Athlete's Foot

more about Athlete's Foot

Tinea pedis

 A common fungal infection that affects the

spaces between toes (Interdigital spaces) and
the sole of the foot.

 White Scaly Skin causes an itching on the

bottom of the foot and in between the toes. 
The skin will eventually soften, causing the
whitish borders to peel off easily.  The center
of the lesion may be irritated, red, and in some
cases, a watery discharge can be seen.
 Other types of Tinea Pedis may be the
moccasin variety (white, thick, dense and
scaly sole), which consists of large areas of
cracked skin, inflammation, fluid filled vesicles
or bullae.

 White/pink Scaly Skin in the affected areas,

with no itching whatsoever.

 Made upon a clinical examination

 A scraping of the skin in the affected area can
be put on a glass slide and stained with
Potassium hydroxide.  When viewed under a
microscope, this will show the branched
structure of the fungus.

 If needed, the scraping can be sent out to

laboratory for culturing and identifying the
exact type of the fungus

 Humid and warm environments -- socks,

locker room showers, and floors of swimming
 pools.
 Hot weather
 Athletic activities
 Tight fitting shoes (e.g., ballet shoes)

 Immunosuppressed such as those with AIDS

on long-term steroids or cancer treatments

 Dermatophytes (e.g., trichophyton,

epidermophyton) and fungi (mold like
organisms).

 Normally live in the dead layers of skin, nails,

and hair follicles.  It is transmitted through
minor cuts on the skin.  If conditions are just
right, Tinea Pedis will grow and cause
symptoms.

 Make sure to dry your feet after showering

 Wear shower or pool shoes in public places
 Wear shoes that allow for good ventilation
 Avoid wearing shoes for long periods of time
 Wear socks that keep the feet dry
 Antifungal creams (e.g., clotrimazole) are
applied twice daily, while cortisone is added if
there is inflammation or severe itching (e.g.,
Lotrisone) for 2-4 weeks.

 For severe cases, oral medications such as

Sporanox, griseofulvin, and Diflucan may be
prescribed.

 Erythrasma
 Psoriasis
 Intertrigo

 Contact Dermatitis
Influenza
more about Influenza

The flu

 Influenza is a viral illness -- as such it is

primarily an infection of the lungs.
 Influenza can be a life-threatening illness in
the very young, debilitated, and elderly.

 Every year -- in the fall and winter -- specific

strains of Influenza are prevalent.

 In young children and infants it is a less

distinct illness.
 Classic influenza:

1. Dry cough
2. Sore throat
3. Stuffy/runny nose
4. Headache
5. Fever
6. Chills
7. Lack of energy
8. Muscle aches
9. Red eyes

10. Occasional nausea

 Influenza A or Influenza B.

 Transmitted person-to-person by respiratory

droplets.
 Clinical diagnosis by symptoms, such as fever,
lack of energy, and respiratory symptoms
 Decreased white blood cell count is common
 Virus may be cultured

 Antibody testing may be positive in the 2nd

week

 Bed rest as needed

 Adequate fluid intake
 Nonsalicylate containing antipyretics (e.g.,
Tylenol or ibuprofen for fever and ache)
 Cough suppressants as needed
 Antiviral medications, e.g., Ribavirin
aerosolized, amantadine hydrochloride for
influenza type A outbreaks

 Antibiotics are not effective against Influenza

but may be prescribed if a secondary infection
such as Bronchitis or Pneumonia is suspected.

 Pneumonia
 Bronchitis, Bronchiolitis
 Otitis Media (middle ear infection)
 Sinusitis
 Laryngotracheitis

 Reye's Syndrome -- a rare complication in

children in which liver failure and brain
swelling occur.  Aspirin increases the
likelihood of this syndrome and should always
be avoided in children (Tylenol and ibuprofen
are usually safe for children, with doctor's
supervision)

 The Influenza vaccine, generally available

annually in October or November, provides
protection against influenza strains of the
coming year.  Vaccines are made each year
specifically for the current year.  High risk
individuals who should definitely get the
vaccine include children 6 months of age and
older in chronic care facilities; children with
 respiratory illnesses, such as asthma; those
with metabolic diseases, including Diabetes
Mellitus, kidney dysfunction; those taking
immunosuppressive therapy such cancer
medication; and those receiving long-term
aspirin therapy.

Pneumonia
more about Pneumonia

Lung infection, lobar pneumonia, or Bronchial

Pneumonia

 The cells in the body need oxygen to survive.

When one breathes in oxygen-rich air, it
travels through the nose or mouth and into the
lungs via a system of pipe like air canals
known as bronchi.
 The left and the right lungs are spongy organs
located underneath the rib cage on either side
of the chest cavity.

 In pneumonia, inflammation (irritation,

swelling) or infection of the lungs cause fluid
and pus to fill a section of a lung(Lobar p.) or
form patches in both lungs (Bronchial p.),
interfering with the uptake of oxygen.

 Bacterial p.:

1. Fever > 38.3 degrees Celsius or 100

degrees Fahrenheit
2. Chills -- sudden onset
3. Cough -- dry
4. Cough -- productive with sputum that
has a rusty color.  It may be thick and
have a pinkish tone or blood specks
(Streptococcus p.).  In Aspiration p.,
 sputum may be foul-smelling and
green. Pseudomonas p. may produce
greenish sputum.  In Klebsiella p.,
sputum will look like currant jelly.
5. Chest pain -- sharp, especially upon
inhalation (Pleurisy)
6. Rapid shallow breathing
7. Shortness of breath (SOB) -- especially
with activity
8. Headache, nausea, vomiting, Diarrhea,
and weakness may occur with all types,
but more often is due to Legionella p.
9. Abdominal pain
10. Fatigue

 Viral p.:

1. Starts with upper respiratory symptoms

such as a dry cough, low-grade fever (<
100 degrees Fahrenheit), headache,
Nasal Congestion, sore throat, along
with muscle and joint aches
2. Skin rash may appear as in Measles
3. Cough -- dry, can have sputum
4. Chest pain -- especially with breathing,
and on one side
5. Chills
6. Shortness of breath, especially with
activity
7. Nausea, vomiting, Diarrhea

 Mycoplasma p.:

1. Slow progression
2. Headache
3. Low-grade fever
4. Cough -- dry, violent runs of coughing
5. Nasal Congestion
6. Sore throat
7. Muscle and joint pain
8. Wheezing sound when breathing

 Pneumocystis Carinii p.:

1. Often first presentation in HIV Infection

or AIDS
 2. Symptoms may develop suddenly.
3. Cough with white-clear sputum
4. Shortness of breath -- at first only with
activity, but then advancing to SOB at
rest
5. Weakness
6. Fatigue
7. Chills
8. Weight loss

9. Loss of appetite

 Pneumonia is not a single disease.

 Infections:

- Bacteria (bacterial p.) or wet p. -- when the

body's resistance is lowered due to certain
conditions (i.e., age, disease, alcohol,
Malnutrition) the normal bacteria of the mouth
and the throat multiply and invade one or all of
the 5 sections (lobes) of the lungs.  The
infected lobe (or lobes) then fills with fluid and
pus (Consolidation), in turn interfering with the
lung's normal oxygen exchange.

1. The infection can spill into the blood

stream and invade the whole body. 
Bacteria can also enter the lungs from
the air or from other sites in the body. 
Infections can either be acquired from
the community at large or while in the
hospital.
2. Streptococcus pneumonia is the most
common cause of bacterial (Lobar)
pneumonia.
3. Other bacteria include H. influenzae
(winter and early spring),
Staphylococcus aureus (common in
intravenous drug abusers -- IVDA, and
more common in infants versus
children), Chlamydia, Moraxella
catarrhalis (smokers), Legionella
(summer and fall, in water delivery
systems, air conditioning units), and
 gram-negative bacteria such as
Pseudomonas aeruginosa, Klebsiella,
and anaerobes.

 Aspiration p. occurs when stomach contents

get into the lungs.  Aspiration takes place
when the normal swallowing mechanism is
impaired while unconscious (e.g., seizure,
stroke, overdose), and from acid Reflux or
vomiting (alcoholics and hypotonic, weak,
debilitated infants).  Multiple types of bacteria
can infect the lungs in these ways.
 Empyema -- refers to the pus in the space
between the 2 layers of pleura covering the
lungs.
 Viruses -- usually acquired by inhaling air
borne infected virus droplets from someone's
sneezing or coughing.  Viruses are
responsible for 50% of all pneumonias, usually
causing upper respiratory illness (airways near
the throat and mouth), but can work their way
down to the lower airways where the lungs
are, and produce a patchy type of pneumonia
that usually resolves on its own.  Some of the
viruses include influenza virus(types A, B, C --
most common in adults), RSV (most common
in infants), parainfluenza (1,2,3,4), adenovirus,
CMV, Chicken Pox, EBV, Measles.  Viral
pneumonia usually occurs in children who are
between 2 and 3 years of age.
 Mycoplasma pneumoniae (i.e., Walking
Pneumonia) -- classified as a small organism
between a virus and a bacteria, it causes
pneumonia with a nagging dry cough that
comes in violent attacks.  Accounts for
approximately 70% of all pneumonias in
children ages 9 -15.
 Pneumocystis carinii (PCP) -- believed to be a
fungus, it often causes pneumonia in patients
with AIDS or decreased body defenses.
 Tuberculosis (TB) -- caused by the organism
known as Mycobacterium Tuberculosis (i.e.,
M. bovis and M. africanum).  It is contagious,
and can infect the lungs and other organs
(brain, spine, kidney, etc.).
 Rickettsiae -- small organisms that cause
 diseases such as Rocky Mountain Spotted
Fever. It may also have a mild to severe effect
on the lungs.
 Parasites -- ascariasis (round worm) in
children
-- Others -- substances can get into the lungs
and cause a blockage of the air passages,
promoting bacterial overgrowth or directly
inflaming the lung tissue.
 Food -- vomiting or swallowing a small object,
like a pea
 Gases -- furniture polish
 Dust -- usually dust, fungus, or mold inhalation
in farmers, mushroom pickers, or miners
(nickel dust).
 Liquids -- gasoline, kerosene

 Foreign body (e.g., inhaling a coin or tooth that

was loose in the mouth)

 Varies with type of pneumonia

1. History:
 Symptoms
 Illnesses
 Surgeries
 Medications
 Habits
 Travel
 Hobbies
 Allergies
 Occupation
2. Physical exam:
 Skin may show a rash, cyanosis
(blue lips)
 Increased heart and respiratory
rate (number of breaths per
minute)
 Blood pressure may be low
 There may be fever
 The chest (rib cage) may expand
poorly
 There may be decreased breath
sounds or abnormal sounds
(friction rub, rales, crackles,
 wheezing) due to destruction of
lung tissue, narrowing of
airways, or presence of fluid and
pus.
 Changes in mentation -- confusion, Anxiety

- Tests:

1. Sputum samples may be collected and

sent for microscopic analysis using
special stains to reveal the particular
bacterium.
2. Sputum may be sent for cultures grown
in order to identify the organism type,
along with sensitivity to antibiotics.
3. Cultures may take anywhere from 48
hours (bacteria) to several weeks (TB)
until final results are known.
4. Viral cultures can be done as well.
5. Blood may also be collected and sent
for bacterial cultures (positive in 8-20%
of bacterial p).
6. Blood may show high ESR (viral), white
blood cell count (may be normal in
elderly and low in Viral p.), low oxygen
levels (hypoxia), low Sodium levels
(empyema or Lung Abscess), high LDH
enzyme (PCP), and acidity (acidosis).
7. Blood can also be screened for
presence of specific Proteins called
antibodies.
8. In Mycoplasma p., 1-2 weeks after
infection there are high levels of IgM
antibodies in almost 80% of patients.
9. One can look for organisms such as
viruses (herpes, influenza, RSV) by
doing a throat swab using a sterile Q-tip
and swabbing the throat; or by
performing tracheal aspiration (suction
tube used to suck secretions from the
trachea, i.e. the main airway).
10. In PCP, an HIV test may be needed --
CD4 cell count falls below 200 if HIV is
present.
11. Pictures of the lungs are done using --
Chest X-Ray -- may show infection in
 one or more lobes of the lungs
(bacterial p.), diffuse pattern of infection
(PCP, V. p., M. p.), and effusions.
12. CAT scan or MRI is rarely necessary
unless cancer or abscess is suspected;
or when preparing for a procedure.
13. Your doctor may consult with an
infectious disease specialist, or a
pulmonologist (lung specialist).

 The pulmonologist may recommend:

1. Bronchoscopy -- flexible tube with a

camera at its tip is passed through the
mouth to the lungs, taking a sample of
secretions for culture or biopsy (taking a
tiny piece).

2. Thoracentesis is performed by inserting

a needle between the ribs and
removing fluid for analysis.  This is
done in effusions and empyema.

 Recent viral infections

 Hospitalizations:

1. Tube feeding
2. Mechanical ventilation
3. Antibiotic use

 Alcohol
 Smoking
 Age -- extremes of age, i.e., infants and elderly
(> 65)
 Weakened immune system, or body's natural
defenses are weakened:

1. AIDS
2. Cancers
3. Chemotherapy -- cancer-killing drugs
 Diseases:

1. Chronic obstructive lung disease

(COPD)
2. Kidney failure
3. Heart disease
4. Diabetes Mellitus

 Impaired gag reflex:

1. Seizure
2. Stroke
3. Overdose of drugs
4. IVDA (intravenous drug abuse)

 Close community living:

1. Family members
2. Military
3. Prison
4. Mental hospitals
5. Nursing homes

 Occupational -- farmers, people exposed to

infected birds (e.g., pigeons, parakeets),
miners

 Depends on the type

 Prevention:

1. Reduce risk factors

2. Vaccination -- against Measles,
influenza, Pneumococcal p., especially
in those over age 65 and those who
have other significant diseases
3. Bed-ridden individuals -- avoid
prolonged bed rest, perform exercises
in bed, breathing and coughing
exercises after an operation.
4. Avoid alcohol, drugs, nasogastric tube
feedings.
5. Avoid smoking.
6. Avoid taking antibiotics for viral
pneumonias.
 7. Foods high in vitamins, minerals, and
other nutrients

 May need admission to hospital if patient has

a high fever, shortness of breath, or in shock.
 If treated on outpatient basis, one needs to be
monitored closely afterward to make sure he is
improving.
 Bed rest, plenty fluids, and Tylenol for pain are
usually sufficient for mild uncomplicated
cases.
 Antibiotic pills may be started if the patient
does not appear too sick.
 General antibiotics (e.g., erythromycin) may be
given until the cultures come back from the
lab, then changed to the appropriate specific
antibiotic.
 Antibiotics are not given for virus infections.
 Antivirus medications such as Amantadine
(influenza A and B) or Ribavirin (RSV, hanta
virus) and Gancyclovir (CMV, herpes) are
available and only given to those whose
infections have been identified and typed.
 If the patient is very sick, he or she should be
admitted to the hospital.
 Intravenous (IV) fluids started.
 Oxygen given, if oxygen blood levels are low.
 IV antibiotics started.
 If one has TB or other dangerous forms of
pneumonia, isolate from other patients.
 If unable to breathe, respiratory support is
provided via mechanical ventilation (machine
breathes for you).
 A respiratory therapist may be needed to work
with the patient.
 Follow up laboratory tests and X-Rays are
done to check treatments.

 Medical follow up after discharge and a repeat

X-Ray in 6-9 weeks.

 Contact your physician immediately. If the

patient has difficulty breathing, call 911. 
Further Information can be obtained from the
 American Lung Association in the U.S. by
calling 1-212-315-8700.

 Pulmonary cancer (Lung Cancer)

 Pulmonary Emboli
 Pulmonary Contusion -- bruise like damage
after an accident
 Pneumothorax -- air or gas between the two
layers of the pleura

 Sarcoid

Ringworm of the
Scalp
more about Ringworm of the Scalp

Tinea Capitis

 Tinea capitis is a fungal infection of the scalp. 

It is usually seen only in children between the
ages of 4 and 14 years, and is very rare in
adults.  It usually causes patchy hair loss and
a flaky rash.  Treatment is with anti-fungus
shampoos and/or pills.

 Those affected generally have patchy areas of

hair loss.  The hair is usually weak and breaks
in the middle.
 The scalp is often red, itchy, and scaly in the
area of the hair loss.

 Sometimes there may be little bumps filled

with pus.

 Tinea capitis is due to a fungal infection of the

 scalp.

 Examination -- the doctor easily recognizes

the typical appearance of the rash.
 The doctor may also scrape the rash and look
and examine it under the microscope.
 Sometimes a culture of the rash may be
needed to make the diagnosis.
 Rarely will a biopsy need to be done.

 If this diagnosis is suspected in an adult, he

will need to be referred to a dermatologist, as
it rarely occurs other than in children.

 Treatment is often started with a selenium

sulfide shampoo that is used every 1 to 3
days.  This is combined with an oral anti-
fungus medicine called Griseofulvin.
 Children are treated with Griseofulvin at a
dose of 5 mg per kg of body weight per day, or
approximately 125-250 mg/d.  It is taken daily
for 6 weeks.  The child is then re-evaluated
and the rash re-examined.

 Continue medication for 2 weeks after the rash

shows no evidence of the fungus.

 Psoriasis
 Seborrheic Dermatitis

 Alopecia areata

 Special Information

1. A severe form of tinea capitis, called

kerion formation, can occur and lead to
a lot of scarring of the scalp as well as
hair loss.  This needs to be treated by a
dermatologist.
2. Griseofulvin can cause birth defects
and should not be taken by women who
 are pregnant or by those trying to
become pregnant.
3. All women who are going to take
Griseofulvin need to take a pregnancy
test before starting the medicine.

4. Women on birth control pills need to be

careful because Griseofulvin can
decrease the effectiveness of the pills. 
Therefore, all women taking
Griseofulvin need to be using two forms
of contraception.

Malaria
more about Malaria

 Malaria is a disease caused by four species of

intracellular parasites of the genus
plasmodium, comprised of Plasmodium vivax,
Plasmodium Malariae, Plasmodium ovale, and
Plasmodium falciparum.  Malaria is commonly
found in the tropics, subtropics, parts of
Mexico, Central, and South America,
Dominican Republic, Haiti, Middle East, Africa,
Southeast Asia, Indian subcontinent, China,
and Oceana.
 Malaria is transmitted from human to human
by mosquito bite.  Once injected into the
bloodstream of a human host (via bite), the
parasite travels to the liver, undergoes
alteration, after which it is released back into
the bloodstream to invade the red blood cells
(RBC).

 In the RBC, the parasites multiply and cause

the red blood cells to rupture.  The incubation
time from mosquito bite to infection ranges
from 6 to 60 days, with variances depending
on the specific Malaria infection.
 Attacks of the following symptoms every other
day or every third day, with sequences lasting
4-6 hours in the following order -- shaking
chills, fever up to 41degrees Celsius (103
degrees Fahrenheit), and severe sweating.
 Additional symptoms:

1. Fatigue
2. Dizziness
3. Headache
4. Dry cough
5. Nausea/vomiting
6. Loss of appetite
7. Abdominal cramps
8. Mild Diarrhea
9. Joint aches
10. Muscle aches

11. Backache

 Examination:

1. Enlarged spleen
2. Mild liver enlargement
3. Jaundice in severe falciparum infections

 Laboratory findings:

1. Appropriate staining, such as Giemsa,

thin/thick, etc., will determine diagnosis
2. During paroxysm, there can be
transiently elevated white blood cell
count (WBC), but between attacks there
is decrease.

3. In severe Malaria caused by

Plasmodium, falciparum liver functions
tests may be abnormal, severe anemia
may present, decreased platelets, and
reticulocytosis.

 All species except Chloroquine-resistant

Plasmodium falciparum --
 o Oral treatments

1. Chloroquine phosphate for P.

falciparum or P. Malariae
2. Chloroquine phosphate plus
primaquine phosphate for P.
vivax and P. ovale

o Intravenous treatments (for severe

attacks)

1. Quinine dihydrochloride or
quinidine gluconate, then begin
oral Chloroquine.  If the cause is
P. vivax or P. ovale, treatment
also needs to be followed with
Primaquine.
2. Artemether followed by
Chloroquine by intramuscular
injection, then begin oral
Chloroquine.  Primaquine
intramuscular injection should
follow if the cause is P. vivax or
P. ovale.

 Chloroquine-resistant P. falciparum

1. Quinine sulfate, plus one of the

following:  1) Doxycycline, 2)
Clindamycin, 3) Pyrimethamine, and
Sulfadiazine, 4) Tetracycline, or 5)
Pyrimethamine and Sulfadoxine.
2. Mefloquine
3. Halofantrine
4. Atovaquone/Proguanil
5. Atrovaquone/Doxycycline
6. Artesunate followed by Mefloquine

 Severe infections of Chloroquine-resistant

Plasmodium falciparum

1. Intravenous quinine dihydrochloride or

quinidine gluconate plus intravenous
Doxycycline or Clindamycin.  This is
followed by oral quinine sulfate.
 2. Artemether intravenously followed by
Mefloquine

 Seek immediate emergency medical

treatment.  This is a life-threatening medical
condition.

 Chloroquine-sensitive Plasmodium falciparum

and Plasmodium Malariae

- Chloroquine

 Chloroquine-resistant Plasmodium falciparum

1. Mefloquine
2. Doxycycline
3. Malarone
4. Chloroquine plus Progaunil

 Plasmodium ovale and Plasmodium vivax

- Primaquine

 Lymphoma
 Influenza
 Typhoid Fever
 Urinary Tract Infection
 Pneumococcal Pneumonia
 Hepatitis
 Dengue fever
 Relapsing Fever
 Amebic liver Abscess
 Kala azar

 Leptospirosis

 Special Considerations

1. When traveling to Malaria-infested

regions, the above are general
guidelines.  Review the current Center
for Disease Control's (CDC) up-to-date
 bulletins for Malaria prevention in a
given area.  Likewise, the above are
general guidelines for treatment of
Malaria and are subject to change. 
Management of Malaria treatment
usually involves an infectious disease
specialist.
2. If you are traveling to an area known to
have Malaria:

3. See your physician and consider

contacting the Centers for Disease
Control (they have an excellent web
site).  There are often physicians who
specialize in travel

Conjunctivitis
more about Conjunctivitis

Pink eye, bacterial conjunctivitis, infectious

conjunctivitis, red eye, or allergic conjunctivitis

Normal Abnormal
 Conjunctivitis is a condition in which the
conjunctiva covering the white part of the eye
becomes inflamed, red, and irritated. Anything
that irritates or infects the conjunctiva can
cause conjunctivitis. Viral and allergic causes
tend to have clear or "white eye discharge."
Bacterial causes, e.g., staphylococcus, tend to
have yellow or green eye discharge.
 White of eye is red
 Eye itching
 Watery eye discharge
 White eye discharge

 Yellow or green eye discharge

 Viruses
 Gonorrhea
 Chlamydia
 Staphylococcus
 Streptococci
 Haemophilus
 Pseudomonas
 Moxarella
 Allergies

 Dry eyes

 Clear discharge, sudden onset -- usually Viral

Conjunctivitis ("Pink Eye")
 Clear discharge, seasonal, or related to
environment-allergic
 Colored discharge -- usually bacterial (can still
occasionally be viral) -- cultures may be done

 Sicca (dry) Eyes -- diagnosed by Schirmer's

test

 Viral (pink eye) -- none, but wash hands

cautiously and avoid touching eye, as it is very
contagious
 Gonorrhea -- Ceftriaxone by injection
 Chlamydia -- Doxycycline, Erythromycin,
Azithromycin
 Bacterial causes -- antibiotic eye drops, e.g.,
Polytrim
 Allergic Eye -- topical lodoxamide, Naphcon A
eye drops, other allergy eye drops
 Dry Eyes -- artificial tear drops
  Treatment precaution:

- Some antibiotic eye drop preparations contain

corticosteroids. Corticosteroids can be helpful in
some infections, but can make others worse. In most
instances, drops containing corticosteroids should
only be prescribed by an ophthalmologist (medical
doctor who specializes in eye diseases).

 Contact Lenses

- Contact lens use increases the risk of bacterial

conjunctivitis. Extended wear contacts have the
highest risk. Use proper sterile techniques when
handling your lenses. Follow instructions on how to
clean your lenses carefully.

Yellow Fever
more about Yellow Fever

 Yellow fever is a viral disease (Flaviviridae, an

RNA arbovirus) transmitted by the bite of
infected mosquitoes (Aedes africanus, aegypti,
Haemagogus).  It usually occurs in Africa and
South America.  When an infected mosquito
bites someone who has the disease, it
spreads it to the next host who it feeds on. 
Symptoms usually develop 3-6 days after the
bite.

 Symptoms can be mild or severe

1. Mild symptoms include fatigue,

headache, fever, nausea, vomiting, and
sensitivity to light.  Occasionally, some
patients develop Slow Heart Rate.

2. Severe symptoms develop in about

15% of infected patients.  Initially, the
 symptoms are similar to those listed
above.  Patients feel better after about
3 days.  This is followed by the
development of more severe
symptoms, such as high fever, Slow
Heart Rate, Low Blood Pressure,
jaundice (yellowish discoloration of the
skin and eyes), bleeding from the
intestine or mouth, and confusion. 
Occasionally, patients may even go into
coma.

 The cause is a virus that is spread by

mosquitoes.  This virus multiplies in the human
body and causes the symptoms of the
disease.

 A diagnosis is made by blood tests used to

detect antibodies to the virus.

 Other lab tests show low white blood cell count

(on the CBC and differential), loss of protein in
the urine (on the Urinalysis), elevation of liver
function tests (AST, ALT, Bilirubin), and
thinning of the blood (elevation of PT, PTT,
and clotting time parameters).

 There is no specific treatment for the virus, so

the goal of the treatment is to manage the
symptoms and complications associated with
the disease.

 Prevention of the infection is the main key to

controlling this disease.  Eradication of the
virus is very difficult, and emphasis must be
placed on mosquito control.

 If you plan to travel to areas where the virus is

common, very effective vaccinations are
available to help prevent infection.  These
vaccinations should be obtained prior to travel
to the affected areas.  Pregnant women
 cannot be given this vaccination, and
consequently should probably avoid traveling
such areas.

 Hepatitis
 Malaria
 Leptospirosis
 Dengue

 Hemorrhagic fever

AIDS
more about AIDS

Acquired Immune Deficiency Syndrome or HIV

infection

 AIDS is caused by infection with the human

immunodeficiency virus HIV-1.  The HIV virus
infects cells in the body that fight infection. The
primary cell infected is the CD4 lymphocyte,
but it infects other infection-fighting cells as
well.  This causes immune system impairment
and difficulty fighting infection. Because the
immune system has a role in cancer
prevention, there is also an increase in certain
cancers.  To be HIV positive means that one is
infected with the HIV virus.  To be given the
diagnosis of AIDS, one must be infected with
HIV, which means that the HIV infection has
compromised the immune system to the extent
that an AIDS-defining illness (one of multiple
illnesses) has occurred.  Before current "triple
therapy" was developed, nearly all those who
were HIV positive went on to develop AIDS. 
Now it is not the case.  But, not all persons
respond to "triple therapy" and a proportion
still goes on to develop AIDS.
 HIV syndrome occurs 3 to 6 weeks after
infection and includes :

1. Fever
2. Sweats
3. Sore throat
4. Enlarged lymph glands
5. Headaches
6. Weight loss
7. Joint aches
8. Muscle aches
9. Diarrhea
10. Rash
11. Oral ulcers

 Symptoms of any opportunistic illness (i.e.,

bacteria, fungi, protozoa, and viruses)
 Some may not develop any symptoms for
years after exposure.
 Candidiasis (white patches in mouth)
 Pneumocystis carinii (lung infection
characterized by dry cough and shortness of
breath)
 Atypical mycobacterium
 Toxoplasmosis (infection in brain with
confusion)
Progressive multifocal leukoencephalopathy
(causes dementia)
 Herpes simplex (causes ulcers that persist
over 1 month)
 Lymphoma (enlarged glands)
 Kaposi's sarcoma (purple skin lesions)
 Diarrheas -- cryptosporidosis and isoporiasis
 Recurrent pneumonias
 Tuberculosis (cough)
 HIV encephalopathy (dementia)
 HIV wasting syndrome
 Cytomegalovirus infection /blindness
 Cryptococcosis (especially meningitis)
 Disseminated coccidiomycosis (fungal
infection found in Southwest United States,
typically affects lungs, but in HIV may go into
spinal fluid and cause meningitis)
 AIDS wasting (weight loss) syndrome
 Depression and social/family isolation
 Neuropathies

 Pain

 HIV can be found in many types of bodily

secretions (i.e., semen, urine, tears, saliva,
blood, breast milk, spinal fluid, vaginal
secretions).  However, the risk of transmission
is highest through semen and sexual activities.
 Anal sex -- highest transmission rate
 Heterosexual sex, homosexuals, bisexual
males who engage in unprotected sex
 Intravenous drug abusers who share needles
 Oral Sex -- lower, but risk still present
 Blood and blood product transfusions between
1977-1985 (now rare, because blood products
are carefully screened)
 Contaminated needle stick as in healthcare
professionals (1:300 risk)
 Children born to mothers with HIV infection
 Not spread through casual contact such as
touching, hugging, or sharing toilet seats
 Not transmitted by insect bites such as
mosquitoes

 No documented cases of HIV infection from

saliva or tears; however, if there is an open
sore on the skin or mouth, the risk increases.

 Examination:
 May be normal
 Signs & symptoms of AIDS-defining illnesses
(see below)
 Laboratory Findings:

1. HIV antibody test -- the HIV virus

multiplies in the body for weeks or
months before the body responds by
making antibodies to it, at which time
the HIV test is considered positive. 
Decreased CD4 lymphocyte (also
known as T-helper cells) count (the
lower the count the more likely to
develop infections and illness)
 2. Symptoms begin to occur with CD4
count falling below 350/ml
3. Anemia
4. Polyclonal hypergammaglobulenimia
5. High cholesterol

6. Skin antigen testing fails to react to

typical antigens

 The goal of treatment is to keep CD4 count

above 200/ml, prevent/control opportunistic
infections, and improve the quality of life.
 Anti-retroviral drugs (Highly Active Anti
Retroviral Therapy or HAART) -- these
interfere with the HIV virus' ability to replicate. 
Some common ones are listed below:
 Nucleoside analogs

1. Zidovudine (AZT)
2. Zalcitabine (ddC)
3. Lamivudine
4. Stavudine

 Protease inhibitors

1. Indinavir
2. Ritonavir
3. Nelfinavir
4. Saquinavir

 Triple therapy -- it has been found that

combining two nucleoside analogue drugs with
one protease inhibitor can substantially reduce
the viral burden, infection rate, and death rate
in HIV infection.

 Post-exposure prophylaxis (e.g., after a needle

stick)

1. AZT probably beneficial

2. AZT plus other antiretroviral drugs

probably will be shown to be more
effective.
  Before the more effective "triple therapy" was
developed, various regimens were
recommended to prevent specific infections. 
For example, Trimethoprim-Sulfamethoxazole
for Pneumocystitis carinii included various
regimens that are now reserved for those who
fail to respond or are intolerant of "triple
therapy."

1. Abstinence
2. Safe sex (use of condoms and oral
barriers)
3. HIV testing prior to a relationship
4. Stop intravenous drug abuse, sharing of
dirty needles, and other high-risk
behaviors.

5. Healthy lifestyle and join support groups

if at risk

 Tuberculosis
 Many cancers
 Hyperthyroidism
 Endocarditis
 Systemic lupus erythematosus
 Chronic meningitis
 Ulcerative colitis
 Crohn's disease
 Celiac sprue

 Malabsorption syndromes

Cholera
more about Cholera

 Cholera is an acute diarrheal infection that

affects the intestinal tract.  It is caused by a
potent enterotoxin that is often associated with
epidemic outbreaks, or found in pandemic,
 warm regions.

 Bacterium Vibrio cholera.  Vibrio cholerae is

often found in aquatic environs, such as
brackish water marshes, and is often
associated with algal blooms (plankton).
 Cholera is spread by contaminated water and
food.  Rarely, it is transmitted by direct person-
to-person contact.

 It has a short incubation period, from less than

one day to five days, and produces an
enterotoxin that is responsible for the
symptoms.

 The majority of individuals infected with V.

cholerae do not develop major symptoms,
even though the bacterium is present in their
stool for 7-14 days.
 Less than 10% of those infected with cholera
develop typical cholera, characterized by
copious, painless, watery diarrhea, and
nausea and vomiting that can lead to
moderate to severe Dehydration, and even
death if treatment is delayed.
 Peculiar, characteristic, thin, high-pitched
voice is often present.
 The excessive diarrhea and vomiting may lead
to loss of fluids and important Electrolytes
(e.g., Potassium), Dehydration, kidney
problems, and acidosis (acidification of the
blood).

 Eventually, the Low Blood Pressure and loss

of Potassium and other Electrolytes may result
in heart problems and overall circulatory
failure.

 The diagnosis is made clinically.  The watery

diarrhea is speckled with flakes of mucus and
surface cells of the intestine (epithelial cells),
thus the appellation of "rice-water stool,"
containing enormous numbers of vibriones.
 Cholera can be confirmed only by the isolation
of the V. cholerae from the diarrheal stool of
infected individuals.

 Blood tests may be done to evaluate

electrolyte imbalance and kidney function.

 Most cases of diarrhea caused by V. cholerae

can be adequately treated with a solution of
oral rehydration salts, glucose, and electrolyte
replacement, but patients who become
severely dehydrated must be given
intravenous fluids, Sodium chloride, Sodium
bicarbonate, Potassium chloride, etc.

 In severe cases, antibiotics can reduce the

volume and duration of diarrhea, and the
period of Vibrio excretion.  Tetracycline is the
antibiotic of choice, but resistance to it is
increasing.  Other antibiotics include
furazolidone, chloramphenicol, cotrimoxazole,
and erythromycin.

 Physician evaluation is prudent, especially in

young children and infants.  Infants are
especially prone to Dehydration and
electrolyte imbalance.  If severe cases go
untreated, adults and children alike may be at
risk for life-threatening complications.  Do not
hesitate to seek emergency medical treatment,
if you suspect the more virulent forms of this
infection.

 When traveling, it is essential to ensure an

adequate supply of safe drinking water and
food.  Practice good food hygiene by assuring
that cooked foods are not contaminated via
contact with raw foods, including water (and
ice); by cooking food thoroughly and eating it
while still hot; by controlling insects such as
flies and roaches that may come into contact
with food; and by avoiding raw fruits or
vegetables unless properly washed and
 prepared.
 Washing your hands often and routinely after
using the toilet is highly recommended.
 Those eating in private homes are less likely
to develop symptoms than those eating meals
in restaurants or from street vendors, the most
common and most dangerous source of
contamination.
 The safest drinks are bottled carbonated
water, beer, wine, and hot coffee and tea. 
When brand name bottled beverages are
unavailable, water should be boiled or
chemically treated with iodine or chlorine
tablets, which can be purchased in specialized
stores, like camping or travel retail outlets. 
Boiling water for five minutes (longer at high
altitudes) will make it safe to drink.  However,
portable water filters are not a proven method
of purification in affected areas, and are not
currently recommended.

 Oral cholera vaccines that provide high-level

protection for several months against cholera
caused by V. cholerae O1 have recently
become available in a few countries but their
use does not mean that above precautions
should be ignored.

 Additional information on cholera, as well as

other travel-related health concerns, can be
obtained from the CDC by automated hotline
(404) 332-4559 (note: the CDC is a catch-all
for health warnings).

Food
Poisoning
more about Food
Poisoning

 Food Poisoning is a "catch all" term for

multiple syndromes that affect the stomach. 
 Foods that are often the cause are as follows:
under-cooked poultry, eggs, meats, and dairy
products.  Any food can serve as a medium for
these organisms.

 Nausea/vomiting
 Diarrhea
 Abdominal cramps

 Sometimes fever

 Staphylococcus -- found in food that has been

left unrefrigerated, which produces a toxin that
causes the symptoms (often found in high
protein foods, such as egg salad, heavy
creams, and ham).
 Bacillus cereus -- found in cooked rice left
unrefrigerated, also in cereals, vegetables,
meats and dried foods.
 Salmonella -- found in undercooked poultry or
meats.
 Enterotoxigenic E. coli -- may be found in most
foods, raw fruits, vegetables, and
contaminated water.
 E. Coli 0157:H7 -- can cause severe bleeding
in the colon.  This is the cause of deaths from
"bad meat" at restaurants.
 Entamoeba histolytica -- a parasite found in
areas where human feces may contaminate
the soil or water.
 Giardia -- fecal contaminated water
 Botulism -- improperly canned foods
(especially non-acidic vegetables, canned
meats)
 Clostridia -- found in meats, vegetables, and
gravies

 Shigella -- found in raw vegetables,

contaminated water, other foods (e.g., egg
salad)

 Food sent for culture and evaluation for toxins

 Stool sent for culture and evaluation for toxins
 Blood count if significant bleeding with
Diarrhea

 Electrolytes, BUN, and Creatinine to evaluate

person for Dehydration

 Clear liquids -- water, electrolyte-containing

beverages, e.g., sports drinks, Pedialyte, and
juices
 BRAT diet (if feel need to eat) -- bananas, rice,
applesauce, and toast
 Intravenous fluids if necessary
 Ciprofloxacin for 5 days may shorten the
course of some bacterial infections (It is the
physician's decision to determine whether to
use)
 If there is an underlying cause (such as
Giardia), treatment appropriate to the cause.
 AntiDiarrheal medications, e.g., Imodium --
use only if there is no blood in the Diarrhea. 
Try to minimize use, as slowing Diarrhea may
cause the infection to last longer.

 If Botulism is suspected -- patient receives

Botulism anti-toxin.  This is a life-threatening
emergency.  See section on Botulism.

 Avoid eating unrefrigerated food (note since

the cause is a toxin produced by the bacteria,
and not the bacteria themselves, re-heating
does not help -- it kills the bacteria, but the
toxin is still present.  Eat at restaurants with
high health standards.  Individuals involved in
food preparation need to always wash their
hands with anti-bacterial soap.

 Gastroenteritis
 Common Gastritis
 Acute Diarrhea
 Chronic Diarrhea

 Food intolerance
Syphilis
more about Syphilis

Primary Syphilis or Secondary Syphilis

Primary Syphilis Secondary Syphilis

 Syphilis is a sexually transmitted disease
caused by the bacterium Treponema
pallidum.  The infection is usually transmitted
person to person through minor cuts in the
skin or mucous membranes (genitals or
mouth) during sexual intercourse.  Syphilis has
three stages: Primary, Secondary, and Tertiary
Diseases.

 Primary Syphilis:

1. Genital ulcer-usually painless with firm,

indented borders
2. Swollen lymph glands in the groin

 Secondary Syphilis:

1. A rash is usually composed of red

lesions that can either be small or
large.  The rash is also present on the
palms and soles of the feet (only a few
conditions have a rash in these places)
2. Condylomata Lata -- sweeping skin
lesions in the moist areas of skin and
 mucous membranes
3. Silvery ulcer patches on the mucous
membranes (mouth or vagina)
4. Diffuse lymph node swelling in the body
5. Yellow skin or eyes (occasionally)
6. Low-grade fever
7. Lack of energy
8. Loss of appetite
9. Joint and muscle aches
10. Headaches
11. Neck stiffness (rare-a sign of
Meningitis)

12. Eye inflammation

 VDRL or RPR are screening tests

 FTA-ABS (antibody test for syphilis) confirms
the diagnosis

 Microscopic exam -- dark field microscopy

techniques show Treponema pallidum from
material that has been aspirated from lesions
of the affected regional lymph nodes

 Penicillin by injection is the treatment of choice

 Alternatives include Tetracycline, Doxycycline,
or Azithromycin
 There is no need for local treatment of lesions
 Jarisch-Hersheimer reaction, the sudden
killing of the Treponema pallidum bacteria that
results in the release toxic products, may
occur.  This causes fever and a worsening of
the current symptoms.
 Treatment should not be stopped unless the
symptoms are severe.  Antipyretics (fever
reducing medications such as Tylenol or
aspirin) and corticosteroids can be used to
prevent or modify this reaction.

 The Jarisch-Hersheimer reaction generally

resolves itself in 24 hours.

 Safe sex practices.  Abstinence is ideal until

 the syphilis is properly treated.
 Condoms are only effective in the covered
areas
 Exposed parts should be washed with soap
and water after sex (both males and females)
if couples do not refrain from engaging in
sexual relations.

 Persons exposed to syphilis in the preceding 3

months should be treated for presumed
syphilis, as blood tests may initially be
negative.

 Gonorrhea
 Chlamydia
 Chancroid
 Herpes

 HIV

Tetanus
more about Tetanus

Lockjaw

 Tetanus is a disease caused by a toxin or

poison manufactured by bacteria.  The toxin
affects the nerves and muscles, causing them
to spasm and become tense.  Prevention is
the best option.  Vaccination against the
disease is available and very effective.  If one
develops the disease, treatment involves
careful monitoring, antibiotics, and other
medicines.

 Symptoms on average begin 8-12 days after

the infection, but can occur as late as 15
 weeks later.
 At first, there may be just pain and tingling at
the site of the infection.
 Followed commonly by jaw stiffness, neck
stiffness, trouble swallowing, and irritability.
 Eventually, one experiences spasms and
stiffness of other muscles, including those of
the face, back, and jaw. There may be
difficulty opening the mouth.
 Increased and exaggerated reflexes
 Occasionally, the patient's throat may close-
up, or he may stop breathing.
 Usually, there is no fever.  Patients are usually
awake and sentient.
 Extreme sensitivity to any stimulus or
sensation -- it is not uncommon for patients
with this condition to express Convulsions
when exposed to even minor sensations.

 There is a high risk of developing other

complications, i.e., Heart Failure, inability to
urinate, or inability to have a bowel
movement.  Some with tetanus may not be
able to breathe on their own, requiring support
and careful monitoring in the hospital.

 The cause of the disease is a bacterium

known as Clostridium tetani.  This bacterium
usually gets into a wound and then secretes a
toxin that causes the symptoms of the
disease, i.e., Muscle Spasms, tense nerves,
exaggerated reflexes, and hypersensitivity to
sensation.
 Those who most often develop the infection
are migrant farm workers, people who have
not been immunized, intravenous drug users,
newborns, and the elderly.  Also, people who
take medicine by injection have a higher risk of
infection.

 Any type of wound (including Frostbite, Burns,

and infections) increases one's chance of
developing tetanus.
 Diagnosis is made by symptoms and the
doctor's examination.  There is no dependable
blood test available at this time to make the
diagnosis.

 Once the patient develops the infection, they

need to be treated with antibiotics (most often
penicillin) and also with tetanus immune
globulin (5000 units).
 Once recovered, he will still need to receive
the immunizations so as not to develop the
disease in the future.
 Those recovering from tetanus will need rest
and quiet-preferably, a dark, quiet, isolated
room.
 Sometimes, sedatives will be required.
 Monitoring for arrested breathing and Heart
Failure is advised.

 This disease still carries a high risk of death

and the patient has to be watched very
closely. In the past, up to 40% affected died. 
Now, however, with better technology, the risk
of death is lower.

 Prevention of the infection is the main key to

controlling this disease.  Very effective
vaccines are available, so the disease can be
completely prevented.
 In childhood, the vaccine is given as a series
of DTaP (stands for diptheria, tetanus, and
Pertussis) vaccines (usually given at 2
months, 4 months, 6 months, 15 to 18 months,
and then at 4 to 6 years.  After that a repeat
vaccine called Td is given at 11 to 16 years).
 In adults who have never been vaccinated, the
person is given 2 Td (stands for diptheria or
tetanus toxoid) doses 4 to 6 weeks apart, and
then a third dose after 6-12 months.
 For people who have been fully vaccinated,
they get booster doses of Td every 10 years. 
However, if they have a major wound that is
dirty, they will need a repeat dose of Td if it
has been over five years since their last
 immunization.

 If the patient has not been vaccinated and they

have a dirty wound, they are given the
vaccination, but they also need to be given a
medicine called tetanus immune globulin (250
units) which will protect them until the
vaccination takes effect.

 Meningitis
 Encephalitis
 Spinal cord Abscess
 Strychnine poisoning

 Reaction to medication

Tuberculosis
more about Tuberculosis

TB or consumption

Tuberculosis of
Normal Abnormal Skin
 Tuberculosis is an infection caused by an
organism called Mycobacterium Tuberculosis. 
This is an organism capable of causing
infections throughout the body, but the most
common location is the lungs.
 M. Tuberculosis is a bacterium found
throughout the world.  It is often very difficult to
treat.  Often, when the organism invades the
body it triggers an immune response, killing off
most of the organisms in the course of the
 initial infection.  This is called a primary
infection and often does not cause significant
symptoms.
 However, a few organisms will remain
dormant, only to become active years later. 
This is called a reactivation.  Various factors
that weaken the immune system, such as
multiple medical problems, chemotherapy, HIV
Infection, or any other immuno-suppressive
conditions may trigger or contribute to
reactivation of the infection.
 Symptoms depend on which organ or part of
the body is infected.  Treatment also depends
on the part of the body infected and the extent
of the disease.  Anti-Tuberculosis medications
are the main treatment.  Treatment is a long
process and requires months to years of
therapy, often with multiple medications.

 Also, an increasing number of patients fail to

respond to the usually effective medications. 
They have drug-resistant Tuberculosis. If their
infection fails to respond to antibiotics, it is
almost always fatal.

 As stated, symptoms can vary depending on

which part of the body is infected.
 Tuberculosis can infect almost any part of the
body including, but not limited to, the lungs,
heart, brain, bone, spine, stomach, kidneys,
and fallopian tubes.
 The specific symptoms depend on the area of
the body infected.
 Some general symptoms include weight loss,
loss of appetite, low-grade fever, night sweats,
and fatigue.
 Pulmonary Tuberculosis occurs when the
organism infects the lungs.  Symptoms include
a cough, which may be dry or productive of
phlegm.  Often, there is coughing up of blood. 
An examination may not reveal any significant
abnormalities.  Occasionally, the doctor may
detect the presence of fluid collection in the
lungs.
 Tuberculosis Meningitis -- is a Tuberculosis
 infection of the brain or spinal cord. 
Symptoms may start with irritability and
restlessness.  Eventually, the patient develops
stiff neck, headache, vomiting, Seizures,
changes in mental condition or behavior, or
coma.
 Intestinal Tuberculosis -- is an infection of the
intestinal tract. It was not very common in the
United States until AIDS.  Some of the
symptoms include stomach pain, Diarrhea,
Intestinal Obstruction, granuloma formation,
intestinal ulcerations with bleeding, or
narrowing of the intestines.
 Tuberculosis lymphadenitis -- involves M
Tuberculosis infecting the lymph nodes,
causing enlargement of the nodes and forming
masses in the neck.  This is known as
scrofula, and may sometimes drain to the skin.
 Tuberculosis Pericarditis -- occurs when the
organism invades and infects the lining of the
heart. This can cause fluid build-up around the
heart, leading to more significant problems,
including shortness of breath, fluid build-up in
the lungs, Low Blood Pressure, and even
death.
 Tuberculosis peritonitis -- involves an infection
and fluid build-up in the abdomen.  This is
often very difficult to diagnose and is often
missed. In addition to build-up of fluid in the
abdomen, symptoms may include fever,
weight loss, and weakness.  Even with testing
of the fluid, it is difficult to diagnose and may
necessitate Laparoscopy to confirm diagnosis.
 Tuberculosis salpingitis -- is an infection of the
uterine fallopian tubes that causes pelvic pain. 
Examination may reveal the presence of
masses in the pelvis, and the patient may
report irregular periods. It is not sexually
transmitted.

 It is important to understand that many of

these symptoms may also be present with
numerous other medical conditions.  Quite
often, Tuberculosis is not even suspected until
other more common conditions are treated
without success.
 As above, Tuberculosis is caused by
Mycobacterium Tuberculosis, an organism
found throughout the world.
 Respiratory droplets most often spread it
person-to-person when people cough.
 Initially, the infection is acquired from another
person.  Once the organism enters the body, it
spreads via the bloodstream and lymph
system throughout the body.  This is called
primary Tuberculosis, and often there are no
symptoms.  The immune system fights off the
infection, destroying the majority of
organisms.  Some become dormant and
survive within the body for years or even
decades.  These organisms usually do not
cause any problems.
 However, in a few cases, reactivation of the
disease occurs.  This does not require any
new infection.  The organism, dormant and
inactive for years, has become active again.
 The risk of reactivation increases if the
immune system is weakened for any reason.
 On average, a normal person who has been
infected with Tuberculosis has about a 10%
chance of developing a reactivation of the
disease over the course of their lifetime. In
people with HIV, however, they have a risk of
about 7% per year.
 In the past, it was thought that almost all adult
cases of Tuberculosis were due to
reactivation.  However, newer testing methods
have revealed that a sizeable number of adult
cases may actually be due to newly acquired
infections, especially in areas where there are
a large number of people with Tuberculosis.

 People from certain parts of the world, such as

the Philippines, China, Southeast Asia, Haiti,
and India have a much higher risk of having
resistant Tuberculosis.  Resistant Tuberculosis
occurs when the organism is not sensitive to
the usual anti-Tuberculosis medicines.
 Diagnosis in almost all cases should be
approached with suspicion.  TB is notorious for
progressing very slowly, and exhibiting only
the most vague of symptoms.  It is often
missed or misdiagnosed for a long period of
time.  Often, when patients are treated
unsuccessfully for numerous other diseases,
only then is the diagnosis of Tuberculosis
actually considered.  The doctor needs to be
informed of any risk factors that may increase
the chance of Tuberculosis in order to
consider it sooner.
 Even when the diagnosis is considered early,
confirming it can take a long time.  In some
cases, tests are performed and the diagnosis
made within a few days. In other cases, the
organism will have to be cultured, which may
take 4-8 weeks. At times, tests may appear
normal at first, and then come back abnormal,
i.e., positive for TB.
 In making the diagnosis, two main tests are
used.

1. The first is called an AFB stain or

smear, in which a sample of suspect
tissue is stained with special dye, and
examined under microscope.  This test
is usually done within a day or two.
2. In the second test, a culture is used in
an attempt to grow the organism in the
lab.  M Tuberculosis is very slow
growing and this test can take up to 6-8
weeks for results.  In some cases, the
AFB stain may not show anything, but
the cultures may come back weeks
later with positive results.  The culture
results are extremely important
because they determine which drugs
will work against the organism.
3. There are other tests used, such as
PCR, Bactec, and RFLP, but the two
above are the main diagnostic tools.

 Tests for diagnosing Tuberculosis depend

upon where the infection is located.  The
guiding principle is that some of the suspect
 tissue or fluid has to be removed and studied. 
If necessary, a biopsy is performed.
 For pulmonary Tuberculosis --

1. The principal method of diagnosis

involves finding the organism in sputum
samples.  Specimens are obtained
immediately after waking up (best
results) on 3 consecutive days. The
sputum is then tested to see if the
organism is present.
2. When it is difficult to secure a sputum
sample, a Bronchoscopy may be
required, using a camera to look into
the lungs and obtain specimens from
the lungs and breathing tubes.
3. The last option is to try to culture the
organism from early morning stomach
fluid.
4. Whenever Tuberculosis is suspected,
Blood cultures are used to discover if
the organism is in the bloodstream.
5. A chest X-Ray is used to discover
infection of the lung.
6. CT scans can also help identify lung
infection.

 In order to diagnose Tuberculosis in other

parts of the body, tests are done of the
suspect areas, including CT scan, Ultrasound,
MRI scan, Echocardiogram, endoscopy, etc.
 These tests are only suggestive.  Final
diagnosis can only be made by obtaining a
specimen for establishing the presence of the
Tuberculosis organism, i.e., from sample of
fluid or biopsy of the suspected site of
infection.
 In cases of suspected tuberculous Meningitis,
a spinal tap may be done.

 Another test, called a PPD, is usually

administered to anyone suspected of having
TB.  See the section below labeled
"Prevention" for more details.  In most patients
with Tuberculosis, it will give a positive
reaction.  However, sometimes, the test can
 be negative even in someone with the
disease.  Similarly, a positive test does not
absolutely confirm TB.  The test is helpful as
part of the work-up, but it does not make the
diagnosis.

 Risk factors for developing Tuberculosis

include:

1. Being around someone with active

Tuberculosis
2. Having a chronic illness such as
diabetes
3. Having a weakened immune system,
either from HIV, chemotherapy,
prolonged steroid use, etc.
4. Working in the health care field
5. Living in a long-term care facility, such
as a nursing home, mental institution, or
prison.

6. Also, older people are at an increased

risk of developing Tuberculosis.

 Treatment for Tuberculosis should be started

on all individuals in whom the doctor suspects
the disease.  If there is any risk that the patient
may not take the medications, or may expose
others, then initial treatment needs to be done
in the hospital.  Most of the time, other
household members have already been
exposed, and isolation from them is not
needed.  However, if there is a possibility of
new exposures, then isolation is in order. In
the hospital, patients are placed in a special
room (called a negative pressure room), to
prevent spread of the disease to staff and
others.  All hospital staff and family members
in contact with the patient will have to wear
protective masks.
 Treatment -- there are many options and
treatment needs to be tailored to the individual
and his lifestyle, as well as to the location and
type of the infection
1. There are two main conditions of
treatment. In the first case, the patient
is treated at home, coming in for
periodic check-ups. In the second,
called DOT (directly observed therapy),
the patient comes into the health
department or other agency 2-3 times a
week for medication, to ensure that he
is actually taking his medicines.
2. The four main drugs used to treat
Tuberculosis are Isoniazid, Rifampin,
Pyrazinamide, and either Ethambutol or
Streptomycin.  Usually four (4) of these
drugs are given in combination to treat
almost all Tuberculosis infections.
3. Treatment is with four medications until
the tests identify which anti-
Tuberculosis medicines will be most
effective.  Medications are adjusted
accordingly.  Usually, all four are
continued for about 4-6 weeks.  If the
organism proves to be sensitive to
Isoniazid and Rifampin, they are
continued, and Ethambutol or
Streptomycin is stopped. Pyrazinamide
is continued for 8 weeks then stopped. 
Therapy is continued for at least 6
months, or for at least 3 months after
the cultures are negative -- whichever is
longer.
4. There are various combinations of
treatment and the best option will have
to be tailored to the patient's needs by
the doctor and the health care
department.
5. In patients with HIV, they need to
continue treatment for a minimum of 9
months, or for 6 months after the
cultures are negative.
6. If cultures are not available to guide the
doctor, options will need to be
discussed with a specialist because the
type, length, and method of treatment
all vary.
7. Directly observed therapy (DOT) is
more expensive to administer, but it
 ensures that the patient takes his
medicines, especially in those with
drug-resistant Tuberculosis, and in
those who refuse to take their
medication or have difficulty following
directions.
8. Treatment for Tuberculosis outside the
lungs is usually the same as pulmonary
Tuberculosis, but it is usually continued
for at least 9 months.
9. Steroids can be used for people with
Tuberculosis Meningitis and
Tuberculosis Pericarditis to help reduce
inflammation.
10. Streptomycin should not be used by
pregnant women. Pyrazinamide use
during pregnancy is not advised either.
11. All treatment starts with multiple
medications because of the risk of
resistance if only 1 or 2 medications are
used.  Treatment should start with all
four, and then altered according to
results.
12. Patients should take all of their
medicines until the doctor tells then to
stop. If the doctor's orders are not
followed, there is a high risk of not
adequately treating the infection. The
organism may become resistant,
making repeat infection difficult to treat.

 Tuberculosis lymphadenitis is treated with

surgery to remove all infected lymph nodes,
after which the patient is placed on anti-TB
medications.
 Tuberculosis Meningitis -- using the four anti-
TB medications described above, treatment
has to be started even before all of the test
results are back.  Occasionally, steroids may
also be used in the case of nerve deficits.
 Tuberculosis Pericarditis -- requires drainage
of the fluid and anti-TB medications. In some
cases, the sac surrounding the heart may
have to be removed.
 Tuberculosis peritonitis -- is treated with the
usual combination of anti-TB medications.
 Tuberculosis salpingitis -- this is treated with
the usual anti-TB medications. If there is a
large mass, or if the TB does not respond to
medication, surgery may be necessary.

 The risk of contracting drug-resistant TB

increases in regions known to have a high
incidence of drug-resistant TB.  Other high risk
factors for drug resistant TB include close
contact with someone with drug-resistant TB,
previous unsuccessful treatment for TB, and
previous failure to take all medicines and
complete treatment.  The risk of drug-resistant
TB is especially high in the United State in
large urban centers, such as New York,
Dallas, and Los Angeles.  In those with drug-
resistant TB, the infection is almost always
fatal, unless an alternative drug regimen is
found and followed.  This requires the input of
trained specialists to help structure treatment
options.

 There are many potential complications of

varying severity that may occur with
Tuberculosis, depending on the location and
kind of infection.
 In lung infections, there can be fluid build-up
around the lungs, resulting in shortness of
breath and/or fluid collection within the lung. In
such cases, removal of part of the lung may be
necessary.
 In cases of Intestinal Tuberculosis infections,
patients may develop obstruction, perforation,
malabsorption, or bleeding from the intestine.
 In those with brain infections, patients may
develop chronic brain syndrome, Seizures,
neurological deficits, Stroke, or hydrocephalus.

 People with heart infections can develop

constrictive Pericarditis.

 Seek medical attention as soon as possible.

 It is important to inform the doctor or health
care workers immediately if you think that you
 have Tuberculosis.  Precautions can be taken
to prevent spread of the infection.

 Until the diagnosis is made, it is best to try to

avoid contact with others to prevent spreading.

 Prevention is the key to controlling this

disease.
 The first line of prevention is to try to keep the
infection from spreading by isolating anyone
with an active virus until the infection is
brought under control. In modern hospitals,
negative pressure rooms prevent the infection
from spreading within the hospital.
 Also, facemasks may be used to trap the
organism and prevent its spread.  All those in
contact with the patient should wear them.
They may also be worn by the patient,
allowing him mobility so long as the mask is
secure.
 Anyone even suspected of having the infection
should be isolated immediately, or given a
mask to wear to prevent the infection from
spreading.  Discontinue such precautions only
when it safe to do so-when it has been proven
that the patient no longer has the infection, or
was falsely diagnosed and never had it.
 People with active Tuberculosis are very
infectious, and may easily spread the disease
to others around them by coughing or
sneezing.  As stated above, they must be kept
in isolation until they no longer pose a risk --
when at least 3 separate AFB tests prove
normal and they evidence no other indications
of the presence of the organism.
 The PPD skin test -- is a screening test
commonly done in the United States, and is
often used as part of a strategy to prevent the
disease.

1. The PPD skin test is done by injecting a

small amount of protein (derived from
Tuberculosis bacteria) under the skin of
the forearm -- swelling and redness
indicate a positive result.
2. The test result is determined 48 hours
after injection.
3. It reveals only previous exposure to
Tuberculosis.  It does not determine
whether the test subject has an active
infection, or merely past exposure to
the organism.  The PPD test result has
to be interpreted based on a number of
factors.  Alone it is not conclusive.
4. In a patient with HIV who has had close
contact with someone infected with
active TB, and in patients with X-Ray
evidence of prior healed Tuberculosis, a
PPD test is considered to be positive if
the swelling is more than 5 millimeters
in width.
5. Subjects from countries with a high rate
of TB, HIV-positive IV-drug users, those
in correctional facilities or nursing
homes, people from medically-
underserved areas, and people with
certain medical conditions are
considered to have a positive PPD if the
swelling is more than 10 millimeters in
diameter.
6. The rest of those tested are considered
to have a positive PPD if the swelling is
more than 15 millimeters in diameter.
7. In some cases, test subjects may
initially have a negative skin test but on
repeat testing, their skin test may turn
positive.  This may be a "booster
phenomenon," in which the first test
triggered an immune response, rather
than a true conversion to a positive test.
8. The PPD test is not 100% accurate. 
Some who do not have the infection will
have a positive test result. These false
positives occur occasionally in those
with an infection closely related to
Tuberculosis.
9. Also, there are those who have a
negative test but do have the infection. 
These false negatives occur more often
in the malnourished, older people,
those with AIDS, those on steroids,
 those with severe Tuberculosis, those
with certain types of cancers, people
with kidney failure, people who are very
ill from other causes, or those in whom
the test was not administered properly.
10. People who have been given the BCG
vaccine may have a positive skin test
for a year after the vaccination.  After a
year, their skin test response should be
interpreted the same as anyone else.
11. Also, some people do not react to the
PPD skin test at all.  They are said to
be anergic, and they do not have any
response to skin tests.  Their test
results are of no value.  To determine
anergic test subjects, give other
injections to see if they have any
response.

 Most patients given preventive therapy for

Tuberculosis usually receive six (6) months of
Isoniazid.
 All subjects with a positive PPD should be
given preventive therapy if they fall into one of
the following categories:

1. All people with HIV.  Also, if the person

is HIV positive and has a high risk of
Tuberculosis, then they need to be
given preventive therapy even if their
skin test is negative.
2. All people who are close contacts of
someone with Tuberculosis and have a
positive skin test.  Children must be
treated with preventive therapy even if
their skin test is initially negative. 
Children should be re-tested 3 months
later, and if they test positive, they will
need to continue therapy for a total of
nine (9) months.
3. Anyone who has recently developed a
positive skin test (within the past 2
years).  That is, they previously had a
negative skin test and then became
positive.
4. People with medical conditions that
 increase their chances of developing
Tuberculosis should be treated with
preventive medications.  This includes
patients with diabetes, people on
chronic steroid therapy, those with
blood cancers, intravenous drug users,
people with kidney failure, and people
who are undernourished.

 In the following cases, only those who are

under 35 years old and have a positive PPD
need preventive therapy:

1. People born in countries with a high

rate of Tuberculosis, such as African,
Asian, and South American countries.
2. People from the U.S. who are medically
underserved or have very low incomes.
3. People who live in or work in long-term
care facilities, such as mental
institutions and nursing homes.

 All other people who do not have risk factors

for Tuberculosis but have a positive skin test
with more than 15 millimeters of swelling
should be given preventive therapy if they are
under 35 years of age.
 In most cases, preventive therapy is with
Isoniazid for 6 months.  In children, therapy is
continued for 9 months.
 People who are on Isoniazid are usually given
Vitamin B6 to help reduce side effects of
Isoniazid.
 Also, people on Isoniazid need to have liver
tests done prior to starting therapy.  They will
need to be monitored with questioning to see if
they develop symptoms of hepatitis. If they do,
blood tests will be needed, and the medicine
stopped if they have elevated liver tests. If
they are under 35 and have no symptoms,
routine testing is not needed.  If over 35,
routine blood tests to check the liver may be
warranted.
 BCG vaccine (BCG stands for Bacille
Calmette-Guerin) --
1. In some countries, this vaccine is
routinely used.
2. In the United States, it is not common. It
is used mainly in people who have a
positive PPD but cannot take Isoniazid
prophylaxis.
3. Also, it can be given to PPD negative
children who are exposed to people
with inadequately treated Tuberculosis
but cannot receive the usual preventive
treatments.
4. This vaccine can also be used in areas
where there is a high rate of new
infections, despite appropriate
measures to prevent new infections.

5. BCG has been shown to reduce the risk

of developing Tuberculosis.