Monday, April 12, 2010
Varicella
4:43 AM | 
Diposkan oleh
Hermanto
Varicella or chickenpox is an acute disease caused by varicella-zoster virus (VZV) and characterized by generalized vesicular rash.
The incubation period is usually about 7- 14 days and this disease is known to be spread by direct contact. Airborne spread has also been demonstrated especially in hospitals.
Varicella is more common than other childhood diseases during the early months of life. After the first 2 weeks of life, the disease is generally mild. Maternal antibody transferred across the placenta may not be as effective in protecting infants against this disease as antibodies against other viruses.
Varicella is characterized by a generalized eruption that is centripetal in distribution with erythematous macules, papules, vesicles, and scabbed lesions. The vesicles are superficial, with varying amounts of erythema at their bases.
During the early phase of the eruption, lesions are found on the face, scalp, and trunk. Often, lesions can be detected in the scalp before their appearance on the skin by running the fingers through the hair. Later, new lesions appear on the extremities. By this time, the earlier lesions have dried and crusted. Excoriations are common, attesting to the pruritic nature of the lesions.
Mucous membranes of the conjunctiva and oropharynx are more frequently involved in adults than in children. New lesions continue to appear over a 3- or 4-day period, after which the rate of their appearance decelerates markedly.
Most children have a mild illness with few systemic complaints and an average maximal temperature of about 38.3° C. It is more common for adults to have considerable malaise, muscle ache, arthralgia, and headache. These may precede the first skin lesions by 24 to 48 hours.
The most common complication of Varicella is bacterial infections of the skin. The major complications of varicella in adults are encephalitis and pneumonia.
Infection produces a diffuse interstitial type of pneumonia with hypoxia resulting from poor diffusion of gases. Diffuse calcification of the lung parenchyma may be found years after recovery.
Encephalitis in childhood is most commonly manifested by a cerebellitis, which usually occurs at the end of the first week or during the second week after the onset of rash. This complication is almost always self-limited.
To help diagnose, serologic confirmation of the diagnosis can be made using a variety of techniques. The enzyme-linked immunosorbent assay (ELISA) and the latex agglutination assay are the most generally available. The laboratory director should be consulted regarding appropriate time of collection of specimens as well as interpretation of data.
Major therapeutic objectives are the prevention of superinfection and relief of pruritus. To relief pruritus can be accomplished frequently by application of calamine lotion. It is advisable to trim and file nails to reduce the damage from scratching. Bacterial superinfection can best be prevented by encouraging daily bathing with an antibacterial soap.Relief of systemic symptoms may require additional medication such as acetaminophen, although this may increase pruritus.
Antiviral that usually used for adolescent and adults is acyclovir (800 mg per oral five times daily for 5-7 days).
Thursday, March 18, 2010
Molluscum Contagiosum (Dimple Warts)
Molluscum contagiosum is a viral disease that caused pox virus family that clinically form papuls, and there are grooves on the surface with a mass contain molluscum bodies. Molluscum warts occur characteristically in small children and in young adults, although they may be seen occasionally in any age group. The incubation of this warts is estimated to vary from 14 days to 6 months.
This warts usually starts from single or small lesion and then spread wide to face, trunk, extremities. For Young adults more often present with lesions on the lower abdomen, pubic escutcheon, or inner thighs contracted during sexual transmission.
For children, molluscum warts are usually spread by close physical contact. Especially with their activities such as swimming in pool facilities, communal shower facilities, and contact sports.
For young adult, the most common of transmission is sexual contact.
For people with low immunity such as AIDs, Leukemia, people with chemotherapy, this warts can be the provoking factor too.
Histopathologic examination can help us to diagnose this disease. We can find molluscum bodies that contain virus particles from infected epidermis.
Patient should avoid communal swimming pools, baths, and shared clothing items. Because that activities can make contamination to other people.
The principle of treatment is to remove the mass containing molluscum bodies. We can use tools such as blackheads extractor, syringes, or curette. For young adults, should also be therapy for their sexual partner.
The most effective in adult cases is Light freezing with liquid nitrogen (LN2). This treatment useful, non scaring and must be repeated every 10 to 14 days until clear.
The prognosis of this disease better if all the lesions have been removed.
Friday, March 12, 2010
Acute Pancreatitis
Acute pancreatitis is an inflammatory process arising in the exocrine pancreas, with variable involvement of peripancreatic tissues or remote organ systems. Incidence of acute pancreatitis from about 10 to 50 case per 100,000 per year.
Gallstone disease and alcoholism are the most common etiology of this disease in industrialized country. Other etiologies are infection (ascariasis, mumps, cytomegalo virus infection), hyperlipidemia, chronic hypercalcemia, abdominal trauma (blunt or penetrating), surgery.
Acute pancreatitis primary complain is abdominal pain (about 95%). The characteristic of this pain are epigastric location and radiates to the back in one-half to two-thirds of patients and usually worsened by ingesting food or alcohol or by vomiting. Patient usually assume a knee-to-chest position to relief their pain. Other symptoms are nausea, vomiting and distention of abdominal.
On examination, abdominal tenderness is usually present. It may be mild and limited to the epigastrium or marked, diffuse, and accompanied by abdominal rigidity and rebound tenderness.
Fever, tachycardia, tachypnea and hypotension manifest depend of the severity of this disease. Patient with biliary obstruction usually present icterus.
Serum amylase consentration has been used to diagnose acute pancreatitis for more than 70 years. But serum amylase levels may also be elevated in several conditions that can closely mimic acute pancreatitis (e.g., cholangitis, gastrointestinal perforation or ischemia, ruptured ectopic pregnancy).
Abdominal CT scan also has a great contribution to help us diagnose acute pancreatitis. Abdominal ultrasonography may be useful in determining whether gallstones are the cause of an episode of acute pancreatitis.
Providing supportive care, Decreasing pancreatic inflammation and preventing the complications are the goal of treatment. For mild acute pancreatitis, patient need full bed rest, intravenous hydration and electrolytes, analgesia to relief pain. For severy acute pancreatitis, patient usually need an intensive care unit with careful attention to monitoring of hemodynamics , urine output, and respiratory and renal function. Patients should initially be kept at bed rest with no oral intake, and large amounts of intravenous narcotic analgesics are typically needed for pain relief as well as nasogastric suction for treatment of severe ileus, nausea, and vomiting. Several pharmacologic agents have been tried to inactivate trypsin and other serine proteases, decrease pancreatic secretion and reduce inflammation.
The most lethal complication is hypovolemia shock due to transudation and exudation of fluid into the retroperitoneum and peritoneum.
Friday, March 5, 2010
Learning about Antrax
Antrax isi zoonotic infection caused by Bacillus anthracis (an aerobic, nonmotile, gram-positive bacillus). Antrax causes human disease by way of direct animal contact or through exposure to contaminated animal hides, meat or other products. No human-to-human transmission has been demonstrated.
In 1979, in Sverdlovsk in the former Soviet Union, the largest known epidemic of inhalational anthrax occurred; it was later found to have been the result of an accidental release of anthrax spores from a military research facility.
Antrax can manifest to cutaneus type (the most cases), inhalational, oropharyngeal, gastrointestinal, sepsis, and meningeal disease. The cutaneus type is beginning as a nonspecific, erythematous, painless, pruritic papule or macule that appears after an incubation period of 3 to 4 days. This type is usually more severe on the neck or face than on the trunk or extremities. The vesicle subsequently ulcerates and forms a characteristic centrally depressed black chancre (or malignant pustule). For inhalation type or wool sorter's disease, this disease begins with an influenza-like prodrome that lasts for 1 to 6 days, followed by sudden deterioration with dyspnea, strider, cyanosis, and hypoxemia. Spesific clinical manifestation of this type is widening of the mediastinum due to hilar adenopathy.
Laboratory confirmation can be made by demonstration of the causative organism in blood, tissue fluids, and exudates by direct microscopic examination and culture, or by animal inoculation. Another laboratory studies are ELISA, PCR and a rapid hand-held immunochromatographic assay. Drug of choice of this disease is Penicillin that virtually eliminates the spread of cutaneous anthrax and essentially reduces the mortality rate to zero. Another alternative drugs are tetracycline, erythromycin, chloramphenicol, and ciprofloxacin.
To prevent Antrax, we should give vaccination of domestic livestock, prohibition of the slaughter of unvaccinated animals, and burning of animals suspected of having anthrax.
Wednesday, March 3, 2010
Brain Abscess
Brain abscess affects the brain's parenchyma directly, whereas parameningeal infections produce suppuration in potential spaces covering the brain and spinal cord (epidural abscess and subdural empyema) or produce occlusion of the contiguous venous sinuses and cerebral veins (cerebral venous sinus thrombosis).
The condition that predispose to the development brain abscess are : otogenic (otitis media, mastoiditis), dental (dental abscess), penetrating or non penetrating head injury, cerebral infarction and tumor, post operative neurosurgical procedure, sinus (sinusitis), cardiac (infective endocarditis), pulmonary (lung abscess, bronchiectasis).
Clinical manifestation that usually present are fever, meningeal sign, increasing intracranial mass effect (nausea, depressed level of consciousness, and papilledema). Focal neurologic deficits depend on the site of the lesion, which in turn will be determined by the causal or predisposing condition. Headache is an important initial symptom in 80 to 90% of patients with bacterial abscess.
Examination of the cranium, ears, paranasal sinuses, oral cavity, heart, and lungs may provide important clues to the etiology. lumbar puncture is contraindicated for patients with signs of increased intracranial pressure. Cultures of blood and sputum may identify the organism and its antimicrobial sensitivity.
Magnetic resonance imaging (MRI) allows detection of early changes, such as brain edema, and is preferable to computed tomography (CT).
Brain abscess need urgent intervention. Because of the risk for cerebral herniation with large lesions, treatment of cerebral edema (intravenous dexamethasone) may be needed even while initiating surgical intervention.
Nonsurgical treatment may be considered in patients with : small lesion size, an already identified pathogen, no symptoms or signs of increased intracranial pressure requiring neurosurgical intervention, a deep or inaccessible lesion, multiple abscesses, a contraindication to surgery (e.g., a bleeding diathesis).
Factors associated with a poor prognosis include age, multiple abscesses, and diagnostic delay in the absence of systemic signs of infection.
Tuesday, March 2, 2010
Silicosis
Silicosis refers to the parenchymal lung diseases associated with crystalline silica exposure, including acute, accelerated, and chronic or classic silicosis. For acute silicosis, an alveolar filling process follows heavy exposure within a few years. 5-10 years for accelerated silicosis and more than 10 years for chronic silicosis.
Free silica (SiO2), or crystalline quartz, is still a major occupational hazard. The major occupational exposures include: mining, employment in abrasive industries (e.g. stone, clay, glass, and cement manufacturing), packing of silica flour, stonecutting, foundry work.People with acute silicosis presents with rapidly progressive dyspnea, they are also at increased risk for mycobacterial infection (with weight loss and fever manifestation).
The diagnosis of chronic silicosis is made on the basis of characteristic radiographic findings and history of employment in a job associated with exposure to silica-containing dust. But we must consider another differential diagnosis for lung masses such as lung cancer, mycobacterial infection.
The chest radiography of chronic silicosis shows small nodules that tend to predominate in the upper lobes. Calcification of the nodules is rare, as is so-called eggshell calcification of enlarged hilar nodes. In acute silicosis, we can find widespread consolidation in chest radiograph. CT may be helpful both in identifying nodules, which are preferentially located in the posterior aspect of the upper lobes, as well as in identifying larger opacities and more coalescence than might be noted on regular chest x-rays.Treatment of silicosis are supportive therapy such as oxygen and rehabilitation. Diagnosis and treatment of mycobacterial infection also important, because silicosis can increase risk factor of this infection.
The prognosis of accelerated silicosis and acute silicosis is poor because of progressiveness loss of lung function. For chronic silicosis, it can lead to progressive impairment and respiratory failure.
Saturday, February 27, 2010
Learning about Marfan Syndrome
Marfan syndrome is caused by mutation in gene for structural molecules of the extracellular matrix especially fibrilin-1 (FBN1) on chromosome 15 that lead abnormalities in microfibrillar assembly and stability. This disease also reduce microfibrils in elastic or non elastic tissues.
Incidence of Marfan Syndroem is about 1 in 10,000 in most racial and ethnic groups. The disorder is inherited as an autosomal dominant trait. At least 25 percents of people wih Marfan Syndrome do not have an affected parent, and therefore probably represent new mutations.
The specific diagnoses of Marfan Syndrome will continue to be made in the clinic rather than the molecular genetics laboratory.
All of clinical manifestation depend on whether the molecular defect resides in a gene for collagen, fibrillin, elastin, or other matrix protein, the bones, ligaments, joints, blood vessels, eyes, or skin are affected to various degrees.
Clinical features are tall stature with long and thin extremities, low subcutaneous fat, arm span >8cm excess of height, arachnodactyly, long and narrow face, high arched palate, dental crowding, scoliosis, pectus excavatum or carinatum, pes planus, protrusion acetabuli, joint laxity. Treatment for this disorder are corrective surgery for scoliosis, orthodontia for dental crowding.
This syndrome also can manifest aneurysma dilatation of aorta ascending, aortic regurgitation, mitral valve prolapse, aortic dissection. The treatment for this manifestation are β-adrenergic blockade, composite aortic graft.
Another clinical features are ectopia lentis, myopia, flat cornea, retinal detachment. The treatment for this disorder are corrective lenses.
Friday, February 26, 2010
Post Traumatic Stress Disorder (PTSD)
PTSD is a condition marked by the development of symptoms with duration more than a month after exposure to traumatic life events. People with this disorder will reacts to this experience with fear and helplessness, persistently relives the event, and tries to avoid being reminded of it. Their reaction significantly affect important area of life (e.g family, work).
This disorder usually arise from experiences in war, torture, natural catastrophes (tsunami, hurricane, earthquake), assault, rape, and serious accidents, for example, in cars and in burning buildings.
The National Comorbidity Study found that 60 percent of males and 50 percent of females had experienced some significant trauma. The mental status examination often reveals feelings of guilt, rejection, and humiliation. Patients may also describe dissociative states and panic attacks, illusions and hallucinations may be present. Associated symptoms can include aggression, violence, poor impulse control, depression, and substance-related disorders. Cognitive testing may reveal that patients have impaired memory and attention.
Keys to correctly diagnosing PTSD involve a careful review of the time course relating the symptoms to a traumatic event. PTSD is also associated with reexperiencing and avoidance of a trauma, features typically not present in panic or generalized anxiety disorder.
The major approaches for people with PTSD are support, encouragement to discuss the event, and education about a variety of coping mechanisms (e.g., relaxation). Sedatives and hypnotics drugs can also be helpful.
Thursday, February 25, 2010
Learn about Breast Tumor in Teenage Girls
If teenage girls and women during their early reproductive years found tumor in their breast. The first one we must think about Fibroadenoma mammae (FAM). Because Fibroadenoma is the most common breast tumor in this age. They are rarely seen in women after the age of 40 or 45. Fibroadenomas are benign solid tumors composed of stromal and epithelial elements. Clinically, they may increase in size over a period of several months. They easily palpable and may be lobulated form.
Fibroadenomas do not have malignant potential, although neoplasia may develop in the epithelial elements within them, just as in epithelium elsewhere in the breast. Cancer in a newly discovered fibroadenoma is exceedingly rare.
On excision, fibroadenomas are well-encapsulated masses that may detach easily from surrounding breast tissue. A tissue diagnosis is required to rule out malignancy.
Fibroadenoma has two subtypes. The first one is Giant Fibroadenoma that attains an unusually large size, typically greater than 5 cm. And latter is Juvenile Fibroadenoma that occurs in adolescents and young adults and histologically is more cellular than the usual fibroadenoma. Although these lesions may display remarkably rapid growth, surgical removal is curative.
Wednesday, February 24, 2010
Black Widow Spider Bites
We can found Widow spiders (genus Latrodectus) throughout the world. At least one of five species inhabits all areas of the United States except Alaska. The most popular widow spider is the black widow (Latrodectus mactans).
Female spiders (Black widow) has a leg span of 1 to 4 cm and a shiny black body with a distinctive red ventral marking (often hourglass shaped). Variations in color occur among other species, some of them appearing brown or red and some without the ventral marking. The nonaggressive female widow spider bites in defense. Males are too small to bite through human skin.
Widow spiders produce neurotoxic venom with minimal local effects with major component is α-latrotoxin that acts at presynaptic terminals by enhancing release of neurotransmitters.
When they bite us, may be felt painless or felt as a “pinprick.” Local findings are minimal.
Neuromuscular symptoms may occur as early as 30 minutes after the bite such as :
· Severe pain and spasms of large muscle groups
· Abdominal cramps and rigidity
· Dyspnea as the result from chest wall muscle tightness
· Hypertension, diaphoresis, and tachycardia as the result of autonomic stimulation.
· Other symptoms : nausea, vomiting, headache, paresthesias, fatigue, and salivation.
· Symptoms usually peak at several hours and resolve in 1 to 2 days.
· Death is an unusual result of widow spider bites.
For mild bites, we can treat with local wound care such as cleansing, intermittent application of ice, and tetanus prophylaxis as needed. In some cases, we can use narcotics and benzodiazepines to relieve muscular pain.
In the United States, antivenom derived from horse serum is available (Black Widow Spider Antivenin, Merck & Co., West Point, PA). We must be careful use this antivenom because this antivenom can cause anaphylactoid reactions or serum sickness. So, before use antivenom, better we do skin testing for possible allergy. In some studies have demonstrated that antivenom can decrease hospital stay.
Tuesday, February 23, 2010
Sexual Sado-Masochism
Sexual Sadism
The terminology of this disorder was named after the Marquis de Sade, an 18th century French author and military officer who was repeatedly imprisoned for his violent sexual acts against women.
Most persons with sexual sadism are male and before the age of 18 years.
Sadism is a defense against fears of castration; persons with sexual sadism do to others what they fear will happen to them and derive pleasure from expressing their aggressive instincts.
Sexual sadism is related to rape, although rape is more aptly considered an expression of power. Some sadistic rapists, however, kill their victims after having sex (so-called lust murders).
According to John Money, there are five contributory causes of sexual sadism :
· Hereditary predisposition
· Hormonal malfunctioning
· Pathological relationships
· History of sexual abuse
· The presence of other mental disorders.
DSM-IV-TR Diagnostic Criteria for Sexual Sadism :
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.
B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
Sexual Masochism
Masochism’s terminology from the activities of Leopold von Sacher-Masoch, a 19th century Austrian novelist whose characters derived sexual pleasure from being abused and dominated by women.
According to DSM-IV-TR, persons with sexual masochism have a recurrent preoccupation with sexual urges and fantasies involving the act of being humiliated, beaten, bound, or otherwise made to suffer.
Sexual masochistic practices are more common among men than among women.
Psychodynamic
SigmundFreud believed masochism resulted from destructive fantasies turned against the self.
In some cases, persons can allow themselves to experience sexual feelings only when punishment for the feelings follows. Persons with sexual masochism may have had childhood experiences that convinced them that pain is a prerequisite for sexual pleasure. About 30% of those with sexual masochism also have sadistic fantasies.
Moral masochism involves a need to suffer, but is not accompanied by sexual fantasies.
DSM-IV-TR Diagnostic Criteria for Sexual Masochism :
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Treatment
1. Psychotherapy
· Insight-oriented psychotherapy : to help them understand the dynamics of behavioral patterns. Supportive psychotherapy : to help them repair the interpersonal, social, or occupational damage that occurs.
· Cognitive behavioral therapy : helps them recognize dysphoric states that precipitate sexual acting out.
· Marital therapy or couples therapy : to help them regain self-esteem.
2. Pharmacotherapy
Prognosis
Because of the chronic course of sexual masochism and the uncertainty of its causes, treatment is often difficult. The fact that many masochistic fantasies are socially unacceptable or unusual leads some people who may have the disorder not to seek or continue treatment. Severe or difficult cases of sexual masochism should be referred to professionals who have experience treating such cases.
Prevention
Because it is sometimes unclear whether sadomasochistic behavior is within the realm of normal experimentation or indicative of a diagnosis of sexual masochism, prevention is a tricky issue. Often, prevention refers to managing sadomasochistic behavior so it primarily involves only the simulation of severe pain and it always involves consenting partners familiar with each other's limitations.
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