Wednesday, March 28, 2012

Diarrhea Disease

General introduction

Concept common disease in childhood

frequency and characters of stool

Ages 6m~2y 50% ＜1y

Seasons viral origins—late autumn and spring beginning
bacterial origins—summer

noninfectious diarrhea— every season

Predisposing factor-1

Ø Gastric acid secretion , secretion and activity of enzyme , quality and quantity of diet change quickly.

Ø Water metabolism ，tolerance of hydropenia ，easy to body fluid disorder.

Ø Nerves, endocrine, circulation, liver and renal function: not mature, easy to digestive tract function disorder.

Grow and develop , demand for nutrients , burden of the stomach and intestines , easy to indigestion.

Artifical feeding: enteritis morbility 10 times higher

than breast feeding.

milk: nutritional ingredient destroyed

milk tool: disinfection.

Ø Rotavirus

Ø Astrovirus

Ø Calicivirus: Norwalk virus, sapovirus

Ø Enterovirus: Coxsackie virus, echovirus, enteric adenovirus

Ø Coronavirus: torovirus

o Bacillus coli

   enteropathogenic E. coli ………………………EPEC
    enterotoxigenic E. coli …………………………ETEC
    enteroinvasive E. coli …………………………..EIEC
    enterhemorrhagic E. coli ………………………EHEC
    enteroadherent aggregative E. coli ……………EAEC

o Campylobacter jejuni, Yersinia enterocolitica, others

o Fungi ：blastomyces albicans

o Protozoa (parasite) ：giardia lamblia, amebic protozoa

Ø Disorder intestinal function

Ø Infect intestinal tract directly

Ø Irritation of rectum (eg. bladder infection)

alteration of intestinal flora

Ø Much antibiotics used transport of carbohydrate

lactase

o Dietary factors

* quality and quantity of food (feeding starch and fat too early)

* Allergic diarrhea: milk or bean

* Primary and secondary disaccharidase deficiency

Ø Osmotic diarrhea: much poorly absorbed and hyperosmotic solute

Ø Secretory diarrhea: electrolytes hypersecretion

Ø Exudative diarrhea: inflammatory states causing liquor exudation

Ø Motility disturbance: dynamic abnormality of intestine

Ø Noninfectious diarrhea: feeding factors

o Dehydration

o Metabolic acidosis

o Electrolytes disorder

Mild and severe diarrhea

Ø Mild: the times of stool and character change

—— stool :frequency ,loose, liquid,

color: yellow or greenyellow,

smell: sour flavor, shape: egg soup

—— vomiting: seldom

—— general poisoning symptom: without

—— dehydration, electrolytes abnormality

and general toxicity symptoms': none

Mild and severe diarrhea

Ø Severe: accompany dehydration, electrolytes

abnormality and general toxicity symptoms

— digestive tract symptom : diarrhea serious ,mucus blood sample stool, anorexia, nausea, abdominal

pain and abdominal distention

— general poisoning symptom : lethargy, dysphoria,

unconsciousness and coma

— dehydration, electrolytes abnormality ,

acid base imbalance

Severity clinical signs of dehydration

Ø Vomiting and diarrhea :Alkalinity intestinal juice lost

Ø Eat :calorie , malabsorption®lipoclasis ®keto-bodies

Ø Hypovolemia®pachemia®blood flow slowly®

hypoxia® anaerobic glycolysis ® lactic acid

Ø dehydration® blood flow ®excluding acid ®

acid metabolic product

Ø Dispirited, dysphoria, drowsiness, coma

Ø Hypernea (Kussmauls breathing)，exhalation cool

Ø Expiratory gas smells ketone

Ø Cherry lips

Ø Nausea, vomit

K⁺(potassium)<3.5mmol/L (normal: 3.5～5.5 mmol/L)

causes：

Ø Excessive losses: vomit, diarrhea.

Ø Inadequate intake.

Ø Renal function of keeping kalium ,it continues excluding kalium when with hypokalemia.

Ø depressed

Ø Tension of skeletal muscle ，tendon reflex，

even respiratory muscle weakness

Ø Tension of smooth muscle , abdominal distention

intestinal sound or disappear

Ø Myocardium excitability , arrhythmia, ECG: T-wave

is low or inversion, U-wave occurs, prolonged P-R

interval and Q-T interval, ST section descending.

Ø Baseosis

Ø Ca²⁺﹤1.75mmol/L (7mg/dl) ;

Mg²⁺﹤0.6mmol/L (1.5mg/dl).

Ø Symptoms usually occur after dehydration and

acidosis resolved, or fluid replacement.

Ø Clinical manifestation: thrill, tetany, convulsion.

Ø If convulsion hasn’t relieved after supplement

calcium, pay attention to hypomagnesemia.

Ø Season: cool months (autumn and winter)

Ø Age: 6m~2y

Ø Symptom: fever, vomit, mild general toxicity symptoms.

Ø Stool: frequency, amount, water; yellow-water or egg soup-like; a small amount of mucus.

Ø Dehydration: mild/moderate，isotonic/hypertonic

Ø Complication: convulsion, myocardium damaged.

Ø Prognosis: self-limited, course: 3~8d.

Ø Viral antigen detection: from stool.

Ø Season: summer

Ø Symptom: vomit and diarrhea, no obvious general toxicity symptoms.

Ø Stool: water-like or egg soup-like, without mucus, blood or pus, no WBC (test under microscope).

Ø Dehydration: dehydration, electrolyte and acid-base disorder usually occur.

Ø Prognosis: self-limited, course: 3~7d.

Ø Similar with bacillary dysentery.

Ø Symptom: diarrhea with fever, nausea, vomit, abdominal pain, tenesmus. Severe general toxicity symptoms, e.g. ardent fever, consciousness change, even septic shock.

Ø Stool: with mucus, blood and pus, smell of fish, with WBC (test under microscope).

Ø Stool culture: pathogenic bacterium.

Ø Pathogen: usually Blastomyces albicans.

Ø Age: ﹤2y.

Ø Complication by other infection, or after using antibiotics for long time.

Ø Persistent course, usually thrush companion.

Ø Stool: yellow thin stool, more foam with mucus, sometimes tofukasu-like.

Ø test under microscope: fungal spore and hypha.

Ø Gastric mucosa analosis ® bacterium and yeast fungus

Ø Intestinal mucosa thinner®indigestion and malabsorption

Ø Bacterium in upper small intestine ®enterocyte damaged

Ø Dynamic abnormality of intestine.

Ø Using antibiotics for long time.

Ø Immune function defect ® liability to agents

vicious cycle

o Not difficult

o According to clinical manifestation, laboratory tests and character of stool.

Ø Usually ﹤6m, bloating, breast-feeding.

Ø Usually with eczema.

Ø Normal appetite, growth and developed.

Ø After cofood addition, stool turns to normal.

Ø A special type of lactose intolerance

Ø Epidemiology character

Ø Stool culture: a dysentery bacillus discovered

Ø Symptom: ardent fever, severe toxicity symptoms, abdominal pain and distension, vomit frequently.

Ø Stool: first, yellow thin or egg soup-like;

then, red pasty or adsuki bean soup-like.

Ø X-ray of abdomen: local aerate and expansion in

small intestine, intestinal wall pneumatosis.

* Adjust and continue feeding, not abrosia or

restricting water, prevent malnutrition.

* Prevent and cure dehydration.

* Rational administration: proper antibiotics, microecosystem preparation, assist-digestive drugs, mucosa protectant, antivomit drugs. Usually disusing antidiarrheal.

* Strengthen nursing, symptomatic treatment, prevent

complications.

* Fluid therapy (next week lesson)

Measles

Measles is…

* an acute viral infection characterized by a maculopapular rash erupting successively over the neck, face, body, and extremitis and accompanied by a high fever.

ETIOLOGY

Measles virus

*An RNA virus of the genus Morbillivirus in the family of Paramyxoviridae

*One serotype, human’s only host

*Stable antigenicity

*Rapidly inactivated by heat and light

*Survival in low temperature.

EPIDEMIOLOGY

*Infection sources

n Patients of acute stage and viral carriers of atypical measles

*Transmission

n Highly contagious, approximately 90% of susceptible contacts acquire the disease.

n Respiratory secretions: maximal dissemination of virus occurs by droplet spray during the prodromal period (catarrhal stage).

n Contagious from 5 days before symptoms, 5 days after onset of rash

n Seasons: in the spring, peak in Feb-May

PATHOGENESIS AND PATHOLOGY

*Portal of entry

n Respiratory tract and regional lymph nodes

n Enters bloodstream (primary viraemia) è monocyte – phagocyte system è target organs (secondary viraemia)

*Target organs

n The skin; the mucous membranes of the nasopharynx,

bronchi, and intestinal tract; and in the conjunctivae, ect

Resulting In-----

1) Koplik spots and skin rash: serous exudation and proliferation of endothelial cells around the capillaries

2) Conjunctivis

PATHOGENESIS AND PATHOLOGY

3) Laryngitis, croup, bronchitis :general inflammatory reaction

4) Hyperplasia of lymphoid tissue: multinucleated giant cells (Warthin-Finkeldey giant cells) may be found

5) Interstitial pneumonitis: Hecht giant cell pneumonia.

6) Bronchopneumonia: due to secondary bacterial infections

7) Encephalomyelitis: perivascular demyelinization occurs in areas of the brain and spinal cord.

8) Subacute sclerosing panencephalitis(SSPE):

degeneration of the cortex and white matter with intranuclear and intracytoplasmic inclusion bodies

CLINICAL MANIFESTATION

Typical Manifestation:

patients havn’t had measles immunization, or vaccine failure with normal immunity or those havn’t used immune globulin

1. Incubation period (infection to symptoms) :

6-18days (average 10 days)

2. Prodromal period:

n 3-4 days

n Non-specific symptoms: fever, malaise, anorexia, headache

n Classical triad: cough, coryza, conjunctivitis (with

photophobia, lacrimation)

CLINICAL MANIFESTATION

Enanthem (Koplik spots):

n Pathognomonic for measles

n 24-48 hr before rash appears

n 1mm, grayish white dots with

slight, reddish areolae

n Buccal mucosa, opposite the

lower 2^nd molars

n increase within 1day and spread

n fade soon after rash onset

CLINICAL MANIFESTATION

3. Rash period

3-4days

Exanthem:

Erythematous, non-pruritic, maculopapular

n Upper lateral of the neck, behind ears, hairline,

face è trunk  arms and legs feet

n The severity of the disease is directly related to

the extent and confluence of the rash

,

CLINICAL MANIFESTATION

Temperature:

n Rises abruptly as the rash appears

n Reaches 40℃ or higher

n Settles after 4-5 days – if persists, suspect secondary

infection

Coryza, fever, and cough:

n Increasingly severe up to the time the rash has covered the

body

Lymphadenopathy (posterior cervical region, mesenteric) splenomegaly, diarrhoea, vomiting

Chest X ray:

n May be abnormal, even in uncomplicated cases

CLINICAL MANIFESTATION

4. Recovery period

3-4days

Exanthem:

n Fades in order of appearance

n Branny desquamation and brownish discoloration

Entire illness – 10 days

CLINICAL MANIFESTATION

Atypical Manifestation:

1. Mild measles

n In patients: administered immune globulin products during the incubation period and immunized against measles; in infants <8mo

n Long incubation period and short prodromal phase

n Mild symptom

n No Koplik spot

n The rash tends to be faint, less macular, pinpoint

n No branny desquamation and brownish discoloration occur as the rash fades

n No complications and short course

CLINICAL MANIFESTATION

2. Severe measles:

n In cases with malnutrition, hypoimmunity and secondary

infection

n Persistent hyperpyrexia, sometimes with convulsions and even

coma

Exanthem:

n Completely covered the skin

n Confluent, petechiae, ecchymoses

n The hemorrhagic type of measles (black measles), bleeding

may occur from the mouth, nose, or bowel. disseminated

intravascular coagulation (DIC)

CLINICAL MANIFESTATION

3. Atypical measles syndroma:

n Recipients of killed measles virus vaccine, who later come in

contact with wild-type measles virus.

n Distinguished by high fever, severe headache, severe abdominal

pain, often with vomiting, myalgias, respiratory symptoms,

pneumonia with pleural effusion

Exanthem:

n First appears on the palms, wrists, soles, and ankles, and

progresses in a centripetal direction.

n Maculopapular è vesicular è purpuric or hemorrhagic.

n Koplik spots rarely appear

CLINICAL MANIFESTATION

4. Measles absent of rush

n Immunodepressed, or passive immunized recently cases and

occasionally in infants <9mo who have appreciable levels

of maternal antibody

n Non-specificity

n Difficult to diagnosis

COMPLICATIONS

1. Respiratory Tract

* Laryngitis, tracheitis, bronchitis – due to measles itself

* Laryngotrachobronchitis (croup) –cause airway obstruction to require tracheostomy

* Secondary pneumonia – immunocompromised, malnourished patients. pneumococcus, group A

Streptococcus, Staphylococcus aureus and

Haemophilus influenzae type B.

* Exacerbation of TB

COMPLICATIONS

2. Myocarditis

3. Malnutrition and Vitamin A deficiency

COMPLICATIONS

4. CNS

*The incidence of encephalomyelitis is 1-2/l,000 cases of measles

*Onset occurs 2-5 days after the appearance of the rash

*No correlation between the severity of the rash illness and

that of the neurologic involvement

n Earlier - direct viral effect in CNS

n Later – immune response causing demyelination

n Significant morbidity, permanent sequelae – mental

retardation and paralysis

*Subacute sclerosing panencephalitis (SSPE): extremely rare, 6-10 years after infection. Progressive dementia, fatal. Interaction of host with defective form of virus

LABORATORY EXAMINATION

*Isolation of measles virus from a clinical specimen (e.g., nasopharynx, urine)

*Significant rise in measles IgG by any standard serologic assay

*Positive serologic test for measles IgM antibody

*Immunofluorescence detects Measles antigens

*Multinucleated giant cells in smears of nasal mucosa

*Low white blood cell count and a relative lymphocytosis in PB

*Measles encephalitis – raised protein, lymphocytes in CSF

DIAGNOSIS

characteristic clinical picture:

Measles contact

Koplik spot

Features of the skin rash

The relation between the eruption and fever

Laboratory confirmation is rarely needed

DIFFERENTIAL DIAGNOSIS

*The rash of measles must be differentiated from that of

*rubella;

*roseola intantum;

*enteroviral infections;

*scarlet fever;

*and drug rashes.

DIFFERENTIAL DIAGNOSIS

TREATMENT

*Supportive, symptom-directed

Antipyretics for fever

Bed rest

Adequate fluid intake

Be protected from exposure to strong light

*Antibiotics for otitis media, pneumonia

*High doses Vitamin A in severe/ potentially severe measles/ patients less than 2 years

Wednesday, March 28, 2012

Diarrhea Disease

General introduction

Concept common disease in childhood

frequency and characters of stool

Ages 6m~2y 50% ＜1y

Seasons viral origins—late autumn and spring beginning bacterial origins—summer

noninfectious diarrhea— every season

Predisposing factor-1

Ø Gastric acid secretion , secretion and activity of enzyme , quality and quantity of diet change quickly.

Ø Water metabolism ，tolerance of hydropenia ，easy to body fluid disorder.

Ø Nerves, endocrine, circulation, liver and renal function: not mature, easy to digestive tract function disorder.

Grow and develop , demand for nutrients , burden of the stomach and intestines , easy to indigestion.

Artifical feeding: enteritis morbility 10 times higher

than breast feeding.

milk: nutritional ingredient destroyed

milk tool: disinfection.

Ø Rotavirus

Ø Astrovirus

Ø Calicivirus: Norwalk virus, sapovirus

Ø Enterovirus: Coxsackie virus, echovirus, enteric adenovirus

Ø Coronavirus: torovirus

o Bacillus coli

enteropathogenic E. coli ………………………EPEC enterotoxigenic E. coli …………………………ETEC enteroinvasive E. coli …………………………..EIEC enterhemorrhagic E. coli ………………………EHEC enteroadherent aggregative E. coli ……………EAEC

o Campylobacter jejuni, Yersinia enterocolitica, others

o Fungi ：blastomyces albicans

o Protozoa (parasite) ：giardia lamblia, amebic protozoa

Ø Disorder intestinal function

Ø Infect intestinal tract directly

Ø Irritation of rectum (eg. bladder infection)

alteration of intestinal flora

Ø Much antibiotics used transport of carbohydrate

lactase

o Dietary factors

* quality and quantity of food (feeding starch and fat too early)

* Allergic diarrhea: milk or bean

* Primary and secondary disaccharidase deficiency

Ø Osmotic diarrhea: much poorly absorbed and hyperosmotic solute

Ø Secretory diarrhea: electrolytes hypersecretion

Ø Exudative diarrhea: inflammatory states causing liquor exudation

Ø Motility disturbance: dynamic abnormality of intestine

Ø Noninfectious diarrhea: feeding factors

o Dehydration

o Metabolic acidosis

o Electrolytes disorder

Mild and severe diarrhea

Ø Mild: the times of stool and character change

—— stool :frequency ,loose, liquid,

color: yellow or greenyellow,

smell: sour flavor, shape: egg soup

—— vomiting: seldom

—— general poisoning symptom: without

—— dehydration, electrolytes abnormality

and general toxicity symptoms': none

Mild and severe diarrhea

Ø Severe: accompany dehydration, electrolytes

abnormality and general toxicity symptoms

— digestive tract symptom : diarrhea serious ,mucus blood sample stool, anorexia, nausea, abdominal

pain and abdominal distention

— general poisoning symptom : lethargy, dysphoria,

unconsciousness and coma

— dehydration, electrolytes abnormality ,

acid base imbalance

Severity clinical signs of dehydration

Ø Vomiting and diarrhea :Alkalinity intestinal juice lost

Ø Eat :calorie , malabsorption®lipoclasis ®keto-bodies

Ø Hypovolemia®pachemia®blood flow slowly®

hypoxia® anaerobic glycolysis ® lactic acid

Ø dehydration® blood flow ®excluding acid ®

acid metabolic product

Ø Dispirited, dysphoria, drowsiness, coma

Ø Hypernea (Kussmauls breathing)，exhalation cool

Ø Expiratory gas smells ketone

Ø Cherry lips

Ø Nausea, vomit

K+ (potassium)<3.5mmol/L (normal: 3.5～5.5 mmol/L)

causes：

Ø Excessive losses: vomit, diarrhea.

Ø Inadequate intake.

Ø Renal function of keeping kalium ,it continues excluding kalium when with hypokalemia.

Seasons viral origins—late autumn and spring beginning
bacterial origins—summer

enteropathogenic E. coli ………………………EPEC
enterotoxigenic E. coli …………………………ETEC
enteroinvasive E. coli …………………………..EIEC
enterhemorrhagic E. coli ………………………EHEC
enteroadherent aggregative E. coli ……………EAEC

K⁺(potassium)<3.5mmol/L (normal: 3.5～5.5 mmol/L)

Ø Ca²⁺﹤1.75mmol/L (7mg/dl) ;

Mg²⁺﹤0.6mmol/L (1.5mg/dl).