not recommended
200. 200
Ascaris lumbricoides
(Round worm)
The largest intestinal nematodes ,can
reach up to 40cm in length
Lives in the lumen of jejunum
Each worm can produces up to 240,000
egg per day
201. 201
Cont.
Maturation takes place in the soil
Larva hatched in the intestine
Invade the mucose
Migrate through the circulation to the
lungs => alveoli => bronchus
Swallowed => Intensine => Develop
into adult, then lives for 1 – 2 years
202. 202
Transmission
Fecaly contaminated soil
Poor sanitation
Affects young children
Transported vegetables as means of
transmission outside endemic areas
206. 206
Treatment
The aim is to prevent complications
Albendazole 400mg stat
Mebendazole 500mg stat
Pyrantel pamoate 11mg/kg stat maximum
1gm. Safe in pregnancy.
207. 207
Hook worm
Etiology:
A. duodenale
N. americanus
Ova changed to larva in soil
Larva penetrates the skin
Through bloods stream reach lungs
Swallowed => reaches the intestine
and lives for about a decade
208. 208
Clinical Presentation
Pruritic maculopapular dermatitis => ground itching at the site of skin
penetration as well as serpiginous tracks of subcutaneous migration
Pneumonitis – milder degree than that of Ascaris
Epigastric pain – post prandial accentuation
Diarrhea
Iron def. anemia, hypoprotenemia
Risk factor for diseases development:
Worm burden
Prolonged duration of infection
Inadequate iron intake
211. 211
Strongyloidiasis
Etiology: S. Stercoralis
S. stercoralis is distinguished by its ability—
unusual among helminths—to replicate in the
human host
Replicates with in the human host =>
autoinfection
In immuno-compromized host => become
invasive => Disseminate widely
Can be fatal
212. 212
Transmission
Fecal contaminated soil
Larva penetrates the skin--- lung---
sputum---ingested again to repeat the
cycle
Common in hot humid regions
213. 213
Clinical Presentation
Recurrent urticaria – buttocks & wrists
Migration –”Larva currens” – Running larva
Abdominal or epigastric pain which resembles
peptic ulcer pain except that it is aggravated
by food ingestion.
Nausea, diarrhea, Gl bleeding, mild chronic
colitis and weight loss
Pulmonary symptoms – rare
Eosinophilia - common
214. 214
Disseminated form=> fatal
GI, lung, CNS, Peritoneum, liver, kidney
Risk of bacteremia increases-
Gram negative sepsis
Pneumonia
Meningitis
Complications are common with HTLV-I
but not with HIV.
215. 215
Diagnosis
Stool for larva
Eggs are not detectable in stool
Rx. Even in the asymptomatic state, strongyloidiasis must be treated because of
the potential for subsequent fatal hyperinfection. Ivermectin (200 g/kg daily for
2 days) is more effective than albendazole (400 mg daily for 3 days). For
disseminated strongyloidiasis, treatment with ivermectin should be extended for
at least 5–7 days or until the parasites are eradicated.
Tinidazole
216. 216
Giardiasis
Intestinal protozoa
Infection occurs following ingestion of
hard cyst which excyst in the SI to
fagellated trophozoites.
Inhabits the proximal SI.
As few as 10 cysts sufficient to cause
infection in humans.
217. 217
Risk factors
Day care centers
poor fecal hygiene
Anal-oral contact
Food borne transmission
Water borne causes episodic infection. It resists killing by
chlorination.
Can occur as an epidemic or endemic
The greater susceptibility of the young than of the old and of
newly exposed persons than of chronically exposed populations
suggests that at least partial protective immunity may develop.
218. 218
Clinical presentation
Acute:
Abdominal pain, bloating, belching, flatus, nausea, vomiting and
diarrhea.
Duration > 1 week.
Chronic:
Increase in flatus, loose stools, Wt loss
Symptoms can be continuous or episodic
Complication:
Malabsorption
Weight loss
Growth retardation
Dehydration
Rarely causes death
A number of extraintestinal manifestations have been described, such as
urticaria, anterior uveitis, and arthritis
Course and treatment response is the same with HIV.
219. 219
Diagnosis
Cysts in feces or trophozoites
Ag detection in feces
Treatment:
Metronidazole (250 mg thrice daily for 5 days) usually >90%-----
cure rate.
Tinidazole (2 g once by mouth) is reportedly more effective than
metronidazole)
If refractory: prolonged therapy with metronidazole(750mg tid x 21
days)
224. 224
Reading assignment
Amaebiasis---Rx for acute colitis is
metronidazole 750mgPO or IV tid for 5–
10 days plus luminal agents (iodoquinol
and paromomycin) eradicate the cyst.
Cestodes
Taeniasis
Cysticercosis
Echinococosis
225. 225
TETANUS
Definition:
A neurological disorder characterized by
increased by muscle tone and spasm
caused by tetanospasmin, produced by
Clostridium Tetani.
Etiology:
C. Tetani a gram positive rods, aerobic
found in soil world wide also found in
animal and human feces.
226. 226
Mode of entry
Abrasion, laceration, puncture wounds
Complicates chronic skin ulcers, abscess
and gangrene
Burns, otitis media, surgery, abortion,
birth, body piercing and drug abuse
227. 227
PATHOGENESIS
Toxins binds to peripheral motor unit
terminal and axons
Intraneural transmissions blocks release
of GABA at presynaptic terminal
Agonist and antagonist recruitment lead
to spasm
At NM junction blocks release of
transmitters causes weakness or
paralysis
233. 233
Grading
Grade I (mild):
Moderate trismus, generalized spasticity
Grade II (moderate):
Short lasting spasms, RR>30-35/min, mild
dysphagia
Grade III (severe):
Generalized spasticity, prolonged spasms,
RR>40/min, apnaeic episodes, PR>120/min,
severe dysphagia
Grade IV (V. severe):
G III + severe dysautonomia HTN on hypotension
234. 234
Treatment
Principles
1. Eliminate the source of toxin
2. Neutralize the unbound toxin
3. Prevent muscle spasm
General measures
Respiratory support
Nursing in quiet room and ICU
Hydration and feeding
Input and output monitoring
235. 235
Specific Rx.
Wound debridment
Antibiotic-metronidazole or penicilline
Antitoxin
TAT 10,000 iv and 10,000 im
TIG 3000-6000 u im
Control spasm
Diazepam , chlorpromazine 6 hrly
Baclofen, succinyl choline
Mx of complication-dysautonomia, respiratory
237. 237
ANTHRAX
Definition:
An infection caused by Bacillus anthraces
It is disease of the herbivores-Goat,
Sheep & cattle
Humans infected by contact with the
agent from infected animals or their
products or via ingestion, inhalation, or
skin contact
238. 238
Contd….
B.anthracis is a gram positive rods,
sporulating, aerobic, non motile found
in soil
Mode of entry:
Skin-cutanous anthrax- in 95%
Inhalational: in 5%
Ingestion of raw or undercooked meat-GI
antrax-very rare
239. 239
Pathogenesis
Multiply in the blood stream
Produces toxins and cytokines causes
edema, inhibition of PMN leads to shock
and death
240. 240
Clinical presentation
Cutaneous anthrax
Site-face, neck, extremity
Small red macules with in days
Papules
Pustules
Central necrotic-black eshcar with surrounding
edema-painless
Painful regional LAP
Fever is uncommon
Secondary bacterial infection---high grade fever
seen in 10% then death
245. 245
Dx.
Clinical presentation
Contact history
Gram staining
Treatment
Crystalline penicillin iv till edema subsides then po
for 7-10 days.
Wound debridment
Post exposure –a 60 days antibiotic : doxycycline
or cipro
Vaccination-AVA--adsorbed
248. 248
Learning Objectives
Describe the basic virology and life
cycle of HIV
Describe the normal immunological
response to HIV-1
List the mechanisms used by HIV-1 to
evade the normal immune responses
Explain how HIV causes disease
Describe the natural course of HIV-1
249. 249
HIV Epidemic
Sudden outbreak in USA of opportunistic infections and
cancers in homosexual men in 1981
Pneumocystis carinii pneumonia (PCP), Kaposi’s
sarcoma, and non-Hodkins lymphoma
HIV isolated in 1984 - Luc Montanier (Pasteur Institute,
Paris) and Robert Gallo (NIH, Bethesda, USA)
HIV diagnostic tests developed in 1985
First antiretroviral drug, zidovudine, developed in 1986
Exploding pandemic
Has infected more than 50 million people around the
world
Has killed over 22 million people
251. 251
Genetic Origin of HIV-1
The simian origin of
HIV is broadly
acknowledged
HIV-1 is most
closely related at a
phylogenetic level to
SIVcpz from P. t.
troglodytes
253. 253
Classification of HIV
HIV class: Lentivirus
Retrovirus: single stranded RNA transcribed to double
stranded DNA by reverse transcriptase
Integrates into host genome
High potential for genetic diversity
Can lie dormant within a cell for many years,
especially in resting (memory) CD4+ T4 lymphocytes
HIV type (distinguished genetically)
HIV-1 -> worldwide pandemic (current ~ 33.2 M
people)
HIV-2 -> isolated in West Africa; causes AIDS much
more slowly than HIV-1 but otherwise clinically similar
254. 254
HIV-1 and HIV-2 Differ in Multiple Ways
Accessory genes
HIV-1 vpu
HIV-2 vpx
Distribution
HIV-1 – global pandemic
HIV-2 – West Africa
Rate of progression to severe
immunosuppression
HIV-1 – median time to AIDS = 10 years
HIV-2 – median time to AIDS = longer, but ?
255. 255
Classification of HIV-1
HIV-1 groups
M (major): cause of current worldwide epidemic
O (outlier) and N (Cameroon): rare HIV-1 groups that
arose separately
HIV-1 M subgroups (clades)
>10 identified (named with letters A to K)
Descended from common HIV ancestor
One clade tends to dominate in a geographic region
Clades differ from each other genetically
Different clades have different clinical and biologic
behavior
256. 256
Classification of HIV
HIV-21
Group M2 Group N Group O
Clades A, B3, C, D, F, F2, G, H, J, K
Recombinants: Common: AE, AG
Uncommon: AGHK, FD, AFGHJK, AB, BC
McCutchenn F, et al. XIII IAC, 2000. Abstract 165
1 HIV-1 most common, but HIV-2 now circulating outside Africa,
especially India
2 Most infections due to group M viruses
3 Clade B: 98–99% USA, 90% Europe
HIV-1
257. 257
Origin and Distribution of HIV-1 Clades
HIV-1 rapidly evolves by two mechanisms:
Mutation: changes in single nucleosides of the RNA
Recombination: combinations of RNA sequences from
two distinct HIV strains
Several common clades (e.g., A/G ad A/E) are
recombinants
Geographic distribution of HIV group M clades
A in Central Africa
B in North American, Australia, and Europe
C in Southern and Eastern Africa (Ethiopia)
263. 263
How HIV Enters Cells
gp120 env protein binds to CD4 molecule
CD4 found on T-cells macrophages, and microglial cells
Binding to CD4 is not sufficient for entry
V3 loop of gp120 env protein binds to co-receptor
CCR5 receptor - used by macrophage-tropic HIV
variants
CXCR4 receptor - used by lymphocyte-tropic HIV
variants
Binding of virus to cell surface results in fusion of viral
envelope with cell membrane
Viral core is released into cell cytoplasm
265. 265
Viral-host Dynamics
About 1010 (10 billion) virions are
produced daily
Average life-span of an HIV virion in
plasma is ~6 hours
Average life-span of an HIV-infected CD4
lymphocytes is ~1.6 days
HIV can lie dormant within a cell for many
years, especially in resting (memory) CD4
cells, unlike other retroviruses
267. 267
Intracellular
infection
Naïve
B-Cell
Naïve
T8 cell
Naïve T4
helper cell
MHC I presentation
of endogenous
antigen MHC II
presentation of
exogenous antigen
Cell-mediated
(CTLs)
Humoral
(plasma cells /
antibodies)
Free antigen
Th1 Th2
Overview of Adaptive Immune
Response Extracellular
infection
APC
Diagram courtesy of Dr. Samuel Anderson
268. 268
General Principles of
Viral-host Interactions:
Host: mounts HIV-specific immune responses
Cellular (cell-mediated) - most important
Humoral (antibody-mediated)
Virus: subverts the immune system
Infects CD4 cells that control normal immune responses
Integrates into host DNA
High rate of mutation
Hides in tissue not readily accessible to immune system
Induces a cytokine environment that the virus uses to its own
replicative advantage
Achieved by “activation” of the immune system
269. 269
Cellular Immune Responses to
HIV
CD8 Cytotoxic T lymphocyte (CTL)
Critical for containment of HIV
Derived from naïve T8 cells, which
recognize viral antigens in context of MHC
class I presentation
Directly destroy infected cell
Activity augmented by Th1 response
270. 270
Cellular Immune Responses to HIV
CD4 Helper T Lymphocyte (Th)
Plays an important role in cell-mediated response
Recognizes viral antigens by an antigen presenting cell (APC)
Utilizes major histocompatibility complex (MHC) class II
Differentiated according to the type of “help”
Th1 - activate Tc (CD8) lymphocytes, promoting cell-mediated
immunity
Th2 - activate B lymphocytes, promoting antibody mediated
immunity
271. 271
Humoral Immune Response to
HIV
Neutralization
Antibodies bind to surface of virus to
prevent attachment to target cell
Antibody-dependent cell-mediated
cytotoxicity (ADCC)
Fc portion of antibody binds to NK cell
Stimulates NK cell to destroy infected cell
272. 272
HIV Evasion Methods
Makes (1010 ) 10 billion copies/day -> rapid
mutation of HIV antigens
Integrates into host DNA
Depletes CD4 lymphocytes
Down-regulation of MHC-I process
Impairs Th1 response of CD4 helper T
lymphocyte
Infects cells in regions of the body where
antibodies penetrate poorly, e.g., the central
nervous system
274. 274
Cells Infected by HIV
Numerous organ systems are infected by
HIV:
Brain: macrophages and glial cells
Lymph nodes and thymus: lymphocytes and
dendritic cells
Blood, semen, vaginal fluids: macrophages
Bone marrow: lymphocytes
Skin: langerhans cells
Colon, duodenum, rectum: chromaffin cells
Lung: alveolar macriphages
275. 275
General Mechanisms of HIV
Pathogenesis
Direct injury
Nervous (encephalopathy and peripheral
neuropathy)
Kidney (HIVAN = HIV-associated nephropathy)
Cardiac (HIV cardiomyopathy)
Endocrine (hypogonadism in both sexes)
GI tract (dysmotility and malabsorption)
Indirect injury
Opportunistic infections and tumors as a
consequence of immunosuppression
276. 276
General Principles of
Immune Dysfunction in HIV
All elements of immune system are affected
Advanced stages of HIV are associated with
substantial disruption of lymphoid tissue
Impaired ability to mount immune response to
new antigen
Impaired ability to maintain memory responses
Loss of containment of HIV replication
Susceptibility to opportunistic infections
277. 277
Mechanisms of CD4
Depletion and Dysfunction
Direct
Elimination of HIV-infected cells by virus-specific
immune responses
Loss of plasma membrane integrity because of
viral budding
Interference with cellular RNA processing
Indirect
Syncytium formation
Apoptosis
Autoimmunity
278. 278
EM of supernatant
of HIV infected
tissue culture
Budding of HIV from
Infected Tissue
Culture Cell
279. 279
Syncytium Formation
Observed in HIV infection, most
commonly in the brain
Uninfected cells may then bind to
infected cells due to viral gp 120
This results in fusion of the cell
membranes and subsequent syncytium
formation.
These syncytium are highly unstable,
and die quickly.
281. 281
Role of Cellular Activation in
Pathogenesis of HIV
HIV induces immune activation
Which may seem paradoxical because HIV
ultimately results in severe immunosuppression
Activated T-cells support HIV replication
Intercurrent infections are associated with
transient increases in viremia
The magnitude of this increase correlates
inversely with stage of HIV disease
Accounts for why TB worsens underlying HIV
disease
282. 282
Role of Cytokine Dysregulation in
Pathogenesis of HIV
HIV is associated with increased expression
of pro-inflammatory cytokines
TNF-alpha, IL-1,IL-6, IL-10, IFN-gamma
Associated with up-regulation of HIV replication
HIV results in disruption and loss of
immunoregulatory cytokines
IL-2, IL-12
Necessary for modulating effective cell-
mediated immune responses (CTLs and NK
cells)
283. 283
Consequence of Cell-mediated
Immune Dysfunction
Inability to respond to intracellular
infections and malignancy
Mycobacteria, Salmonella, Legionella
Leishmania, Toxoplama, Cryptosporidium,
Microsporidium
PCP, Histoplamosis
HSV, VZV, JC virus, pox viruses
EBV-related lymphomas
287. 287
Transmission
Modes of infection
Sexual transmission at genital or colonic mucosa
Blood transfusion
Mother to infant
Accidental occupational exposure
Viral tropism
Transmitted viruses is usually macrophage-tropic
Typically utilizes the chemokine receptor CCR5 to
gain cell entry
Patients homozygous for the CCR5 mutation are
relatively resistant to transmission
288. 288
Laboratory Markers of HIV
Infection
Viral load
Marker of HIV replication rate
Number of HIV RNA copies/mm3 plasma
CD4 count
Marker of immunologic damage
Number of CD4 T-lymphocytes cells/mm3 plasma
Median CD4 count in HIV negative Ethiopians is
significantly lower than that seen in Dutch controls
Female 762 cells/mm3 (IQR 604-908)
Male 684 cells/mm3 (IQR 588-832)
290. 290
Primary HIV Infection
The period immediately after infection
characterized by high level of viremia (>1
million) for a duration of a few weeks
Associated with a transient fall in CD4
Nearly half of patients experience some
mononucleosis-like symptoms (fever, rash,
swollen lymph glands)
Primary infection resolves as body mounts HIV-
specific adaptive immune response
Cell-mediated response (CTL) followed by humoral
Patient enters “clinical latency”
291. 291
HIV RNA Set Point Predicts
Progression to AIDS
HIV RNA viral loads after infection can
be used in the following ways:
To assess the viral set point
To predict the likelihood of progression to
AIDS in the next 5 years
The higher the viral set point:
The more rapid the CD4 count fall
The more rapid the disease progression to
AIDS
292. 292
Patterns of HIV Disease
Progression
HIV
Infection
Long-term
Non-progressors
Rapid Progressors
Typical Progressors
<3 years
7-10 years
>10-20 yr
Normal, Stable CD4
85-90 %
<5 %
<10 %
293. 293
Pathogenesis of HIV Infection:
No Progression with Low-level
Viremia
CD4
RNA
Primary HIV Chronic Non-progressive HIV Infection
RNA Set Point ~ 103
297. 297
CD4 T-cell Count and
Progression to AIDS
In contrast to VL, baseline CD4 is not a
good predictor of time to progression to
AIDS
However, as the CD4 count declines
over time, patients will develop
opportunistic infections
Develop in a sequence predictable
according to CD4 count
WHO Staging system
298. 298
Key Points
HIV is a retrovirus, capable of integrating
into host genome and establishing chronic
infection
HIV can be classified into subgroups
(clades) which have characteristic
geographic distribution
The important steps in the lifecycle of HIV
include cell entry, reverse transcription,
integration, and maturation/assembly
Cell-mediated immunity is critical for
containment of HIV infection and other
299. 299
Key Points (2)
HIV activates the immune system to
increase its own replication
CD4 count declines by both direct and
indirect mechanisms
HIV RNA set point predicts rate of
progression to AIDS
CD4 count decline is associated with a
predictable sequence of opportunistic
infections
301. 301
PCP
A fungal exists in two forms
Trophs-smaller
Cysts-larger
Transmission
Reactivation of latent infection
Person to person
Environmental source
303. 303
PCP cont….
PCP in AIDS characterized by
High organism burden
Fewer neutrophilis
High diagnostic yield following induced
sputum or BAL
Better oxygenation and survival
304. 304
PCP cont….
PCP due to other causes
Low organism and high neutrophilis
High rate of mortality :30-60% (compared
to 10-20 % of HIV associated PCP)
305. 305
Diagnosis
Symptoms +
CXR: bilateral perihilar infiltrates
Pleural effusion and LAP are rare
High resolution CT is more sensitive
Extensive ground glass attenuation or
cystic lesion
LDH
307. 307
PCP Diagnosis …
Sputum induction with saline
Yield: 50-90%
BAL: >95%
Staining
For Trophic forms: papanicolaou,wright-Giemsa,
or Gram-weigert
For cysts: Gomori methylamine silver, cresyl echt
violet, toluidine blue o, or calcofluor white.
Monoclonal antibodies-can stain both trophs
and cysts. Has high sensitivity and specificity.
PCR
308. 308
Pneumocystis Treatment
Standard regimen:
Cotrimoxazole (15-20 mg TMP + 75-100 mg
SMX)/kg/day in 3 doses IV or PO for 3 weeks
Alternative treatments:
Dapsone 100 mg qd + Trimethoprim 15
mg/kg/day PO divided tid x 3 wks
Primaquine 15-30 mg qd + Clindamycin 600 mg
po q8h x 3 wks
Atavaquone 750 mg tid po
Pentamidine 4 mg/kg aerosole
310. TUBERCULOSIS
Leading cause of death in HIV patients
accounting for one third of cases.
Clinical presentation depends on the
degree of immunosupression
Ethiopia is among the high TB burden
countries in the world
310
311. 311
High TB burden African countries
Countries Rank in the list of HBCs
Nigeria 4
Ethiopia 7
South Africa 9
Kenya 10
DR Congo 11
Tanzania 14
Uganda 16
Mozambique 18
312. 312
April 2-4, 2008 WHO convened
International meeting on the Three I’s,
(Intensified TB case finding, IPT and TB
Infection Control) Geneva with
stakeholders.
Came up with recommendations on the
Three I’s
=>”Three I’s should be central part of
HIV care and treatment and also critical
for the continued success of ART scale-
up”
314. 314
IPT
Prevent TB in HIV infected individuals so that
they may lead a longer, disease-free life.
reducing the risk of developing TB by 33–67%
for up to 48 months
IPT combined with ART among PLWH
significantly reduces the incidence of TB
315. 315
Indications
Adults and children more than five
years
HIV positive and with no evidence of active
TB and no contraindication
Children under five years
History of contact with pulmonary TB
patient and not symptomatic, regardless of
HIV status
316. 316
ART, IPT and TB Incidence
N=6391
Cluster
randomized trial
IPT in Brazil
Incidence
(per
100py)
No IPT, No ART 7.4
No IPT, ART 1.5
IPT, No ART 1.0
IPT, ART 0.6
Golub, IAS 2006; # MOPE0395
P<.0001 for all
318. 318
Safety of IPT
Transient transaminases common
Hepatotoxicity is a serious side effect
Death can occur if INH not discontinued
With monitoring and education, risks of
hepatitis and death small (0.001%-0.004%)
Risk increased with older age, alcohol use
319. 319
Effect of INH Resistance on
Treatment Outcomes
Retrospective cohort
study
1148 new TB cases
First-line therapy
HRZE or HRZS x 2m
HR x 4m
Success
Rate
Failure
rate
Drug
susceptible
85% 2%
INH-
resistant
82% 4%
Espinal, JAMA 2000; 283:2537-45.
320. CNS Toxoplasmosis
Is caused by the intracellular protozoan
parasite, Toxoplasma gondii.
The parasite can reactivate and cause
disease, usually when the CD4
lymphocyte count falls below 100
cells/mm 3.
320
321. Patients with cerebral toxoplasmosis
typically present with headache,
confusion, and fever.
Focal neurologic deficits or seizures are
also common
321
322. Diagnosis
Definitive
Stereotactic brain biopsy
Presumptive
If the patient has a CD4 cell count <100/mm 3 and:
Is seropositive for T. gondii IgG antibody
Has not been receiving effective prophylaxis for
toxoplasma
Brain imaging demonstrates a typical radiographic
appearance (eg, multiple ring-enhancing lesions)
322
324. 324
Toxoplasmosis Treatment
Pyrimethamine 200 mg once, followed by
Pyrimethamine 50-75 mg/day, plus
Sulfadiazine 1.0-1.5 gm q 6 hrs, plus
Folinic acid 10-20 mg/d* x 6 wks then half dose
In Ethiopian setting Co-trimoxazole is considered 1st line
of choice*
Corticosteroids (dexamethasone 4mg PO or IV q6hrs) used if cerebral edema
present, and discontinued as soon as clinically feasible
*Folinic acid needed with pyrimethamine, but expense limits use in Ethiopia
325. 325
Alternative Regimens
Pyrimethamine and Folinic acid (standard
dose) PLUS
Clindamycin 600 mg q 6 hrs, or
Cotrimoxazole (TMP 5 mg + SMX 25
mg)/kg IV or PO bid, or
Atovaquone 1.5 gm PO bid, or
Pyrimethamine and Leucovorin (standard
dose) PLUS Azithromycin 900-1200 mg PO
qd
326. 326
Suppressive Therapy
Pyrimethamine 25 mg + sulfadiazine 500 mg + folinic
acid 10-25 mg PO qd
Cotrimoxazole DS tablet daily – Can be stopped when
the CD4 count remains ≥ 200, but > 350 in Ethiopian
context for 6 months
327. Treatment Response
With empiric treatment for
Toxoplasmosis, what should we expect?
Nearly 90% of patients will respond
clinically within days of starting therapy
CT and MRI scans show improvement by
14 days following treatment initiation
327
328. 328
Cryptococcal Meningitis
Caused by C. neoformans
Infection acquired through inhalation
Occurs in advanced disease (CD4<100)
Rarely, presents as pneumonitis, or as
disseminated disease that includes skin
(umbilicated vesicles, like molluscum)
Clinical manifestations may be subtle
330. 330
Cryptococcal Meningitis Treatment
Fluconazole: 800 mg/d x 2 wks, then 400
mg/d x 8 wks, then 200 mg/d
or
Amphotericin 0.7 mg/kg/day IV plus
flucytosine 25 mg PO qid for 2 weeks
followed by Fluconazole then 400 mg/d x 8
wks then 200 mg/d
Treat until CD4 >200 x > 3 mo
331. 331
CMV
Typically does not cause disease until CD4
<50
Manifestations in HIV patients:
Retinitis
Unilateral or bilateral visual disturbance
Confirmed by retina exam showing “scrambled eggs & ketchup” (exudates &
hemorrhages)
GI disease
Esophagitis
Colitis with watery diarrhea, abdominal pain
CNS
CMV encephalitis
337. 337
Case 2 Chronic Diarrhoea
42-year old man, new patient
No cotrimoxazole prophylaxis
Persistent diarrhea, watery stools,
cramping
Diagnosis?
338. 338
Isospora belli
Direct stool exam
Large Oocysts (20-30
µm)
Cotrimoxazole 2 SS x
4/day for 10 days
Followed by 2 SS x
2/day for 3 weeks or
CTX 1 DS bid x 7-10
days
Secondary prophylaxis
with cotrimoxazole 2
SS
339. 339
Case 3: Chronic Diarrhoea
Profuse watery diarrhea, no
response to co-trimoxazole and
metronidazole empiric therapy
Stool exam is negative for
cryptosporidiosis, Isospora belli
Diagnosis ???
340. 340
Microsporidiosis
Modified trichrome
method staining
With 100 oil
immersion
Small spores: 1-3 µm
E. Intestinalis – Rx
w/ Albendazole 400
mg po bid x 2-4
weeks or CD4> 200
E. bienuesi – Rx w/
fumagillin 60mg/day
x 14 d
Empiric therapy with ??
Albendazole? HAART!
341. 341
Case 4: Chronic Diarrhoea
Patient presents
with respiratory
symptoms
Skin lesions like
creeping eruption
Diarrhoea
Strongyloides hyperinfection syndrome
R/ Albendazole 400 mg bid 5 days
Can do wet mount or parasite stain on sputum
342. 342
Clostridium difficile
Underestimated
Associated with significant
mortality
Usually in patients who have been
hospitalized
Treatment: metronidazole 500 mg
3x/day x 7 days
343. 343
Diagnosis and Treatment of Common
Causes of Diarrhea in AIDS Patients
Agent CD4 Symptom Diagnosis Rx
E. histolytica any
bloody stool,
colitis
Stool
microscopy
Metronidazol
e
Giardia any Watery diarrhea “ “
Cryptosporidium <150 Watery diarrhea Modified AFB HAART
Isospora belli <100 Watery diarrhea Modified AFB TMP-SMX
Microsporidium <50 Watery diarrhea Giemsa stain
Albendazole
(20% respond
CMV <50
Watery to Bloody
stool, colitis
Biopsy,
barium study
Ganciclovir
344. 344
Oral Thrush 60% of patients
per year with CD4
< 100
10-20% associated
with oesophageal
candidiaisis
White painless
plaques on the
buccal or
pharyngeal mucosa
or tongue surface
that can easily be
scraped off
Candida albicans is an
endogenous yeast
351. 351
Oral and Esophageal Lesion in
HIV/AIDS
Features Candida CMV HSV Apthous Ulcers
Frequency 50-70% 10-20% 2-5% 10-20%
Dysphagia YYY Y Y Y
Odynophagia YY YYY YYY YYY
Thrush 50-70% < 25% <25% <25%
Fever rare often rare rare
Oral ulcers rare uncommon often uncommon
352. 352
KS Clinical Manifestations
Can affect almost any organ system
Most common sites include:
Skin: Nodular lesions purple or black; can progress to
multiple lesions
Oral cavity: flat to nodular lesions
Edema of legs and/or face due to lymphatic
obstruction
GI tract: can have KS anywhere in GI tract, which can
cause intestinal blockage and bleeding; usually
asymptomatic
Pulmonary: can spread along bronchi and vessels;
usually asymptomatic
Diagnosis is usually by observing typical lesions
353. 353
T0 = lesions confined to the skin
and/or lymph nodes/ and or minimal
oral disease*
T1 = tumour-associated oedema or
ulceration
S0 = No B symptoms, no history for
OI, no oral thrush
S1 = history of OI and/or oral thrush,
B symptoms present
ART alone for T0S0 or
T0S1
ART
And chemotherapy
for others
Staging of Kaposi's Sarcoma
354. 354
Kaposi Sarcoma Treatment
HAART
Local therapy for skin lesions
Alitretinoin gel (35-50% response)
Local radiation (20-70% response)
Intralesional vinblastine/vincristine (70-90% response)
Cryotherapy (85% response)
Photodynamic therapy
Surgical excision
Systemic therapy failure of local therapy or
extensive disease
356. 356
Learning Objectives
Describe how the WHO staging system
is used to assist management of
HIV/AIDS
List the clinical conditions that
characterize each WHO stage of
HIV/AIDS
357. 357
WHO Staging System for
HIV/AIDS: Overview
Tool used to guide management of HIV patient in resource
limited settings with limited laboratory access
Clinically based; CD4 count not necessarily required
Simple, flexible and widely used
Latest revised version 2006
Utilizes 4 clinical stages based on the degree of
immunocompromise and prognosis
I,II, III, IV
Staging correlates with degree of immunosuppression
358. 358
WHO Staging System for
HIV/AIDS: Overview (2)
Performed at each clinical visit
Diagnosis
Entry to clinical care (pre-ART)
Follow-up
Stage assessment can be adjusted
upwards or downwards over time
according to response to ART and/or
clinical progression
Staging on ART is referred as T staging
359. 359
WHO Staging of HIV/AIDS
With confirmed HIV infection
Stage I - asymptomatic
Stage II - mild disease
Stage III - moderate disease
Stage IV - advanced
immunocompromise
360. 360
WHO Stage I
Asymptomatic or
Persistent generalized
lymphadenopathy (PGL)
367. 367
WHO Stage III
Conditions where a presumptive diagnosis can be made on the
basis of clinical signs or simple investigations
Severe weight loss (>10% of presumed or measured body
weight)
Unexplained chronic diarrhea for > one month
Unexplained persistent fever (intermittent or constant for >
one month)
Oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis (TB) diagnosed in last two years
Severe presumed bacterial infections (e.g. pneumonia,
empyema, pyomyositis, bone or joint infection, meningitis,
bacteremia)
Acute necrotizing ulcerative stomatitis, gingivitis or
periodontitis
368. 368
WHO Stage III (2)
Conditions where confirmatory
diagnostic testing is necessary
Unexplained anemia (<8 g/dl), and or
Neutropenia (<500/mm3) and or
Thrombocytopenia (<50 000/ mm3) for
more than one month