Peak infuenza activity in the United States can occur anytime from November to treatment depression buy discount kemadrin on-line May but most commonly occurs in January and February treatment of uti purchase cheapest kemadrin. Infuenza is highly contagious symptoms gluten intolerance purchase kemadrin 5 mg without prescription, especially among semienclosed institutionalized populations and other ongoing medications herpes order kemadrin 5mg otc, closed-group gatherings, such as school classrooms. Infuenza and its complications have been reported to result in a 10% to 30% increase in the number of courses of antimicrobial agents prescribed to children during the infuenza season. However, children younger than 24 months of age consistently are at a substantially higher risk of hospitalization than older children. Antecedent infuenza infection sometimes is associated with development of pneumococcal or staphylococcal pneumonia in children. Methicillin-resistant staphylococcal community-acquired pneumonia, with a rapid clinical progression and a high fatality rate, has been reported in previously healthy children and adults with concomitant infuenza infection. Rates of hospitalization and morbidity attributable to complications, such as bronchitis and pneumonia, are even greater in children with high-risk conditions, including hemoglobinopathies, bronchopulmonary dysplasia, asthma, cystic fbrosis, malignancy, diabetes mellitus, chronic renal disease, and congenital heart disease. Infuenza virus infection in neonates also has been associated with considerable morbidity, including a sepsis-like syndrome, apnea, and lower respiratory tract disease. Since infuenza-related pediatric deaths became nationally notifable in 2004, the number of deaths among children reported annually ranged from 46 to 83, until the 2009–2010 season, when the number increased to 279. The 2010–2011 infuenza season had at least 114 laboratory-confrmed, infuenzaassociated pediatric deaths. A pandemic is defned by emergence and global spread of a new infuenza A virus subtype to which the population has little or no immunity and that spreads rapidly from person to person. During the 20th century, there were 3 infuenza pandemics, in 1918 (H1N1), 1957 (H2N2), and 1968 (H3N2). The 2009 infuenza A (H1N1) pandemic was the frst in the 21st century, lasting from April 2009 to August 2010. Pediatric health care professionals should be familiar with national, state, and institutional pandemic plans, including recommendations for vaccine and antiviral drug use, health care surge capacity, and personal protective strategies that can be communicated to patients and families. After inoculation into eggs or cell culture, infuenza virus usually can be isolated within 2 to 6 days. Careful clinical judgment must be exercised, because the prevalence of circulating infuenza viruses infuences the positive and negative predictive values of these infuenza screening tests. Since 2005, all H3N2 strains in the United States have been resistant to adamantanes. Since January 2006, neuraminidase inhibitors (oseltamivir, zanamivir) have been the only recommended infuenza antiviral drugs because of this widespread resistance to the adamantanes and the activity of neuraminidase inhibitors against infuenza A and B viruses. In 2007–2008, a signifcant increase in oseltamivir resistance was reported among infuenza A (H1N1) viruses, and in the 2008–2009 infuenza season, virtually all H1N1 infuenza strains were resistant to oseltamivir. Therapy for infuenza virus infection should be offered to any child with presumed infuenza or severe, complicated or progressive illness, regardless of infuenza-immunization status and for infuenza infection of any severity in children with a condition that places them at increased risk. Children with severe infuenza should be evaluated carefully for possible coinfection with bacterial pathogens (eg, S aureus) that might require antimicrobial therapy. Clinicians who want to have infuenza isolates tested for susceptibility should contact their state health department. If antiviral therapy is prescribed, treatment should be started as soon after illness onset as possible and should not be delayed while waiting for a defnitive infuenza test result, because beneft is greatest when treatment is initiated within 48 hours of onset of symptoms. Treatment should be discontinued approximately 24 to 48 hours after symp-1 toms resolve. The duration of treatment studied was 5 days for both the neuraminidase inhibitors (oseltamivir and zanamivir) and the adamantanes (amantadine and rimantadine). Nevertheless, cautioning parents and patients regarding abnormal behavior is advised. Both amantadine and rimantadine, but especially amantadine, may cause agitation, which resolves with discontinuation of the drug. An increased incidence of seizures has been reported in children with epilepsy who receive amantadine and, to a lesser extent, rimantadine. Because of a lower incidence of adverse events, rimantadine generally is preferred over amantadine for both prophylaxis and treatment. Control of fever with acetaminophen or other appropriate antipyretic agents may be important in young children, because fever and other symptoms of infuenza could exacerbate underlying chronic conditions. Children and adolescents with infuenza should not receive aspirin or any salicylate-containing products because of the potential risk of developing Reye syndrome. Typically, 1 or more strains are changed each year in anti cipation of the predominant infuenza strains expected to circulate in the United States in the upcoming infuenza season. Getting recommended childhood vaccines during a single visit has important benefts of protecting children against many infectious diseases; minimizing the number of visits that parents, caregivers, and children must make; and preventing febrile seizures by protecting children against infuenza and pneumococcal infections, both of which can cause fever. This method of delivery involves a microinjection with a needle 90% shorter than needles used for intramuscular administration. The 3 vaccine strains are attenuated, cold adapted, temperature sensitive viruses that replicate in the cooler temperature of the upper respiratory tract and stimulate both an IgA and IgG antibody response. Recommendations for 2 doses of vaccine will resume for seasons when 1 or more of the vaccine strains change. The effectiveness of infuenza immunization on acute respiratory tract illness is less evident in pediatric than in adult populations because of the frequency of upper respiratory tract infections and infuenzalike illness caused by other viral agents in young children. Age indication for Afuria during the 2011–2012 season, per package insert, is 5 years or older; however, the Advisory Committee on Immunization Practices and American Academy of Pediatrics recommend Afuria not be used in children 6 months through 8 years of age because of increased reports of febrile reactions noted in this age group. People with the following conditions are at increased risk of severe complications from infuenza, and it especially is important they receive annual immunization: • Asthma or other chronic pulmonary diseases, such as cystic fbrosis • Hemodynamically signifcant cardiac disease • Immunosuppressive disorders or therapy (see Special Considerations, p 448) 1 Centers for Disease Control and Prevention. Health care professionals should consult the patient’s medical record, when available, to identify children 2 through 4 years of age with asthma or recurrent wheezing that might indicate asthma. Some children 2 through 4 years of age have a history of wheezing with respiratory tract illnesses but have not been diagnosed with asthma. Consideration should be given to the potential risks and benefts of administering infuenza vaccine to any child with known or suspected immunodefciency. In children receiving immunosuppressive chemotherapy, infuenza immunization may result in a less robust response than in immunocompetent children. The optimal time to immunize children with malignant neoplasms who must undergo chemotherapy is more than 3 weeks after chemotherapy has been discontinued, when the peripheral granulocyte and lymphocyte counts are greater than 1000/fiL (1. Children with hemodynamically unstable cardiac disease constitute a large group potentially at high risk of complications of infuenza. Corticosteroids administered for brief periods or every other day seem to have a minimal effect on antibody response to infuenza vaccine. Prolonged administration of high doses of corticosteroids (ie, a dose of prednisone of either 2 mg/kg or greater or a total of 20 mg/day or greater or an equivalent) may impair antibody response. In addition, immunization of pregnant women may beneft their unborn infants, because transplacentally acquired antibody and human milk may protect infants from infection with infuenza virus. Because 1 voluntary immunization programs have failed to raise coverage rates among health care personnel above an average of 40%, a mandate is necessary to achieve herd immunity, reach Healthy People 2020 objectives, and suffciently protect people who come in contact with health care personnel. There is growing support for a mandate among medical organizations, and hospitals that already have implemented mandatory infuenza immunization for health care personnel have had enormous success. Immunization throughout the season may protect some people against late outbreaks of infuenza. In addition, there may be more than 1 peak of activity during an infuenza season, so later immunization still may help protect from a later peak caused by a different strain of infuenza virus that same season. Annual infuenza immunization is recommended, because immunity can decrease during the year after immunization and because in most years, at least one of the vaccine antigens is changed to match ongoing antigenic changes in circulating strains. If alternate venues are used, a system of patient record transfer is benefcial to ensuring maintenance of accurate immunization records. More conservative approaches, such as skin testing or a 2-step graded challenge, no longer are recommended. Policy statement: recommendation for mandatory infuenza immunization of all health care personnel. As a precaution, clinicians should determine whether the presumed egg allergy is based on a mild or severe reaction (eg, anaphylaxis). Mild reactions are defned as hives alone; severe reactions involve cardiovascular changes, respiratory tract and/or gastro intestinal tract symptoms, or reactions that required use of epinephrine. The decision not to immunize should be thoughtfully balanced against the potential morbidity and mortality associated with infuenza for that individual. The proposed explanation for the low incidence of transmission is that the vaccine virus is shed for a shorter duration and in a much smaller quantity than are wild-type strains.
Diatermia transescleral en el manejo del glaucoma • Vass-2007 neovascular • "Colvin Trucco medications like zovirax and valtrex purchase kemadrin 5 mg, Ricardo symptoms viral infection buy kemadrin 5 mg. Cirugfia combinada: extracapsular treatment irritable bowel syndrome buy kemadrin 5mg without prescription, implante de • Foreign language lente intraocular y trabeculectomfia • Correlagao entre os achados a biomicroscopia ultra-sonica de bolhas • Foreign language filtrantes com ou sem mitomicina C com a pressao intra-ocular counterfeit medications 60 minutes cheap kemadrin master card. Cirugfia combinada: facoemulsificacifin, lente Foreign language intraocular y trabeculectomfia • "Costa, V. Efficacy and safety of adjunctive mitomycin C during Ahmed D-33 Glaucoma Valve implantation: a prospective randomized clinical trial. Ophthalmology 2004; Nimesulide oral administration increases the intraocular pressure-lowering • 111 (6): 1071-6. Low-dose mitomycin C trabeculectomy in patients with advanced • Does not include treatment for open-angle glaucoma (medical, glaucoma. Ophthalmology 93; field indice modifications induced by alpha-agonist compound (clonidine • 100 (5): 599-612. Ophthalmic Surg 93;24 (6): • Short term follow up only (less than 1 month for medical study/1 year 389-94. Efeitos a curto prazo da apraclonidina 1 sobre a pressao intraocular de pressure and ocular perfusion pressure after timolol or latanoprost in pacientes com glaucoma cronico de Gngulo aberto Caucasians with normal-tension glaucoma. Graefes Arch Clin Exp • Foreign language Ophthalmol 2008; • "Costa, Vital Paulino, Vasconcellos, Josq Paulo, Comegno, Paulo E. Ocular surface changes induced by topical • It is combined cataract/glaucoma surgery study published before application of latanoprost and timolol: a short-term study in glaucomatous April 2000 patients with and without allergic conjunctivitis. Curr Eye Res 2008; • Short term follow up only (less than 1 month for medical study/1 year • 33 (5): 477-82. The influence of diclofenac ophthalmic • Meeting abstract solution on the intraocular pressure-lowering effect of topical 0. Two-site Phacotrabeculectomy: ocular hypertension treated topically with pilocarpine or with timolol. Eye Results After One Year of Follow-up (Lond) 90; • Meeting abstract • 4 (Pt 4): 563-71. Randomized comparison of 1• Other (specify):pilocarpine Site and 2-Site phacotrabeculectomy with 3-year follow-up • "Crick, R. The • Included in Gdih 2011 effect of topical treatment by timolol versus pilocarpine on visual field • "Coulangeon, L. A randomized, controlled comparison of macroscopic letter) conjunctival hyperemia in patients treated with bimatoprost 0. The progress of the visual field in chronic simple glaucoma and hypertension and primary open-angle glaucoma] D-35 • Foreign language • Foreign language • "Danias, J. Comparison intraocular pressure reduction in the treatment of normal-tension of the efficacy and longevity of nonpenetrating glaucoma surgery with glaucoma. The Ahmed • Other (specify):pilocarpine Glaucoma Valve in refractory glaucoma: experiences in Indian eyes. The role of early trabeculectomy in the control of chronic carbonic anhydrase inhibitor in patients affected by chronic simple simple glaucoma. The role of initial 5-fluorouracil trabeculectomy in the therapy of glaucoma primary glaucoma. Journal of Ocular Pharmacology and Therapeutics Augenheilkd 79; 2004; • 174 (1): 127-35. Treatment of elevated intraocular pressure with ocular hypertension concurrent levobunolol and pilocarpine. The clinical validity of the treatment satisfaction survey for Ophthalmol Soc U K 80;100 (Pt 2): 286-90. Medical control of intraocular pressure after Eye (Lond) 95; phacoemulsification. Acetazolamide (diamox) therapy in chronic glaucoma; a three-year Comparison of deep sclerectomy with implant and combined glaucoma follow-up study. Result of a medium-term Foreign language double blind study comparing timolol maleate and epinephrine in 120 • "de Galleani, B. Long-Term Success Rates of Trabeculectomy as Initial Therapy the treatment of primary open-angle glaucoma]. Annee Ther Clin Compared With Trabeculectomy After Initial Medical Treatment Ophtalmol 88;39: 131-40; discussion 141-53. A new beta-blocker in the treatment of chronic open angle glaucoma, timolol maleate. A prospective Tolerance of beta-Blocker/Pilocarpine Combination Eye Drops in study on the tonometric and perimetric effect] Primary Open-Angle Glaucoma and High Intraocular Pressure. D) in primary open-angle glaucoma: middle-term retrospective with a collagen implant in primary open-angle glaucoma. Medium-term study retrospective results] Foreign language Foreign language • "Demailly, Philippe, Kretz, G, and Zogheib, R. Effect in ophthalmic suspension with or without preservative agent in patients of instillation of 1 drop on the intraocular pressure] with glaucoma or ocular hypertension]. Short term follow up only (less than 1 month for medical study/1 year for surgical study) but it is not a 24 hour study D-39 • "Denis, P. Residenttravoprost/timolol fixed combinations: a retrospective, multicentre, crossperformed Ahmed(trademark) glaucoma valve surgery sectional study. Duplicate of 170 " Does not include treatment for open-angle glaucoma (medical, • "Desvignes, P. Comparison of Foreign language diurnal intraocular pressure control by latanoprost versus travoprost: • "Detry-Morel, M. Clin Drug Investig 2006;26 (12): 703anhydrase inhibitors in eyewash: medium term retrospective experience 14. Once-daily versus for surgical study) but it is not a 24 hour study twice-daily levobunolol (0. Micropulse diode laser Unique comparators (810 nm) versus argon laser trabeculoplasty in the treatment of open-angle • "Derick, R. Meeting abstract It is combined cataract/glaucoma surgery study published before • "Diestelhorst, M. A 12 week study comparing the fixed Foreign language combination of latanoprost and timolol with the concomitant use of the • "Di Tizio, A. A 12-week, randomized, doubleForeign language masked, multicenter study of the fixed combination of latanoprost and • "Diafas, S. Ophthalmology dorzolamide versus other hypotensive agents to prevent glaucomatous 2006;113 (1): 70-6. German Latanoprost Study Group Data not abstractable Excluded drug • "Dickstein, K. The additive intraocular pressure-lowering effect of gellan ophthalmic timolol with placebo on the 24-hour heart rate response latanoprost 0. Graefes Does not include treatment for open-angle glaucoma (medical, surgical or combined) Arch Clin Exp Ophthalmol 98;236 (8): 577-81. Persistency and clinical outcomes Does not include treatment for open-angle glaucoma (medical, associated with latanoprost and beta-blocker monotherapy: evidence from surgical or combined) a European retrospective cohort study • "Dirks, M. Glaucoma: systemic side effects of topical Patients with Glaucoma or Ocular Hypertension: A Six-month medical therapy-a common and under recognized problem. Efficacy and Patient-Reported Outcomes after 12 Months No subjects with open-angle glaucoma Meeting abstract • "Diggory, P. Meeting abstract Unsuspected bronchospasm in association with topical timolol-a common • "Dirks, M. Age Ageing 94;23 (1): 17Efficacy, Tolerability, and Patient-Reported Measures Between Cosopt 21. J Cataract Refract Choroidal detachment in association with topical dorzolamide: is Surg 2000;26 (1): 71-4. Facoemulsificacifin y It is a case series trabeculectomfia con 5-fluorouracil intraoperatorio: operacifin combinada • "Doi, L. Effects of the combination trabeculectomfia primaria en glaucoma de bngulo abierto of bimatoprost and latanoprost on intraocular pressure in primary open Foreign language angle glaucoma: a randomised clinical trial • "Dorigo, M. Cardiovascular Unique comparators effects of befunolol, betaxolol and timolol eye drops. Changing antiglaucoma therapy from timolol to betaxolol: Effect on optic [Timolol: adverse cardiorespiratory effects] disk blood flow Foreign language Meeting abstract • "Dong, D. Canadian journal of Normal Tension Glaucoma Patients After Latanoprost or Timolol ophthalmology.
Cleaning and decontamination should be done as soon as possible after items have been used treatment west nile virus purchase kemadrin uk. This equipment often is automated and may increase productivity treatment research institute purchase discount kemadrin online, improve cleaning effectiveness medicine 027 generic kemadrin 5mg with mastercard, and decrease worker exposure to symptoms shingles discount kemadrin 5mg line blood and body fluids. Items composed 73 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 of more than one removable part should be disassembled. Care should be taken to ensure that all parts 811 are kept together, so that reassembly can be accomplished efficiently. Employees must not reach with their gloved hands into trays or containers that hold these sharps to 214 retrieve them. Other parameters that may influence drying are the density of the wraps and the design of the 964 set. There are several choices in methods to maintain sterility of surgical instruments, including rigid containers, peel-open pouches. In central processing, double wrapping can be done sequentially or nonsequentially. The nonsequential process uses two sheets wrapped at the same time so that the wrapping needs to be performed only once. This latter method provides 74 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 multiple layers of protection of surgical instruments from contamination and saves time since wrapping is done only once. Written and illustrated procedures for preparation of items to be packaged should be readily available and used by 454 personnel when packaging procedures are performed. All items to be sterilized should be arranged so all surfaces will be directly exposed to the sterilizing agent. Due to the variety of textiles and metal/plastic containers on the market, the textile and metal/plastic container manufacturer and the sterilizer manufacturers should be 819 consulted for instructions on pack preparation and density parameters. There are several important basic principles for loading a sterilizer: allow for proper sterilant circulation; perforated trays should be placed so the tray is parallel to the shelf; nonperforated containers should be placed on their edge. The 3-mil 967 polyethylene is applied after sterilization to extend the shelf life for infrequently used items. One study examined the effect of time on the sterile integrity of paper envelopes, peel pouches, and nylon sleeves. The most important finding was the absence of a trend toward an increased rate of contamination over time for any pack when placed in 971 covered storage. Following the sterilization process, medical and surgical devices must be handled using aseptic technique in order to prevent contamination. Sterile items that become wet are considered contaminated because moisture brings with it microorganisms from the air and surfaces. Any package that has fallen or been dropped on the floor must be inspected for damage to the packaging and 75 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 contents (if the items are breakable). If the package is heat-sealed in impervious plastic and the seal is still intact, the package should be considered not contaminated. The sterilization procedure should be monitored routinely by using a combination of mechanical, chemical, and biological indicators to evaluate the sterilizing conditions and indirectly the microbiologic status of the processed items. Biological indicators are recognized by most authorities as being closest to the ideal monitors of 974, 975 the sterilization process because they measure the sterilization process directly by using the most resistant microorganisms. An ideal biological monitor of the sterilization process should be easy to use, be inexpensive, not be subject to exogenous contamination, provide positive results as soon as possible after the cycle so that corrective action may be accomplished, and provide positive results only when the sterilization parameters. Studies o demonstrate that the sensitivity of rapid-readout tests for steam sterilization (1 hour for 132 C gravity o o sterilizers, 3 hrs for 121 C gravity and 132 C vacuum sterilizers) parallels that of the conventional 846, 847, 976, 977 sterilization-specific biological indicators and the fluorescent rapid readout results reliably 978 predict 24and 48-hour and 7-day growth. The rapid-readout biological indicator is a dual indicator system as it also detects acid metabolites produced during growth of the G. Per manufacturer’s data, the enzyme always was detected whenever viable spores were present. A suggested protocol for management of positive biological indicators is 839 813 shown in Table 12. If patient-care items were used before retrieval, the infection control professional should assess the risk of infection in collaboration with central processing, surgical services, and risk management staff. There are no published studies that document disease transmission via a nonretrieved surgical instrument following a sterilization cycle with a positive biological indicator. However, in one incident, the broth used as growth o 985 medium contained a contaminant, B. Testing of 839 paired biological indicators from different manufacturers can assist in assessing a product defect. A biological indicator should not be considered a false-positive indicator until a thorough analysis of the entire sterilization process shows this to be likely. The size and composition of the biological indicator test pack should be standardized to create a significant challenge to air removal and sterilant penetration and to obtain interpretable results. When the towels are folded and placed one on top of another, to form a stack (approximately 6 inch height) it should weigh approximately 3 pounds and should have a density of 813 approximately 11. This test pack has not gained universal use as a standard pack that simulates the actual in-use conditions of steam sterilizers. In Europe, biological monitors are not used routinely to monitor the sterilization process. Instead, release of sterilizer items is based on monitoring the physical conditions of the sterilization process that is termed “parametric release. A reused single-use device will have to comply with the same regulatory requirements of the device when it was originally manufactured. The options for hospitals are to stop reprocessing single-use devices, comply with the rule, or outsource to a third-party reprocessor. The reuse of single use medical devices continues to be an evolving area of regulations. Rationale the ultimate goal of the Recommendations for Disinfection and Sterilization in Health-Care Facilities, 2008, is to reduce rates of health-care–associated infections through appropriate use of both disinfection and sterilization. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies, and by a strong theoretical rationale. These include practices for which insufficient evidence or no consensus exists regarding efficacy. Inform each worker of the possible health effects of his or her exposure to infectious agents. The 214, 997employer is responsible for making such equipment and training available. Meticulously clean patient-care items with water and detergent, or with water and enzymatic 6, 83, 101, 104-106, 124, cleaners before high-level disinfection or sterilization procedures. Use cleaning agents that are capable of removing visible 424-426, 466, 468, 469, 471, 908, 910 organic and inorganic residues. Ensure that the detergents or enzymatic cleaners selected are compatible with the metals and other materials used in medical instruments. Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection a. Before use on each patient, sterilize critical medical and surgical devices and instruments that enter normally sterile tissue or the vascular system or through which a sterile body fluid flows 179, 497, 821, 822, 907, 911, 912. However, multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. Follow manufacturers’ instructions for proper use of disinfecting (or detergent) products -such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and 84 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 327, 365, 404 disposal. See 5n for recommendations requiring cleaning and disinfecting blood-contaminated surfaces. However, many scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. In units with high rates of endemic Clostridium difficile infection or in an outbreak setting, use dilute solutions of 5. To detect damaged endoscopes, test each flexible endoscope for leaks as part of each reprocessing cycle. Immediately after use, meticulously clean the endoscope with an enzymatic cleaner that is compatible with the endoscope. Use cleaning brushes appropriate for the size of the endoscope channel or port.
Buy kemadrin 5 mg line. Symptoms of Brain Tumors.
Hilar or mediastinal groups of lymph nodes enlargement with caseous necrosis that may result in: a treatment toenail fungus buy kemadrin 5mg low cost. Obstruction of the bronchus by the enlarged lymph nodes leading to medications zyprexa kemadrin 5 mg without a prescription lobar collapse treatment for plantar fasciitis cheap 5 mg kemadrin with visa. The caseous hilar lymph node may penetrate the bronchial wall and resulting in rupture of the wall with pouring of caseous materials into the bronchus hence symptoms 0f brain tumor generic 5 mg kemadrin otc, tuberculosis broncho-pneumonia ensues. The caseous materials may be disseminated to other parts of the body via blood streams. Miliary tuberculosis It refers to disseminated sites that produce multiple, small yellow nodular lesions in several organs. The lungs, lymph nodes, kidneys, adrenals, bone marow, spleen, menings and liver are common sites for miliary lesions. Seeding of the bacilli in lungs, bones, kidneys, fallopian tubes, bladder, epididimis etc, that may persist in and their subsequent reactivation produces destructive, necrotizing granulmatious disease, sometimes known as end organ tuberculosis. Intestinal primary infection the primary complex is similar to that of the lungs the initial site may be in the gum with lymphatic spread of bacilli to the cervical lymph nodes the commonest location for the primary lesion is the illocaecal region with local mesenteric node involvement. Lymph nodes Tuberculous lymph adenitis is the most common type of extra pulmonary tuberculosis that frequently involves the cervical groups of lymph nodes with enlargement, and subsequent periadenitis followed by matting and eventual ulcerations if left untreated. Skin is also involved in various forms of tuberculosis Post -primary (secondary) tuberculosis Conventionally the term post-primary tuberculosis is used for lung infections occurring 5 years or more after the primary infection. The commonest sites for post primary tuberculosis are the posterior or apical segment of the upper lobe and the superior segment of the lower lobe and their predilection for the anatomy location is due to good ventilation. Hypersensitivity reaction is welldeveloped and it thus, restricts the granulomatous reactions locally. Pulmonary and bronchial arteries around caseous cavities are occluded by endarteritis obliterans where the wall of the artery may weaken resulting in aneurysm formation (mycotic aneurism) that may occasionally rupture and cause hemoptosis. Certain tissues are relatively resistant to tuberculous infection, so it is rare to find tubercles in the heart, skeletal muscle, thyrord and pancreas. This results in less well-formed granulomas, and more frequently necrotic material that contain more abundant acid-fast organisms histologically. These infections are usually widely disseminated throughout the reticuloendothelial systems causing enlargement of involved lymph nodes, liver and 10 spleen. The organisms are present in large numbers as many as 10 organism per gram of tissue. Leprosy Definiton: Leprosy or Hansen disease is a slowly progressive infection caused by Mycobacterium leprae affecting the skin and peripheral nerves and resulting mainly in deformity, paralysis and ulceration. Pathogenesis: the bacillus is acid fast, obligate intracellular organism that does not grow in culture and 0 it grows best at 32-34 C of the temperature of human skin. The bacilli thus produce either potentially destructive granulomas or by interference with the metabolism of cells. The bacilli are taken by alveolar macrophages; disseminate through the blood but grows only in relatively cool tissues of the skin and extremities. Two forms of the disease occur depending on whether the host mounts a T-cell mediated immune response (tuberculoid leprosy) or the host is anergic (lepromatous leprosy). The polar forms are relatively stable but the borderline forms (border line-tuberculoid, borderline-borderline, and borderline-lepromatous) are unstable without treatment. Patients with tuberculoid leprosy form granuloma with few surviving bacteria (paucibacillary disease). Antibody production is not protective in lepromatous leprosy and rather the formation of antigen antibody complexes in lepromatous leprosy leads to erythema nodosum leprosum, a life threatening vasculitis, and glomerulonephrits 173 Because of the diffuse parasite filled lesions lepromatous leprosy is more infectious than those with tuberculoid leprosy. Table: Differences between tuberculoid and lepomatous leprosy Tuberculoid leprosy Lepromatous leprosy Epitheoid granuloma without giant cell Active macrophages, with every many bacilli (globi) Dense zone of lymphocyte infiltration Scanty and diffuse around granuloma Nerves destroyed by granulomas May show neuronal damage but not infiltration or cuffing No clear sub-epidermal zone Clear sub-epidermal zone Bacilli in granuloma are not seen Numerous bacilli 5+ or 6+ Few macules + plaques with well defined Macules, papules, plaques and nodules edges present with vague edges Lesions distributed asymmetrically Lesions distributed symmetrically hair loss no hair loss Lesions are anesthetic Lesions are not anesthetic Nerve thickening often singly and early Nerve thickening is symmetrical and late (stocking & glove patterns) First manifestation may be neural First manifestation never neuronal Lepromin test is strongly positive Lepromin test is negative Clinical course and complications Lepromatous leprosy involves primarily the shin, peripheral nerves, anterior eye, upper airways (down to larynx), testis, hands and feet. The vital organs and the central nervous system are rarely affected presumably because the core temperature is too high for the growth of M. Syphilis Definition: Syphilis is a systemic infection caused by the spirochete Treponema pallidium, which is transmitted mainly by direct sexual intercourse (venereal syphilis) and less commonly via placenta (congenital syphilis) or by accidental inoculation from the infectious materials. Pallidum spirochetes cannot be cultured but are detected by silver stains, dark field examination and immunofluorescence technique. Pathogenesis: the organism is delicate and susceptible to drying and does not survive long outside the body. Morphology: Syphilis is classified into three stages Primary syphilis (chancre): Chancre appears as a hard, erythematous, firm; painless slightly elevated papule on nodule with regional lymph nodes enlargements. Common sites are Prepuce / scrotum in men-70%,Vulva or cervix in females -50% the chancre may last 3-12 weeks. Patients with primary syphilis who stayed for more than two week cannot be reinfected by a challenge. Widespread mucocutaneous lesions involving the oral cavity, plams of the hands and soles of the feet characterize it. Nummular syphilitidis:It is coin-like lesions involving the face and perineum Generalized lymphadenopathy and the uncommon swelling of epithrochlear lymph nodes have long been associated with syphilis. They occur in most organs but in skin, subcutaneous tissue, bone, Joints and testis. In the liver, scarring as a result of gummas may cause a distinctive hepatic lesion known as hepar lobatum. The lesions include aortitis, aortic value regurgitation, aortic aneurysm, and coronary artery ostia stenosis. The proximal aorta affected shows a tree -barking appearance as a result of medial scarring and secondary atherosclerosis. Endartereritis and periaortitis of the vasa vasoum in the wall of the aorta, is responsible for aortic lesions and in time, this may dilate and form aneurysm and eventually rupture classically in the arch. Treponemas do not invade the placental tissue or the fetus until the fifth month of gestation (since immunologic competence only commences then) syphilis causes late abortion, still birth or death soon after delivery or It may persist in latent forms to become apparent only during childhood or adult life. In primary and secondary stages, the fetus is heavily infected and may die of hydrops in utero or shortly after birth. After maternal second stage, the effects of congenital syphilis are progressively less severe. Malaria Malaria is caused by the intracellular protozoan parasite called Plasmodium species and plasomodium Faliprium is the worldwide infections that affect 100 million people and kill 1 to 1. Falciparum): Infected humans produce gametocytes that mosquitoes acquire on feeding. Within these insects’ body, the organism produces sporozites, which the mosquito transmits to human when it feeds 177 Malarial sporozites after being released in the blood within minutes attach to a serum protein thrombosroridin and properidine located on the basolateral surface of hepatocytes. Repeated cycles of parasitemia occur with subsequent ruptures of these cells with resultant clinical manifestations such as chills, fever etc. Morphology: Spleen enlarged upto 1000gm (normally 150grams) and this splenomegaly can be attributed to increased phagocytosis in splenic reticuloendothelial cells in chronic malaria. Pigmented phagocytes may be dispersed through out bone marrow, lymph nodes, subcutaneous tissues and lungs. These patients manifest diffuse symmetric encephalopathy; brain vessels are plugged with parasitized red cells. Hypoglycemiaresult from failure of hepatic gluconeogenesis & glucose consumption by the host and the parasite lactic acidosis -due to anaerobic glycolysis, non cardiogenic pulmonary edema, renal impairment, anemias etc 178 P. In other types of malaria only subpopulations of erythrocytes are parasitized, and thus low level parasitemias and more modest anemias occur. The process of cytoadhernce and rosetting are central to the pathogenesis of falcparum malaria in the other three " benign" malarias sequestrations does not occur and all stages of parasites’ development are evident on peripheral blood smears. Malaria in pregnancy In pregnancy, malaria may be associated with hypoglycemia, fetal distress syndrome and low birth weight. Malaria in children Most of the estimated 1-3 million persons who die of falciparum malaria each year are young African children. Convulsion, coma, hypoglycemia, metabolic acidosis and severe anemia are relatively common. Transfusion malaria Malaria can be transmitted by blood transfusion, needle -stick injury, sharing of needles by infected drug addicts, or organ transplants. The incubation period is short because there is no pre-erythrocytic stage of development. Leishmaniasis Definition: Chronic inflammatory disease of skin, mucous membranes or viscera caused by obligate intracellular Kinetoplastid protozoal parasites (Leishmania species) transmitted through infected sand fly. Cutaneous leishmaniasis Localized single ulcer on exposed skin (slowly expanding and irregular borders, usually heals within 6 months by involution. Diffuse cutaneous leishmaniasis Lesions of diffuse cutaneous leishmaniasis resembles lepromatous leprosy nodules.