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UNIT 06
CLINICAL PHARMACY ASPECTS
CONTENTS
PEPTIC ULCER
ANGINA PECTORIS
HYPERTENSION
ASTHMA
TUBERCULOSIS
DIABETES
ACUTE RENAL FAILURE
AIDS
HEPATITIS
RHEUMATOID ARTHRITIS
4/28/16
PEPTIC ULCER
A peptic ulcer is a sore on the inner lining of the stomach or duodenum
the first part of the small intestine. Less commonly, a peptic ulcer may
Drinking too much alcohol. This is more than 2 drinks a day for men and more than 1
drink a day for women.
In the past, spicy foods, caffeine, and moderate amounts of alcohol were thought to increase
ulcer risk. This is no longer believed to be true.
Risk factors you cannot control
Some things that you cannot control may increase your risk of getting an ulcer. These
include:
A Helicobacter pylori (H. pylori) infection, the most common cause of ulcers.
Physical stress caused by a serious illness or injury (such as a major trauma, surgery,
or the need to be on a ventilator to assist breathing).
Hyper secretory condition, in which your stomach produces too much acid.
A personal or family history of ulcers.
PATHO PHISYOLOGY
1
bloating
2
burping
3
changes in appetite
4
nausea
5
vomiting
6
weight loss
COMPLICATIONS
Complications of peptic ulcer disease include
1
internal bleedingwhen gastric acid or a peptic ulcer breaks a blood
vessel
2
obstructionwhen a peptic ulcer blocks the path of food trying to
leave the stomach
3
perforationwhen a peptic ulcer grows deeper and breaks
completely through the stomach or duodenal wall
4
peritonitiswhen infection or inflammation develops in the
peritoneum, or lining of the abdominal cavity
DIAGNOSIS
A health care provider diagnoses peptic ulcer disease based on
1
2
3
4
5
6
a medical history
a physical exam
lab tests
upper gastrointestinal (GI) endoscopy
upper GI series
computerized tomography (CT) scan
Medical History
Taking a medical history may help a health care provider determine the cause of a
peptic ulcer. If a patient has peptic ulcer disease symptoms, the health care provider
will ask about the patients use of over-the-counter and prescription NSAIDs.
Physical Exam
A physical exam may help the health care provider diagnose the cause of peptic
ulcer disease. During a physical exam, a health care provider usually
1
2
3
Lab Tests
A health care provider will look to see if H. pylori are present using one of three
simple tests:
1
blood test
TREATMENT
It includes
Antibiotics
Antacids
H2 blockers
Bismuth sub salicylate
PREVENTION
No one knows for sure how H. pylori infection spreads, so prevention is difficult.
However, to reduce the chances of infection, health care providers generally advise
people to
1
wash their hands with soap and water after using the bathroom and before
eating
2
make sure that they or those who prepare the food they eat have washed and
cooked it properly
3
drink water from a clean, safe source
ANGINA PECTORIS
Angina pectoris is the result of myocardial ischemia caused by an imbalance between
myocardial blood supply and oxygen demand. It is a common presenting symptom (typically,
chest pain) among patients with coronary artery disease (CAD). Approximately 9.8 million
Americans are estimated to experience angina annually, with 500,000 new cases of angina
occurring every year.
TYPES
Five different kinds of angina have been identified, with the two most common being stable
angina and unstable angina. Stable angina occurs when the heart has to work harder than
normal, during exercise, for example. It has a regular pattern, and if you already know that
you have stable angina, you will be able to predict the pattern. Once you stop exercising, or
take medication (usually nitroglycerin) the pain goes away, usually within a few minutes.
Unstable angina is more serious, and may be a sign that a heart attack could happen soon.
There is no predictable pattern to this kind of angina; it can just as easily occur during
exercise as it can while you are resting. It should always be treated as an emergency. People
with unstable angina are at increased risk for heart attacks, cardiac arrest, or severe cardiac
arrhythmias (irregular heartbeat or abnormal heart rhythm).
Less common kinds of angina include:
variant angina microvascular angina atypical angina
Variant angina is also known as Prinzmetals angina. It often occurs while someone is
resting (usually between midnight and 8:00 in the morning), and it has no predictable pattern
that is, it is not brought on by exercise or emotion. This kind of angina may cause severe
pain, and is usually the result of a spasm in a coronary artery. Most people who have variant
angina have severe atherosclerosis (hardening of the arteries), and the spasm is most likely to
occur near a buildup of fatty plaque in an artery.
ETIOLOGY
Causes of angina pectoris include the following:
Decrease in myocardial blood supply due to increased coronary resistance in large and
small coronary arteries
Increased extravascular forces, such as severe LV hypertrophy caused by
hypertension, aortic stenosis, or hypertrophic cardiomyopathy, or increased LV diastolic
pressures
Reduction in the oxygen-carrying capacity of blood, such as elevated
carboxyhemoglobin or severe anemia (hemoglobin, < 8 g/dL)
Congenital anomalies of the origin and/or course of the major epicardial coronary
arteries
Risk factors
Precipitating factors
Preventive factors
Decrease in myocardial blood supply due to increased coronary resistance in large and small
coronary arteries
Causes of such decreases in myocardial blood supply include the following:
Significant coronary atherosclerotic lesion in the large epicardial coronary arteries (ie,
conductive vessels) with at least a 50% reduction in arterial diameter
Coronary spasm (ie, Prinzmetal angina)
Abnormal constriction or deficient endothelial-dependent relaxation of resistant
vessels associated with diffuse vascular disease (ie, microvascular angina) [12]
Syndrome X
Systemic inflammatory or collagen vascular disease, such as scleroderma, systemic
lupus erythematous, Kawasaki disease, polyarteritis nodosa, and Takayasu arteritis
RISK FACTORS
Major risk factors for atherosclerosis include a family history of premature coronary artery
disease, cigarette smoking, diabetes mellitus, hypercholesterolemia, or systemic
hypertension.
Other risk factors include LV hypertrophy, obesity, and elevated serum levels of
homocysteine, lipoprotein (a), plasminogen activator inhibitor, fibrinogen, serum
triglycerides, or low high-density lipoprotein (HDL).
PATHO PHYSIOLOGY
Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for
about 1-5 minutes and relieved by rest or nitroglycerin
Pain intensity that does not change with respiration, cough, or change in position
Angina decubitus (a variant of angina pectoris that occurs at night while the patient is
recumbent) may occur.
For most patients with stable angina, physical examination findings are normal
A positive Levine sign suggests angina pectoris
Signs of abnormal lipid metabolism or of diffuse atherosclerosis may be noted
Examination of patients during the angina attack may be more helpful
Pain produced by chest wall pressure is usually of chest wall origin
COMPLICATIONS
angina lead to
heart failure , acute renal failure , myocardial infarction , cardiac arrest , death .
Diagnosis
Diagnostic studies that may be employed include the following:
Chest radiography: Usually normal in angina pectoris but may show cardiomegaly in
patients with previous MI, ischemic cardiomyopathy, pericardial effusion, or acute
pulmonary edema
Graded exercise stress testing: This is the most widely used test for the evaluation of
patients presenting with chest pain and can be performed alone and in conjunction with
echocardiography or myocardial perfusion scintigraphy
Coronary artery calcium (CAC) scoring by fast CT: The primary fast CT methods for
this application are electron-beam CT (EBCT) and multidetector CD (MDCT)
Other tests that may be useful include the following:
ECG (including exercise with ECG monitoring and ambulatory ECG monitoring)
Selective coronary angiography (the definitive diagnostic test for evaluating the
anatomic extent and severity of CAD)
Management
General treatment measures include the following:
In high-risk patients, a serum LDL cholesterol level of less than 100 mg/dL is the goal
In very high-risk patients, an LDL cholesterol level goal of less than 70 mg/dL is a
therapeutic option
In moderately high-risk persons, the recommended LDL cholesterol level is less than
130 mg/dL, but an LDL cholesterol level of 100 mg/dL is a therapeutic option
In all persons with low HDL cholesterol levels, the primary target of therapy is to
achieve the ATP III guideline LDL cholesterol level goals with diet, exercise, and drug
therapy as needed
After the targeted LDL level goal is reached, emphasis shifts to other issues; in
patients with low HDL and high triglyceride levels, the secondary priority is to achieve the
non-HDL cholesterol level goal (30 mg/dL higher than the LDL goal); in patients with
isolated low HDL cholesterol levels and triglyceride levels below 200 mg/dL, drugs to raise
HDL can be considered
Other pharmacologic therapies that may be considered include the following:
Enteric-coated aspirin
Clopidogrel
Hormone replacement therapy
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Sublingual nitroglycerin
Beta blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE) inhibitors
Injections of autologous CD34+ cells [2]
Revascularization therapy (ie, coronary revascularization) can be considered in the following:
Patients with 1- or 2-vessel disease and normal LV function who have anatomically
suitable lesions are candidates for percutaneous transluminal coronary angioplasty and
coronary stenting.
Patients with significant left main coronary artery disease, 2- or 3-vessel disease and
LV dysfunction, diabetes mellitus, or lesions anatomically unsuitable for percutaneous
transluminal coronary angioplasty have better results with coronary artery bypass grafting
Other procedures that may be considered include the following:
HYPERTENSION
Hypertension (HTN or HT), also known as high blood pressure, is a long term medical
condition in which the blood pressure in the arteries is persistently elevated. High blood
pressure usually does not cause symptoms. Long term high blood pressure; however, is a
major risk factor for coronary artery disease, stroke, heart failure, peripheral vascular
disease, vision loss, and chronic kidney disease.
TYPES
There are two major types of hypertension and four less frequently found types.
The two major types are:
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Malignant Hypertension.
Isolated Systolic Hypertension
Resistant Hypertension
Primary Hypertension
This type is also called essential hypertension, and it is by far the most common type of
hypertension, and is diagnosed in about 95% of cases. Essential hypertension has no obvious
or yet identifiable cause.
Secondary Hypertension:
This may be caused by:
Kidney damage or impaired function (This accounts for most secondary forms of
hypertension.)
Tumours or overactivity of the adrenal gland
Thyroid dysfunction
Pregnancy-related conditions
Malignant Hypertension
This, the most severe form of hypertension, is severe and progressive. It rapidly leads to
organ damage. Unless properly treated, it is fatal within five years for the majority of
patients. Death usually comes from heart failure, kidney damage or brain haemorrhage.
However, aggressive treatment can reverse the condition, and prevent its
complications. Malignant hypertension is becoming relatively rare, and is not caused by
cancer or malignancy.
Isolated Systolic Hypertension
In this case the systolic blood pressure, (the top number), is consistently above 160 mm Hg,
and the diastolic below 90 mm Hg. This may occur in older people, and results from the agerelated stiffening of the arteries. The loss of elasticity in arteries, like the aorta, is mostly due
to arteriosclerosis. The Western lifestyle and diet is believed to be the root cause.
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Latest studies confirm the importance of treating ISH, as it significantly reduces the incidence
of stroke and heart disease. Treatment starts with lifestyle modification, and if needed, added
drugs.
White coat hypertension
Also called anxiety-induced hypertension, it means blood pressure is only high when tested
by a health professional. If confirmed, with repeat readings outside of the clinical setting, or
a 24-hour monitoring device, it does not need to be treated. However, regular follow-up is
recommended to ensure that persistent hypertension has not developed.
Lifestyle changes like more exercise, less salt and alcohol, no nicotine and weight loss, would
be wise. A low fat, high fibre diet, with increased fruit and vegetable intake, will be
beneficial.
Resistant Hypertension
If blood pressure cannot be reduced to below 140/90 mmHg, despite a triple-drug regime,
resistant hypertension is considered
EPIDEMIOLOGY
Overall, approximately 20% of the worlds adults are estimated to have hypertension, when
hypertension is defined as BP in excess of 140/90 mm Hg. The prevalence dramatically
increases in patients older than 60 years: In many countries, 50% of individuals in this age
group have hypertension. Worldwide, approximately 1 billion people have hypertension,
contributing to more than 7.1 million deaths per year.[5]
National health surveys in various countries have shown a high prevalence of poor control of
hypertension.[6] These studies have reported that prevalence of hypertension is 22% in
Canada, of which 16% is controlled; it is 26.3% in Egypt, of which 8% is controlled; and it is
13.6% in China, of which 3% is controlled.
ETIOLOGY
The exact causes of high blood pressure are not known, but several factors and conditions
may play a role in its development, including:
Smoking
Being overweight or obese
Lack of physical activity
Too much salt in the diet
Too much alcohol consumption (more than 1 to 2 drinks per day)
Stress
Older age
Genetics
Family history of high blood pressure
Chronic kidney disease
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14
If your blood pressure is extremely high, there may be certain symptoms to look out
for, including:
Severe headache
Fatigue or confusion
Vision problems
Chest pain
Difficulty breathing
Irregular heartbeat
Blood in the urine
Pounding in your chest, neck, or ears
COMPLICATIONS
High blood pressure (hypertension) puts extra strain on your heart and blood vessels.
If untreated, over time this extra pressure can increase your risk of a heart attack, stroke,
kidney disease and vascular dementia.
Cardiovascular disease
High blood pressure can cause many different diseases of the heart and blood vessels
(medically known as cardiovascular diseases), including:
stroke when the blood supply to part of the brain is cut off
heart attack when the supply of blood to the heart is suddenly blocked
embolism when a blood clot or air bubble blocks the flow of blood in a vessel
aneurysm when a blood vessel wall bursts causing internal bleeding
vascular dementia when blood flow to the brain is reduced, causing parts of the
brain to become damaged
Kidney disease
High blood pressure can also damage the small blood vessels in your kidneys and stop them
from working properly. Mild to moderate chronic kidney disease does not usually cause any
symptoms.
Kidney disease may need treatment with a combination of medication and dietary changes.
More serious cases may require dialysis (a treatment where waste products are artificially
removed from the body) or a kidney transplant.
DIAGNOSIS
For most patients, health care providers diagnose high blood pressure when blood pressure
readings are consistently 140/90 mmHg or above.
Confirming High Blood Pressure
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A blood pressure test(link is external) is easy and painless and can be done in a health care
providers office or clinic. To prepare for the test:
Dont drink coffee or smoke cigarettes for 30 minutes prior to the test.
Go to the bathroom before the test.
Healthy eating
Being physically active
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The DASH eating plan is a good heart-healthy eating plan, even for those who dont have
high blood pressure. Read more about the DASH eating plan.
Heart-Healthy Eating
Your health care provider also may recommend heart-healthy eating, which should include:
Whole grains
Fruits, such as apples, bananas, oranges, pears, and prunes
Legumes, such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans
Fish high in omega-3 fatty acids, such as salmon, tuna, and trout, about twice a week
When following a heart-healthy diet, you should avoid eating:
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12 ounces of beer
5 ounces of wine
1 ounces of liquor
Managing and Coping With Stress
Learning how to manage stress, relax, and cope with problems can improve your emotional
and physical health and can lower high blood pressure. Stress management techniques
include:
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Meditating
Medicines
Blood pressure medicines work in different ways to stop or slow some of the bodys
functions that cause high blood pressure. Medicines to lower blood pressure include:
Diuretics (Water or Fluid Pills): Flush excess sodium from your body, which
reduces the amount of fluid in your blood and helps to lower your blood pressure. Diuretics
are often used with other high blood pressure medicines, sometimes in one combined pill.
Beta Blockers: Help your heart beat slower and with less force. As a result, your
heart pumps less blood through your blood vessels, which can help to lower your blood
pressure.
Calcium Channel Blockers: Keep calcium from entering the muscle cells of your
heart and blood vessels. This allows blood vessels to relax, which can lower your blood
pressure.
Alpha Blockers: Reduce nerve impulses that tighten blood vessels. This allows blood
to flow more freely, causing blood pressure to go down.
Alpha-Beta Blockers: Reduce nerve impulses the same way alpha blockers do.
However, like beta blockers, they also slow the heartbeat. As a result, blood pressure goes
down.
Central Acting Agents: Act in the brain to decrease nerve signals that narrow blood
vessels, which can lower blood pressure.
Vasodilators: Relax the muscles in blood vessel walls, which can lower blood
pressure.
ASTHMA
Asthma is a chronic disease involving the airways in the lungs. These airways, or
bronchial tubes, allow air to come in and out of the lungs.
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If you have asthma your airways are always inflamed. They become even more
swollen and the muscles around the airways can tighten when something triggers
your symptoms. This makes it difficult for air to move in and out of the lungs,
causing symptoms such as coughing, wheezing, shortness of breath and/or chest
tightness.
For many asthma sufferers, timing of these symptoms is closely related to physical
activity. And, some otherwise healthy people can develop asthma symptoms only
when exercising. This is called exercise-induced bronchoconstriction (EIB) , or
exercise-induced asthma (EIA). Staying active is an important way to stay healthy,
so asthma shouldn't keep you on the sidelines. Your physician can develop a
management plan to keep your symptoms under control before, during and after
physical activity.
People with a family history of allergies or asthma are more prone to developing
asthma. Many people with asthma also have allergies . This is called allergic
asthma .
Occupational asthma is caused by inhaling fumes, gases, dust or other potentially
harmful substances while on the job.
Childhood asthma impacts millions of children and their families. In fact, the
majority of children who develop asthma do so before the age of five.
There is no cure for asthma, but once it is properly diagnosed and a treatment plan
is in place you will be able to manage your condition, and your quality of life will
improve.
EPIDEMIOLOGY
The recent substantial increase in the reported prevalence of asthma worldwide (Figure 1) has
led to numerous studies of the prevalence and characteristics of this condition.2 Foremost
among these are 2 major international initiatives that have collected data using validated
questionnaires, one among children, the International Study of Asthma and Allergies in
Childhood,3 and the other among young adults, the European Community Respiratory Health
Survey.4 Follow-up investigations for both of these studies5,6 have examined temporal trends
within and across populations. During a mean of 7 years following phase I of the
International Study of Asthma and Allergies in Childhood, which in most participating
countries was conducted between 1991 and 1993, the prevalence of asthma was stable or
decreased in some areas of the world but increased substantially in many other areas,
especially among children 1314 years of age
ETIOLOGY
Allergies (Allergic Asthma)
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Substances that cause allergies (allergens) can trigger asthma. If you inhale something you
are allergic to, you may experience asthma symptoms. It is best to avoid or limit contact with
known allergens to decrease or prevent asthma episodes.
Common allergens that cause allergic asthma include:
dust mites
cockroach
pollens
molds
pet dander
rodents
wood fires
charcoal grills
strong fumes, vapors, or odors (such as paint, gasoline, perfumes and scented soaps)
chemicals
Respiratory Illness
colds
flu (influenza)
sore throats
sinus infections
pneumonia
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minutes of sustained exercise. (If symptoms appear sooner than this, it usually means you
need to adjust your treatment.) With proper treatment, you do not need to limit your physical
activity.
Weather
Dry wind, cold air or sudden changes in weather can sometimes bring on an asthma episode.
Feeling and Expressing Strong Emotions
anger
fear
excitement
laughter
yelling
crying
Medicines
Some medicines can also trigger asthma:
sulfites in food
hormonal changes during the menstrual cycle
PATHOPHISYOLOGY
22
Shortness of breath
Chronic coughing
Asthma symptoms, also called asthma flare-ups or asthma attacks, are often caused
by allergies and exposure to allergens such as pet dander, dust mites, pollen or
mold. Non-allergic triggers include smoke, pollution or cold air or changes in
weather.
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Inhaled corticosteroids prevent and reduce airway swelling. They also reduce mucus
in the lungs. They are the most effective long-term control medicines available.
Corticosteroids are not the same as anabolic steroids that are taken by some athletes
and banned in many athletic events.
Inhaled long-acting beta agonists open the airways by relaxing the smooth muscles
around the airways. If used, this type of medicine should always be taken in
combination with an inhaled corticosteroid.
Combination inhaled medicines contain both an inhaled corticosteroid and a longacting beta agonist. If you need both of these medicines, this is a convenient way to
take them together.
Leukotriene modifiers are taken in pill or liquid form. This type of medicine reduces
swelling inside the airways and relaxes smooth muscles.
Theophylline comes as a tablet, capsule, solution and syrup to take by mouth. This
medicine helps open the airways by relaxing the smooth muscles.
Oral corticosteroids are taken in pill or liquid form. This medicine may be
prescribed for the treatment of asthma attacks that dont respond to other asthma
medicines. They also are used as long-term therapy for some people with severe
asthma. Corticosteroids are not the same as anabolic steroids taken by some athletes
and banned in many athletic events.
Quick-Relief Medicines
You use quick-relief medicines to help relieve asthma symptoms when they happen. These
medicines act fast to relax tight muscles around your airways. This allows the airways to
open up so air can flow through them. You should take your quick-relief medicine when you
have asthma symptoms. If you use this medicine more than 2 days a week, talk with your
doctor about your asthma control. You may need to make changes to your treatment plan.
Short-acting beta agonists are inhaled and work quickly to relieve asthma
symptoms. These medicines relax the smooth muscles around the airways and
decrease swelling that blocks airflow. These medicines are the first choice for quick
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Anticholinergics are inhaled but act slower than the short-acting beta agonist
medicines. These medicines open the airways by relaxing the smooth muscles around
the airways. They also reduce mucous production.
Combination quick relief medicines contain both an anticholinergic and a shortacting beta agonist. This combination comes either as an inhaler or nebulizer for
inhalation.
TUBERCULOSIS
Tuberculosis, or TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis,
which most commonly affects the lungs. It is transmitted from person to person via droplets
from the throat and lungs of people with the active respiratory disease.
TYPES
Active TB Disease
Active TB is an illness in which the TB bacteria are rapidly multiplying and invading
different organs of the body .The typical symptoms of active TB variably include cough,
phlegm, chest pain, weakness, weight loss, fever, chills and sweating at night. A person with
active pulmonary TB disease may spread TB to others by airborne transmission of infectious
particles coughed into the air.
Miliary TB
Miliary TB is a rare form of active disease that occurs when TB bacteria find their way into
the bloodstream. In this form, the bacteria quickly spread all over the body in tiny nodules
and affect multiple organs at once. This form of TB can be rapidly fatal.
Latent TB Infection
Many of those who are infected with TB do not develop overt disease. They have no
symptoms and their chest x-ray may be normal. The only manifestation of this encounter may
be reaction to the tuberculin skin test (TST) or interferon gamma release assay (IGRA).
However, there is an ongoing risk that the latent infection may escalate to active disease. The
risk is increased by other illnesses such as HIV or medications which compromise the
immune system. To protect against this, the United States employs a strategy of preventive
therapy or treatment of latent TB infection .
EPIDEMIOLOGY
More than two billion people (about one-third of the world population) are estimated to be
infected with M. tuberculosis [2,3]. The global incidence of tuberculosis (TB) peaked around
2003 and appears to be declining slowly [4]. According to the World Health Organization
(WHO), in 2014, 9.6 million individuals became ill with TB and 1.5 million died [4].
ETIOLOGY
TB is initiated by the infection of a host with Mycobacterium tuberculosis following the
inhalation of droplets (aerosols) containing the bacilli. Once in the lung, the bacilli are
internalized through phagocytosis by the resident macrophages of the lung the AMs.
Belonging to the mononuclear phagocytic system (MPS), AMs are of extreme importance in
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lung defense, keeping the alveoli clean and sterile.[11] AMs activated by the appropriate
stimuli can effectively transfer the phagocytosed M. tuberculosis to the destructive
environment of lysosomes. However, some bacilli are able to escape lysosomal delivery and
survive and multiply inside AMs.[12,13] Then, the infected AMs can remain in the lung, where
the number of pathogens increases exponentially by killing host cells and by spreading
through lymphatic circulation to regional lymph nodes. This stage occurs 38 weeks after
infection and is termed pulmonary TB, for which the lung is the main organ infected, and the
MPS, particularly the AMs, are the major targets. Later on (3 months after infection) infected
AMs can be disseminated to distant highly irrigated organs (e.g., CNS, spongy bone, liver,
kidneys and genitalia).[11,14,15] At this stage of extrapulmonary TB, acute TB meningitis or
disseminated TB can sometimes result in death (Figure 1). Finally, extrapulmonary
manifestations (e.g., lesion in bones and joints) can appear.
RISK FACTORS & PATHO PHISYOLOGY
SILICOSIS
HIV
NUTRITION
DIABETES MELLITUS
GENETIC FACTORS
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Symptoms of Extrapulmonary TB
Extrapulmonary TB, which is also known as disseminated or miliary TB, refers to all the
different types of TB other than pulmonary TB.3 Generally it is the types of TB that do not
affect the lungs. The main exception to this is the type of extrapulmonary TB known as
Pleural TB.
The general symptoms of extrapulmonary TB are the same as for pulmonary TB, but there
can then be specific symptoms relating to the particular site or sites in the body that are
infected.
Hemoptysis
Pleurisy
Pleural effusion
Empyema
Pneumothorax
Aspergilloma
Endobronchitis
Brochiectasis
Laryngitis
Cor pulmonale
Ca bronchus
Enteritus
Miliary Tuberculosis
HIV related opportunistic infections
DIAGNOSIS
These are TB tests which can be used to determine if someone has latent TB, which means
that they are infected with TB bacteria. There are also TB tests, which when considered
alongside other factors, such as whether someone has TB symptoms, can confirm a diagnosis
of active TB or TB disease.
Even if a person has symptoms, TB is often difficult to diagnose, and is particularly difficult
to diagnose rapidly. Rapid diagnosis is what is needed to provide effective TB
treatment for drug resistant TB.
Evidence of TB bacteria
The development of TB disease is a two stage process. In the first stage, known as latent TB,
a person is infected with TB bacteria. In the second stage, known as active TB or TB disease,
the bacteria have reproduced sufficiently to usually cause the person to have become sick.
A diagnosis of active TB can only be confirmed when there is definite evidence of TB
bacteria in the persons body. Some of the diagnostic TB tests look directly for TB bacteria.
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Others such as the chest X-ray look for the effect of the bacteria on the person suspected of
having TB.
Current TB tests some problems
Some of the current TB tests take a long time to obtain a result, and some TB tests are not
very accurate. The TB tests either have low sensitivity (the ability to correctly detect people
with TB) and/or low specificity (the ability to correctly detect people who havent got TB).
If a TB test has low sensitivity, it means that there will be a significant number of false
negatives, meaning that the test result is suggesting that a person has not got TB when they
actually have. Similarly, a low specificity means that there will be a significant number of
false positives suggesting that a person has TB when they actually havent.
Chest X-ray as a TB test
If a person has had TB bacteria which have caused inflammation in the lungs, an abnormal
shadow may be visible on a chest x-ray.1 Also, acute pulmonary TB can be easily seen on an
X-ray. However, what it shows is not specific. A normal chest X-ray cannot exclude extra
pulmonary TB.
Also, in countries where resources are more limited, there is often a lack of X-ray facilities.
The TB skin test
The TB skin test is a widely used test for diagnosing TB. In countries with low rates of TB it
is often used to test for latent TB infection. The problem with using it in countries with high
rates of TB infection is that the majority of people may have latent TB.
The TB skin test involves injecting a small amount of fluid (called tuberculin) into the skin in
the lower part of the arm. Then the person must return after 48 to 72 hours to have a trained
health care worker look at their arm. The health care worker will look for a raised hard area
or swelling, and if there is one then they will measure its size. They will not Include any
general area of redness.2
The TB skin test result depends on the size of the raised hard area or swelling. The larger the
size of the affected area the greater the likelihood that the person has been infected with TB
bacteria at some time in the past. But interpreting the TB skin test result, that is whether it is a
positive result, may also involve considering the lifestyle factors of the person being tested
for TB.3 The TB skin test also cannot tell if the person has latent TB or active TB disease.
The Mantoux TB test is the type of TB test most often used, although the Heaf and Tine tests
are still used in some countries. None of these TB tests though will guarantee a correct
result. False positive results happen with the TB skin test because the person has been
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infected with a different type of bacteria, rather than the one that causes TB. It can also
happen because the person has been vaccinated with the BCG vaccine. This vaccine is widely
used in countries with high rates of TB infection. False negative results particularly happen
with children, older people and people with HIV.
TB Interferon gamma release assays (IGRAs)
The Interferon Gamma Release Assays (IGRAs), are a new type of more accurate TB test. In
this context referring to an assay is simply a way of referring to a test or procedure.
IGRAs are blood tests that measure a persons immune response to the bacteria that cause
TB. The immune system produces some special molecules called cytokines. These TB tests
work by detecting a cytokine called the interferon gamma cytokine. In practice you carry out
one of these TB tests by taking a blood sample and mixing it with special substances to
identify if the cytokine is present.
Two IGRAs that have been approved by the U.S. Food and Drug Administration (FDA), and
are commercially available in the U.S., are the QuantiFERON TB Gold test, and the TSPOT TB test.
The advantages of an IGRA TB test includes the fact that it only requires a single patient visit
to carry out the TB test. Results can be available within 24 hours, and prior BCG vaccination
does not cause a false positive result. Disadvantages include the fact that the blood sample
must be processed fairly quickly, laboratory facilities are required, and the test is for latent
TB. It is also thought that the IGRAs may not be as accurate in people who have HIV.4 In low
prevalence resource rich settings, IGRAs are beginning to be used in place of the TB skin
test.5
Serological tests for TB
Serological tests for TB are tests carried out on samples of blood, and they claim to be able to
diagnose TB by detecting antibodies in the blood. However, testing for TB by looking for
antibodies in the blood is very difficult.
As a result serological TB tests, sometimes called serodiagnostic tests, for TB are inaccurate
and unreliable, and the World Health Organisation has warned that these tests should not be
used to try and diagnose active TB. Some countries have banned the use of serological or
serodiagnostic tests for TB.
Serological tests for TB are very different from the IGRA tests described above.
Sputum smear microscopy as a test for TB
Smear microscopy of sputum is often the first TB test to be used in countries with a high
rate of TB infection. Sputum is a thick fluid that is produced in the lungs and the
31
airways leading to the lungs. A sample of sputum is usually collected by the person
coughing.
To test for TB several samples of sputum will normally be collected.6 In 2012 it was
suggested that two specimens can be collected on the same day without any loss of
accuracy.7 8
To do the TB test a very thin layer of the sample is placed on a glass slide, and this is called a
smear. A series of special stains are then applied to the sample, and the stained slide is
examined under a microscope for signs of the TB bacteria.9
Sputum smear microscopy is inexpensive and simple, and people can be trained to do it
relatively quickly and easily. In addition the results are available within hours. The sensitivity
though is only about 50-60%.10 In countries with a high prevalence of both pulmonary TB
and HIV infection, the detection rate can be even lower, as many people with HIV and TB coinfection have very low levels of TB bacteria in their sputum, and are therefore recorded as
sputum negative.
TREATMENT
Isoniazid
Rifampicin
Pyrazinamide
Ethambutol
and Streptomycin
DIABETES
Diabetes, often referred to by doctors as diabetes mellitus, describes a group of metabolic
diseases in which the person has high blood glucose (blood sugar), either because insulin
production is inadequate, or because the body's cells do not respond properly to insulin, or
both. Patients with high blood sugar will typically experience polyuria (frequent urination),
they will become increasingly thirsty (polydipsia) and hungry (polyphagia).
TYPES & EPIDEMIOLOGY
Type 1 diabetes
The body does not produce insulin. Some people may refer to this type as insulin-dependent
diabetes, juvenile diabetes, or early-onset diabetes. People usually develop type 1 diabetes
before their 40th year, often in early adulthood or teenage years.
32
Type 1 diabetes is nowhere near as common as type 2 diabetes. Approximately 10% of all
diabetes cases are type 1.
Patients with type 1 diabetes will need to take insulin injections for the rest of their life. They
must also ensure proper blood-glucose levels by carrying out regular blood tests and
following a special diet.
Between 2001 and 2009, the prevalence of type 1 diabetes among the under 20s in the USA
rose 23%, according to SEARCH for Diabetes in Youth data issued by the CDC (Centers for
Disease Control and Prevention).
2) Type 2 diabetes
The body does not produce enough insulin for proper function, or the cells in the body do not
react to insulin (insulin resistance). Some people may be able to control their type 2 diabetes
symptoms by losing weight, following a healthy diet, doing plenty of exercise, and
monitoring their blood glucose levels. However, type 2 diabetes is typically a progressive
disease - it gradually gets worse - and the patient will probably end up have to take insulin,
usually in tablet form. Overweight and obese people have a much higher risk of developing
type 2 diabetes compared to those with a healthy body weight. People with a lot of visceral
fat, also known as central obesity, belly fat, or abdominal obesity, are especially at risk. Being
overweight/obese causes the body to release chemicals that can destabilize the body's
cardiovascular and metabolic systems. The risk of developing type 2 diabetes is also greater
as we get older. Experts are not completely sure why, but say that as we age we tend to put on
weight and become less physically active. Those with a close relative who had/had type 2
diabetes, people of Middle Eastern, African, or South Asian descent also have a higher risk of
developing the disease. Men whose testosterone levels are low have been found to have a
higher risk of developing type 2 diabetes. Researchers from the University of Edinburgh,
Scotland, say that low testosterone levels are linked to insulin resistance.
Gestational diabetes
This type affects females during pregnancy. Some women have very high levels of glucose in
their blood, and their bodies are unable to produce enough insulin to transport all of the
glucose into their cells, resulting in progressively rising levels of glucose. Diagnosis of
gestational diabetes is made during pregnancy. The majority of gestational diabetes patients
can control their diabetes with exercise and diet. Between 10% to 20% of them will need to
take some kind of blood-glucose-controlling medications. Undiagnosed or uncontrolled
gestational diabetes can raise the risk of complications during childbirth. The baby may be
bigger than he/she should be. Scientists from the National Institutes of Health and Harvard
University found that women whose diets before becoming pregnant were high in animal fat
33
and cholesterol had a higher risk for gestational diabetes, compared to their counterparts
whose diets were low in cholesterol and animal fats.
ETIOLOGY
Type 1 diabetes is caused by a lack of insulin due to the destruction of insulin-producing beta
cells in the pancreas. In type 1 diabetesan autoimmune diseasethe bodys
immune system attacks and destroys the beta cells. Normally, the immune system
protects the body from infection by identifying and destroying bacteria, viruses, and
other potentially harmful foreign substances. But in autoimmune diseases, the
immune system attacks the bodys own cells. In type 1 diabetes, beta cell destruction
may take place over several years, but symptoms of the disease usually develop over a
short period of time. Type 1 diabetes typically occurs in children and young adults,
though it can appear at any age. In the past, type 1 diabetes was called juvenile
diabetes or insulin-dependent diabetes mellitus. Genetic Susceptibility
Heredity plays an important part in determining who is likely to develop type 1 diabetes.
Genes are passed down from biological parent to child. Genes carry instructions for making
proteins that are needed for the bodys cells to function. Many genes, as well as interactions
among genes, are thought to influence susceptibility to and protection from type 1 diabetes.
The key genes may vary in different population groups. Variations in genes that affect more
than 1 percent of a population group are called gene variants.
Autoimmune Destruction of Beta Cells
In type 1 diabetes, white blood cells called T cells attack and destroy beta cells. The process
begins well before diabetes symptoms appear and continues after diagnosis. Often, type 1
diabetes is not diagnosed until most beta cells have already been destroyed. At this point, a
person needs daily insulin treatment to survive. Finding ways to modify or stop this
autoimmune process and preserve beta cell function is a major focus of current scientific
research.
Environmental Factors
Environmental factors, such as foods, viruses, and toxins, may play a role in the development
of type 1 diabetes, but the exact nature of their role has not been determined. Some theories
suggest that environmental factors trigger the autoimmune destruction of beta cells in people
with a genetic susceptibility to diabetes. Other theories suggest that environmental factors
play an ongoing role in diabetes, even after diagnosis.
Type 2 diabetes develops most often in middle-aged and older people who are also
overweight or obese. The disease, once rare in youth, is becoming more common in
overweight and obese children and adolescents. Scientists think genetic susceptibility and
environmental factors are the most likely triggers of type 2 diabetes.
Genetic Susceptibility
Genes play a significant part in susceptibility to type 2 diabetes. Having certain genes or
combinations of genes may increase or decrease a persons risk for developing the disease.
The role of genes is suggested by the high rate of type 2 diabetes in families and identical
twins and wide variations in diabetes prevalence by ethnicity. Type 2 diabetes occurs more
frequently in African Americans, Alaska Natives, American Indians, Hispanics/Latinos, and
some Asian Americans, Native Hawaiians, and Pacific Islander Americans than it does in
non-Hispanic whites.
Obesity and Physical Inactivity
Physical inactivity and obesity are strongly associated with the development of type 2
diabetes. People who are genetically susceptible to type 2 diabetes are more vulnerable when
these risk factors are present.
34
Insulin Resistance
Insulin resistance is a common condition in people who are overweight or obese, have excess
abdominal fat, and are not physically active. Muscle, fat, and liver cells stop responding
properly to insulin, forcing the pancreas to compensate by producing extra insulin. As long as
beta cells are able to produce enough insulin, blood glucose levels stay in the normal range.
But when insulin production falters because of beta cell dysfunction, glucose levels rise,
leading to prediabetes or diabetes.
RISK FACTORS
Several risk factors have been associated with type 2 diabetes and include:
Overweight
Unhealthy diet
Physical inactivity
Increasing age
Ethnicity
35
36
COMPLICATIONS
Foot complications - neuropathy, ulcers, and sometimes gangrene which may require
that the foot be amputated
Skin complications - people with diabetes are more susceptible to skin infections and
skin disorders
Heart problems - such as ischemic heart disease, when the blood supply to the heart
muscle is diminished
Hypertension - common in people with diabetes, which can raise the risk of kidney
disease, eye problems, heart attack and stroke
Mental health - uncontrolled diabetes raises the risk of suffering from depression,
anxiety and some other mental disorders
Hearing loss - diabetes patients have a higher risk of developing hearing problems
37
Gum disease - there is a much higher prevalence of gum disease among diabetes
patients
Gastroparesis - the muscles of the stomach stop working properly
PAD (peripheral arterial disease) - symptoms may include pain in the leg, tingling
and sometimes problems walking properly
Stroke - if blood pressure, cholesterol levels, and blood glucose levels are not
controlled, the risk of stroke increases significantly
Erectile dysfunction - male impotence.
Infections - people with badly controlled diabetes are much more susceptible to
infections
Healing of wounds - cuts and lesions take much longer to heal
DIAGNOSIS
Blood tests are used to diagnosis diabetes and prediabetes because early in the disease type 2
diabetes may have no symptoms. All diabetes blood tests involve drawing blood at a health
care providers office or commercial facility and sending the sample to a lab for analysis. Lab
analysis of blood is needed to ensure test results are accurate. Glucose measuring devices
used in a health care providers office, such as finger-stick devices, are not accurate enough
for diagnosis but may be used as a quick indicator of high blood glucose.
Testing enables health care providers to find and treat diabetes before complications occur
and to find and treat prediabetes, which can delay or prevent type 2 diabetes from developing.
Any one of the following tests can be used for diagnosis:*
an A1C test, also called the hemoglobin A1c, HbA1c, or glycohemoglobin test
a fasting plasma glucose (FPG) test
*Not all tests are recommended for diagnosing all types of diabetes. See the individual test
descriptions for details.
38
Another blood test, the random plasma glucose (RPG) test, is sometimes used to diagnose
diabetes during a regular health checkup. If the RPG measures 200 milligrams per deciliter or
above, and the individual also shows symptoms of diabetes, then a health care provider may
diagnose diabetes.
Symptoms of diabetes include
increased urination
increased thirst
Other symptoms can include fatigue, blurred vision, increased hunger, and sores that do not
heal.
Any test used to diagnose diabetes requires confirmation with a second measurement unless
clear symptoms of diabetes exist.
The following table provides the blood test levels for diagnosis of diabetes for nonpregnant
adults and diagnosis of prediabetes.
Source: Adapted from American Diabetes Association. Standards of medical care in diabetes
2012. Diabetes Care. 2012;35(Supp 1):S12, table 2.
A1C Test
The A1C test is used to detect type 2 diabetes and prediabetes but is not recommended for
diagnosis of type 1 diabetes or gestational diabetes. The A1C test is a blood test that reflects
the average of a persons blood glucose levels over the past 3 months and does not show daily
fluctuations. The A1C test is more convenient for patients than the traditional glucose tests
because it does not require fasting and can be performed at any time of the day.
The A1C test result is reported as a percentage. The higher the percentage, the higher a
persons blood glucose levels have been. A normal A1C level is below 5.7 percent.
39
An A1C of 5.7 to 6.4 percent indicates prediabetes. People diagnosed with prediabetes may
be retested in 1 year. People with an A1C below 5.7 percent maystill be at risk for diabetes,
depending on the presence of other characteristics that put them at risk, also known as risk
factors. People with an A1C above 6.0 percent should be considered at very high risk of
developing diabetes. A level of 6.5 percent or above means a person has diabetes.
Laboratory analysis. When the A1C test is used for diagnosis, the blood sample must be
sent to a laboratory using a method that is certified by the NGSP to ensure the results are
standardized. Blood samples analyzed in a health care providers office, known as point-ofcare tests, are not standardized for diagnosing diabetes.
Abnormal results. The A1C test can be unreliable for diagnosing or monitoring diabetes in
people with certain conditions known to interfere with the results. Interference should be
suspected when A1C results seem very different from the results of a blood glucose test.
People of African, Mediterranean, or Southeast Asian descent or people with family members
with sickle cell anemia or a thalassemia are particularly at risk of interference.
However, not all of the A1C tests are unreliable for people with these diseases. The NGSP
provides information about which A1C tests are appropriate to use for specific types of
interference and details on any problems with the A1C test atwww.ngsp.orgExternal Link
Disclaimer.
False A1C test results may also occur in people with other problems that affect their blood or
hemoglobin such as chronic kidney disease, liver disease, or anemia.
More information about limitations of the A1C test and different forms of sickle cell anemia
is provided in the NIDDK health topic, For People of African, Mediterranean, or Southeast
Asian Heritage: Important Information about Diabetes Blood Tests, or by calling 1800860
8747.
Changes in Diagnostic Testing
In the past, the A1C test was used to monitor blood glucose levels but not for diagnosis. The
A1C test has now been standardized, and in 2009, an international expert committee
recommended it be used for diagnosis of type 2 diabetes and prediabetes.2
More information about the A1C test is provided in the NIDDK health topic, The A1C Test
and Diabetes, or by calling 18008608747.
2
The International Expert Committee. International Expert Committee report on the role of
the A1C assay in the diagnosis of diabetes. Diabetes Care.2009;32(7):13271334.
Fasting Plasma Glucose Test
The FPG test is used to detect diabetes and prediabetes. The FPG test has been the most
common test used for diagnosing diabetes because it is more convenient than the OGTT and
less expensive. The FPG test measures blood glucose in a person who has fasted for at least 8
hours and is most reliable when given in the morning.
40
People with a fasting glucose level of 100 to 125 mg/dL have impaired fasting glucose (IFG),
or prediabetes. A level of 126 mg/dL or above, confirmed by repeating the test on another
day, means a person has diabetes.
Oral Glucose Tolerance Test
The OGTT can be used to diagnose diabetes, prediabetes, and gestational diabetes. Research
has shown that the OGTT is more sensitive than the FPG test, but it is less convenient to
administer. When used to test for diabetes or prediabetes, the OGTT measures blood glucose
after a person fasts for at least 8 hours and 2 hours after the person drinks a liquid containing
75 grams of glucose dissolved in water.
If the 2-hour blood glucose level is between 140 and 199 mg/dL, the person has a type of
prediabetes called impaired glucose tolerance (IGT). If confirmed by a second test, a 2-hour
glucose level of 200 mg/dL or above means a person has diabetes.
TREATMENT
Treatment for diabetes requires keeping close watch over your blood sugar levels (and
keeping them at a goal set by your doctor) with a combination of medications, exercise, and
diet. By paying close attention to what and when you eat, you can minimize or avoid the
"seesaw effect" of rapidly changing blood sugar levels, which can require quick changes in
medication dosages, especially insulin. If you have type 1 diabetes, you rpancreas no longer
makes the insulin your body needs to use blood sugar for energy. You will need insulin in the
form of injections or through use of a continuous pump. Learning to give injections to
yourself or to your infant or child may at first seem the most daunting part of managing
diabetes, but it is much easier that you think.
Some people with diabetes use a computerized pump -- called an insulin pump -- that gives
insulin on a set basis. You and your doctor program the pump to deliver a certain amount of
insulin throughout the day (the basal dose). Plus, you program the pump to deliver a certain
amount of insulin based on your blood sugar level before you eat (bolus dose).
Insulin comes in four types:
Rapid-acting (taking effect within a few minutes and lasting 2-4 hours)
Regular or short-acting (taking effect within 30 minutes and lasting 3-6 hours)
Intermediate-acting (taking effect in 2-4 hours and lasting up to 18 hours)
Long-acting (taking effect in 6-10 hours and lasting beyond 24 hours)
41
mortality. The term ARF is now reserved for severe AKI, usually implying the need for renal
replacement therapy. The loss of kidney function that defines AKI is most easily detected by
measurement of the serum creatinine, which is used to estimate the glomerular filtration rate
(GFR).
TYPES
42
a heart attack
heart disease
dehydration
a severe burn
an allergic reaction
kidney stones
an enlarged prostate
43
infection
lupus, which is an autoimmune disease that can cause inflammation of many body
organs
hemolytic uremic syndrome, which involves the breakdown red blood cells following
a bacterial infection, usually of the intestines
multiple myeloma, which is a cancer of the plasma cells in your bone marrow
chemotherapy drugs, which are medications that treat cancer and some autoimmune
diseases
PATHOPHISYOLOGY
44
AIDS
AIDS (Acquired immune deficiency syndrome or acquired immunodeficiency syndrome) is a
syndrome caused by a virus called HIV (Human Immunodeficiency Virus). The illness alters
the immune system, making people much more vulnerable to infections and diseases. This
susceptibility worsens as the syndrome progresses. HIV is found in the body fluids of an
infected person (semen and vaginal fluids, blood and breast milk). The virus is passed from
one person to another through blood-to-blood and sexual contact. In addition, infected
pregnant women can pass HIV to their babies during pregnancy, delivering the baby during
45
childbirth, and through breast feeding. HIV can be transmitted in many ways, such as vaginal,
oral sex, anal sex, blood transfusion, and contaminated hypodermic needles.
TYPES
HIV-1 and HIV-2
HIV type 1 and HIV type 2 are two distinct viruses. Worldwide, the predominant virus is
HIV-1, and generally when people talk about HIV without specifying the type of virus they
are referring to HIV-1.
The relatively uncommon HIV-2 virus is concentrated in West Africa, but has been seen in
other countries. It is less infectious and progresses slower than HIV-1. While commonly used
antiretroviral drugs are active against HIV-2, optimum treatment is poorly understood.
EPIDEMIOLOGY
The HIV prevalence rate in South and South-East Asia is less than 0.35 percent, with total of
4.2 4.7 million adults and children infected. More AIDS deaths (480,000) occur in this
region than in any other except sub-Saharan Africa. The geographical size and human
diversity of South and South-East Asia have resulted in HIV epidemics differing across the
region. The AIDS picture in South Asia is dominated by the epidemic in India.
In South and Southeast Asia, the HIV epidemic remains largely concentrated in injecting drug
users, men who have sex with men, sex workers, and clients of sex workers and their
immediate sexual partners.[22] In the Philippines, in particular, sexual contact between males
comprise the majority of new infections. An HIV surveillance study conducted by Dr. Louie
Mar Gangcuangco and colleagues from the University of the Philippines-Philippine General
Hospital showed that out of 406 MSM tested for HIV in Metro Manila, HIV prevalence was
11.8% (95% confidence interval: 8.7- 15.0).[23][24]
Migrants, in particular, are vulnerable and 67% of those infected in Bangladesh and 41%
in Nepal are migrants returning from India.[22] This is in part due to human trafficking and
exploitation, but also because even those migrants who willingly go to India in search of
work are often afraid to access state health services due to concerns over their immigration
status.
ETIOLOGY
HIV is a retrovirus that infects the vital organs of the human immune system. The virus
progresses in the absence of antiretroviral therapy. The rate of virus progression varies widely
between individuals and depends on many factors (age of the patient, body's ability to defend
against HIV, access to health care, existence of coexisting infections, the infected person's
genetic inheritance, resistance to certain strains of HIV).
46
Sexual transmission. It can happen when there is contact with infected sexual
secretions (rectal, genital or oral mucous membranes). This can happen while having
unprotected sex, including vaginal, oral and anal sex or sharing sex toys with someone
infected with HIV.
Perinatal transmission. The mother can pass the infection on to her child during
childbirth, pregnancy, and also through breastfeeding.
Have unprotected sex. Unprotected sex means having sex without using a
new latex or polyurethane condom every time. Anal sex is more risky than is
vaginal sex. The risk increases if you have multiple sexual partners.
Have another STI. Many sexually transmitted infections (STIs) produce open
sores on your genitals. These sores act as doorways for HIV to enter your body.
Use intravenous drugs. People who use intravenous drugs often share
needles and syringes. This exposes them to droplets of other people's blood.
PATHOPHISYOLOGY
47
Fever
Headache
Rash
Sore throat
48
Fever
Fatigue
Swollen lymph nodes often one of the first signs of HIV infection
Diarrhea
Weight loss
Progression to AIDS
If you receive no treatment for your HIV infection, the disease typically progresses to
AIDS in about 10 years. By the time AIDS develops, your immune system has been
severely damaged, making you susceptible to opportunistic infections diseases
that wouldn't usually trouble a person with a healthy immune system.
The signs and symptoms of some of these infections may include:
Chronic diarrhea
Weight loss
49
COMPLICATIONS
Kaposi's sarcoma. A tumor of the blood vessel walls, this cancer is rare in
people not infected with HIV, but common in HIV-positive people.
Kaposi's sarcoma usually appears as pink, red or purple lesions on the skin and
mouth. In people with darker skin, the lesions may look dark brown or black.
Kaposi's sarcoma can also affect the internal organs, including the digestive tract
and lungs.
Lymphomas. This type of cancer originates in your white blood cells and usually first
appears in your lymph nodes. The most common early sign is painless swelling of the
lymph nodes in your neck, armpit or groin.
50
Other complications
cases of wasting syndrome, but it still affects many people with AIDS. It's defined as a
loss of at least 10 percent of body weight, often accompanied by diarrhea, chronic
weakness and fever.
Neurological complications. Although AIDS doesn't appear to infect the nerve
cells, it can cause neurological symptoms such as confusion, forgetfulness, depression,
anxiety and difficulty walking. One of the most common neurological complications is
AIDS dementia complex, which leads to behavioral changes and diminished mental
functioning.
DIAGNOSIS
HIV is most commonly diagnosed by testing your blood or saliva for antibodies to the
virus. Unfortunately, it takes time for your body to develop these antibodies usually
up to 12 weeks.
A newer type of test that checks for HIV antigen, a protein produced by the virus
immediately after infection, can quickly confirm a diagnosis soon after infection. An
earlier diagnosis may prompt people to take extra precautions to prevent
transmission of the virus to others.
Home test
A Food and Drug Administration-approved home test is available. To do the test, you
swab fluid from your upper and lower gums. If the test is positive, you need to see
your doctor to confirm the diagnosis and discuss your treatment options. If the test is
negative, it needs to be repeated in three months to confirm the results.
CD4 count. CD4 cells are a type of white blood cell that's specifically targeted and
destroyed by HIV. Even if you have no symptoms, HIV infection progresses to AIDS when
your CD4 count dips below 200.
51
Viral load. This test measures the amount of virus in your blood. Studies have shown
that people with higher viral loads generally fare more poorly than do those with a lower
viral load.
Drug resistance. This blood test determines whether the strain of HIV you have will
be resistant to certain anti-HIV medications.
TREATMENT
There's no cure for HIV/AIDS, but a variety of drugs can be used in combination to
control the virus. Each class of anti-HIV drugs blocks the virus in different ways. It's
best to combine at least three drugs from two classes to avoid creating strains of HIV
that are immune to single drugs.
The classes of anti-HIV drugs include:
Protease inhibitors (PIs). PIs disable protease, another protein that HIV needs to
make copies of itself. Examples include atazanavir (Reyataz), darunavir (Prezista),
fosamprenavir (Lexiva) and indinavir (Crixivan).
Entry or fusion inhibitors. These drugs block HIV's entry into CD4 cells. Examples
include enfuvirtide (Fuzeon) and maraviroc (Selzentry).
Integrase inhibitors. These drugs work by disabling integrase, a protein that HIV
uses to insert its genetic material into CD4 cells. Examples include raltegravir (Isentress),
elvitegravir (Vitekta) and dolutegravir (Tivicay).
52
You're pregnant.
HEPATITIS
Hepatitis is an inflammation of the liver. The condition can be self-limiting or can
progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most
common cause of hepatitis in the world but other infections, toxic substances (e.g. alcohol,
certain drugs), and autoimmune diseases can also cause hepatitis.
TYPES
53
EPIDEMIOLOGY
It is estimated that approximately 2 billion people worldwide have evidence of past or present
infection with hepatitis B virus (HBV), and 248 million individuals are chronic carriers (ie,
positive for hepatitis B surface antigen [HBsAg]) [2,3]. The overall prevalence of HBsAg is
reported to be 3.6 percent; however, it varies depending upon the geographic area. The
prevalence of chronic HBV ranges from <2 percent in low prevalence areas (eg, United
States, Canada, Western Europe) to 2 to 7 percent in intermediate prevalence areas (eg,
Mediterranean countries, Japan, Central Asia, Middle East, and parts of South America) to 8
percent in high prevalence areas (eg, Western Africa, South Sudan) (table 1) [2-4].
The wide range in the prevalence of patients with chronic HBV in different parts of the world
is largely related to differences in the age at infection, which is inversely related to the risk of
chronicity. The rate of progression from acute to chronic HBV infection is approximately 90
percent for perinatally-acquired infection [5], 20 to 50 percent for infections between the age
of one and five years [6,7], and less than 5 percent for adult-acquired infection [6].
ETIOLOGY
The type of virus that's causing your hepatitis affects how severe your disease is and how
long it lasts.
54
Hepatitis A. You usually get it when you eat or drink something that's got the virus in it. It's
the least risky type because it almost always gets better on its own. It doesn't lead to longterm inflammation of yourliver
Even so, about 20% of people who get hepatitis A get sick enough that they need to go to the
hospital. There's a vaccine that can prevent it.
Hepatitis B. This type spreads in several ways.You can get it from sexwith someone who's
sick or by sharing a needle when using street drugs. The virus also can pass from a mother to
her newborn child at birth or soon afterward.
Most adults with hepatitis B get better, but a small percentage can't shake the disease and
become carriers, which means they can spread it to others even when their own symptoms
disappear.
Hepatitis C. You get this type if you have contact with contaminatedblood or needles used to
inject illegal drugs or draw tattoos.
Sometimes you don't get any symptoms, or just mild ones. But in some cases hepatitis
C leads to cirrhosis, a risky scarring of your liver.
Hepatitis D happens only if you're already infected with hepatitis B. It tends to make that
disease more severe.
It's spread from mother to child and through sex.
Hepatitis E mainly spreads in Asia, Mexico, India, and Africa. The few cases that show up in
the U.S. are usually in people who return from a country where there are outbreaks of the
disease.
Like hepatitis A, you usually get it by eating or drinking something that's been contaminated
with the virus.
RISK FACTORS
You're at increased risk of hepatitis A if you:
55
PATHOPHISYOLOGY
fatigue
flu-like symptoms
dark urine
pale stool
abdominal pain
loss of appetite
56
Chronic hepatitis B or C can often lead to more serious health problems. Because the virus
primarily affects the liver, people with chronic hepatitis B or C are at risk for:
bleeding disorders
kidney failure
hepatic encephalopathy, which can involve fatigue, memory loss, and diminished
mental abilities due to the build up of toxins that affect the brain (especially ammonia)
Liver Biopsy
A liver biopsy is an invasive procedure that involves the doctor taking a sample of tissue from
your liver. This is a closed procedure. In other words, it can be done through the skin with a
needle and doesnt require surgery. This test allows your doctor to determine if an infection or
inflammation is present or if liver damage has occurred.
57
Blood Tests
Blood tests used to detect the presence of hepatitis virus antibodies and antigen in the blood
will indicate or confirm which virus is the cause of the hepatitis.
Viral Antibody Testing
Further viral antibody testing may be needed to determine if a specific type of the hepatitis
virus is present.
Treatments
Treatment options are determined by which type of hepatitis you have and whether the
infection is acute or chronic.
Hepatitis A
Hepatitis A isnt usually treated. Bed rest may be recommended if symptoms cause a great
deal of discomfort. If you experience vomiting or diarrhea, you will be put on a special diet
created by your doctor to prevent malnutrition or dehydration. Vaccination can also prevent
hepatitis A infections by helping your body produce the antibodies that fight this type of
infection. Most children receive the vaccination between ages 12 and 18 months. Vaccination
is also available for adults.
58
Hepatitis B
Acute hepatitis B doesnt require specific treatment. Chronic hepatitis B is treated with
antiviral medications. This form of treatment can be costly because it must be followed for
several months or years. Treatment for chronic hepatitis B also requires regular medical
evaluations and monitoring to determine if the virus is progressing. The CDC recommends
hepatitis B vaccinations for all newborns. The vaccine is also recommended for all healthcare
and medical personnel.
Hepatitis C
Antiviral medications are used to treat both acute and chronic forms of hepatitis C. People
who develop chronic hepatitis C are typically treated with a combination of antiviral drug
therapies. They may also need further testing to determine the best form of treatment. People
who develop cirrhosis (scarring of the liver) or liver disease as a result of chronic hepatitis C
may be candidates for a liver transplant.
Hepatitis D
Hepatitis D is treated with a medication called alpha interferon. According to the Public
Health Agency of Canada, between 60 to 97 percent of people develop hepatitis D again even
after treatment.
Hepatitis E
There are currently no specific medical therapies to treat hepatitis E. Because the infection is
often acute, it typically resolves on its own. People with this type of infection are often
advised to get adequate rest, drink plenty of fluids, get enough nutrients, and avoid alcohol.
Prevention
Hygiene
Practicing good hygiene is one key way to avoid contracting hepatitis. If youre traveling to a
developing country, you should avoid:
ice
seafood
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RHEUMATOID ARTHRITIS
Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your
joints. In some people, the condition also can damage a wide variety of body systems,
including the skin, eyes, lungs, heart and blood vessels.
An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly
attacks your own body's tissues.
Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of
your joints, causing a painful swelling that can eventually result in bone erosion and joint
deformity.
The inflammation associated with rheumatoid arthritis is what can damage other parts of the
body as well. While new types of medications have improved treatment options dramatically,
severe rheumatoid arthritis can still cause physical disabilities.
EPIDEMIOLOGY
Studies of the descriptive epidemiology of RA indicate a population prevalence of 0.5% to 1% and a
highly variable annual incidence (12-1200 per 100,000 population) depending on gender,
race/ethnicity, and calendar year. Secular trends in RA incidence over time have been shown in
several studies, supporting the hypothesis of a host-environment interaction. People with RA have a
significantly increased risk of death compared with age- and sex-matched controls without RA from
the same community. The determinants of this excess mortality remain unclear; however, reports
suggest increased risk from gastrointestinal, respiratory, cardiovascular, infectious, and hematologic
diseases among RA patients compared with controls. Despite extensive epidemiologic research, the
etiology of RA is unknown. Several risk factors have been suggested as important in the development
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or progression of RA. These include genetics, infectious agents, oral contraceptives, smoking, and
formal education. Epidemiologic research is an essential contributor to our understanding of RA.
Joint stiffness that is usually worse in the mornings and after inactivity
Early rheumatoid arthritis tends to affect your smaller joints first particularly the joints
that attach your fingers to your hands and your toes to your feet.
As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips
and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.
About 40 percent of the people who have rheumatoid arthritis also experience signs and
symptoms that don't involve the joints. Rheumatoid arthritis can affect many nonjoint
structures, including:
Skin
Eyes
Lungs
Heart
Kidneys
Salivary glands
Nerve tissue
Bone marrow
Blood vessels
Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go.
Periods of increased disease activity, called flares, alternate with periods of relative remission
when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause
joints to deform and shift out of place.
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Causes
Your sex. Women are more likely than men to develop rheumatoid arthritis.
Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between
the ages of 40 and 60.
Family history. If a member of your family has rheumatoid arthritis, you may have
an increased risk of the disease.
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Obesity. People who are overweight or obese appear to be at somewhat higher risk of
developing rheumatoid arthritis, especially in women diagnosed with the disease when
they were 55 or younger.
Complications
Rheumatoid arthritis increases your risk of developing:
Osteoporosis. Rheumatoid arthritis itself, along with some medications used for
treating rheumatoid arthritis, can increase your risk of osteoporosis a condition that
weakens your bones and makes them more prone to fracture.
Rheumatoid nodules. These firm bumps of tissue most commonly form around
pressure points, such as the elbows. However, these nodules can form anywhere in the
body, including the lungs.
Dry eyes and mouth. People who have rheumatoid arthritis are much more likely to
experience Sjogren's syndrome, a disorder that decreases the amount of moisture in
your eyes and mouth.
Infections. The disease itself and many of the medications used to combat rheumatoid
arthritis can impair the immune system, leading to increased infections.
Abnormal body composition. The proportion of fat compared to lean mass is often
higher in people who have rheumatoid arthritis, even in people who have a normal body
mass index (BMI).
Heart problems. Rheumatoid arthritis can increase your risk of hardened and blocked
arteries, as well as inflammation of the sac that encloses your heart.
Diagnosis
Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs
and symptoms mimic those of many other diseases. There is no one blood test or physical
finding to confirm the diagnosis.
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During the physical exam, your doctor will check your joints for swelling, redness and
warmth. He or she may also check your reflexes and muscle strength.
Blood tests
People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR,
or sed rate) or C-reactive protein (CRP), which may indicate the presence of an inflammatory
process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic
citrullinated peptide (anti-CCP) antibodies.
Imaging tests
Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in
your joints over time. MRI and ultrasound tests can help your doctor judge the severity of the
disease in your body.
PATHOPHISYOLOGY
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TREATMENT
There is no cure for rheumatoid arthritis. But recent discoveries indicate that remission of
symptoms is more likely when treatment begins early with strong medications known as
disease-modifying antirheumatic drugs (DMARDs).
Medications
The types of medications recommended by your doctor will depend on the severity of your
symptoms and how long you've had rheumatoid arthritis.
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effects may include ringing in your ears, stomach irritation, heart problems, and liver
and kidney damage.
Biologic agents. Also known as biologic response modifiers, this newer class of
DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret),
certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab
(Remicade), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz).
These drugs can target parts of the immune system that trigger inflammation that causes
joint and tissue damage. These types of drugs also increase the risk of infections.
Biologic DMARDs are usually most effective when paired with a nonbiologic
DMARD, such as methotrexate.
Therapy
Your doctor may send you to a physical or occupational therapist who can teach you
exercises to help keep your joints flexible. The therapist may also suggest new ways to do
daily tasks, which will be easier on your joints. For example, if your fingers are sore, you
may want to pick up an object using your forearms.
Assistive devices can make it easier to avoid stressing your painful joints. For instance, a
kitchen knife equipped with a saw handle helps protect your finger and wrist joints. Certain
tools, such as buttonhooks, can make it easier to get dressed. Catalogs and medical supply
stores are good places to look for ideas.
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Surgery
If medications fail to prevent or slow joint damage, you and your doctor may consider
surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It
can also reduce pain and correct deformities.
Rheumatoid arthritis surgery may involve one or more of the following procedures:
Tendon repair. Inflammation and joint damage may cause tendons around your joint
to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
Total joint replacement. During joint replacement surgery, your surgeon removes the
damaged parts of your joint and inserts a prosthesis made of metal and plastic.
Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your
doctor.
Alternative medicine
Some common complementary and alternative treatments that have shown promise for
rheumatoid arthritis include:
Fish oil. Some preliminary studies have found that fish oil supplements may reduce
rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a
fishy taste in the mouth. Fish oil can interfere with medications, so check with your
doctor first.
Plant oils. The seeds of evening primrose, borage and black currant contain a type of
fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side
effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or
interfere with medications, so check with your doctor first.
Tai chi. This movement therapy involves gentle exercises and stretches combined
with deep breathing. Many people use tai chi to relieve stress in their lives. Small
studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a
knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.
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