3. S. pneumoniae , H. influenzae , N. meningitidis Purpura fulminans Rickettsia rickettsii Rocky Mountain spotted fever N. meningitidis Meningococcemia Petechiae: Sepsis with skin findings Erythroderma: toxic shock syndrome Group A Streptococcus , Staphylococcus aureus
19. Unusual Presentations of Severe Dengue Fever ~Encephalopathy ~Hepatic damage ~Cardiomyopathy ~Severe gastrointestinal hemorrhage
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21. Tourniquet Test ~Inflate blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes ~Positive test: 20 or more petechiae per 1 inch² (6.25 cm²)
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23. TREATMENT: Outpatient Triage ~No hemorrhagic manifestations and patient is well-hydrated: home treatment ~Hemorrhagic manifestations or hydration borderline: outpatient observation center or hospitalization ~Warning signs (even without profound shock) or DSS: hospitalize
24. Treatment of Dengue Fever ~Fluids ~Rest ~Antipyretics (avoid aspirin and non-steroidal anti- inflammatory drugs) ~Monitor blood pressure, hematocrit, platelet count, level of consciousness ~Continue monitoring after defervescence ~If any doubt, provide intravenous fluids, guided by serial hematocrits, blood pressure, and urine output ~The volume of fluid needed is similar to the treatment of diarrhea with mild to moderate isotonic dehydration (5%-8% deficit)
26. Acquired Immune Deficiency Syndrome (AIDS) ~1st recognized in the U.S. in 1981 when Center for Disease Control (CDC) reported the unexplained occurrence of Pneumocystis carinii pneumonia in 5 previously healthy homosexual men in Los Angeles ~Kaposi’s sarcoma (KS) was also noted in 26 previously healthy homosexual men in New York and L.A. ~1983 – HIV was isolated from pxs with lymphadenopathy ~1984 – clearly demonstrated as causative agent of AIDS ~1985 – ELISA was developed leading to appreciation of the scope and evolution of HIV epidemic in the U.S. and other nations
27. Definition ~currently, CDC classification system for HIV-infected adolescents and adults categorizes persons on the basis of clinical conditions associated with HIV infections and CD4+ T lymphocyte count ~the system is based on 3 ranges of CD4+ T lymphocyte counts and 3 clinical categories and is represented by a matrix of nine mutually exclusive categories
28. 1993 Revised classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults Clinical Categories CD4+ T Cell categories A Asymptomatic, Acute(Primary) HIV or PGL B Symptomatic, Not A or C Conditions C AIDS-Indicator Conditions >500/µL A1 B1 C1 200-499/µL A2 B2 C2 <200/µL A3 B3 C3
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41. Pathophysiology and Pathogenesis - hallmark is profound immunodeficiency resulting from progressive qualitative and quantitative -deficiency of the subset of t helper cells or inducer cells with CD4 molecule on its surface w/c serves as primary cellular receptor for HIV
42. Clinical Manifestations a.Acute HIV syndrome - in 50%-70% of indiv. with primary infection - high levels of viremia measured in million of copies of HIV RNA/ml that last for several wks. - 3-6 weeks after primary infection - fever, pharyngitis, lmphadenopathy, meningitis, encephalitis, mucocutaneous ulceration - Most will recover spontaneously w/ mildly depressed CD4+ T cells
43. b.Asymptomatic stage - Median time for untreated pats. - 10 yrs. - Rate of progression is directly correlated w/ HIV RNA levels c.Symptomatic dse - More severe & life threratening complic. of HIV infec. occurs with CD4+ T cell counts <200/µL - 60% of deaths among - due to P. carinii & viral hepatitis
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45. - Oropharynx and GIT * Thrush - candida * Hairy leukoplakia - EBV * Aphthous ulcers * Esophagitis * Diarrhea cauased by Shigella,Salmonella, * Shigella, Campylobacter -Kidney and GUT * HIV-assoc. nephropathy * dysuria, heamturia or pyuria * Condyloma lata – most common presentation of syphilis in HIV pats.
46. Advanced HIV dis. - CD4+ T cells count falls below a critical level <200/µL & pat. becomes susceptible to opportunistic dse Long term nonprogressors Those who had been infected with HIV for long periods (>10yrs) whose CD4 + T cell counts move w/in normal range & remained stable over the years who had not received antiretroviral tx
47. Diagnosis and Lab Monitoring depends on demonstrations of Ab to HIV & or direct detection of HIV or one of its components ELISA - enzyme immunoassay (EIA) - standard screening test - Sensitivity 99.5%, - nonspecific - 10% of EIA (+) pat . developed HIV infec.
48. Western blot - Confirmatory test If western blot patterns of reactivity do not fall into the (+) or (-) categories - considered “indeterminate” - can be repeated in one month HIV RNA levels – determine the prognosis and assess the response to antiviral tx P24 antigen capture assay – detects viral protein p24 in blood PCR, Nucleic acid sequenced based assay
53. Types: * Influenza A - isolated in 1933 - most severe type causing pandemics - hosts are humans, swine, horses * Influenza B - isolated in 1939 - usually mild illness * Influneza C - isolated in 1950 usually no s/s
54. INFLUENZA A ~ classified by Hemagglutinin (H) & Neuraminidase (N) sub-types ~ Current circulating strains: H1N1 & H3N2 ~ Human subtypes include H1N1, H3N2, H1N2, & H2N2 ~ Avian subtypes: H1 to H15 & N1 to N9 ~ Bird human H5N1, H9N2, H7N7, H7N2, H7N3
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57. AVIAN INFLUENZA IN BIRDS ~ carry the viruses in their intestines ~ shed the virus in their saliva, nasal secretions, & feces ~ contact with contaminated secretions or excretions or w/ surfaces that are contaminated w/ secretions ~ Domestic birds infected w/ direct contact w/ infected waterfowl or poultry ~ contact w/ surfaces (dirt/cages) or materials contaminated w/ virus
58. AVIAN INFLUENZA IN HUMANS ~ Risk is low; usually do not infect humans ~ From contact with infected poultry or surfaces contaminated with secretions/excretions from birds ~ Spread of avian virus from one person to another has been very rare