Syphilis

Syphilis:
A sexually transmitted disease caused by Treponema pallidum.

Syphilis is a major health problem. About 12 million new cases of syphilis occur every year. More than 90% of them are in developing nations where congenital syphilis remains a leading cause of stillbirths and newborn deaths. In North America and Western Europe, syphilis is disproportionately common and rising among men who have sex with men and among persons who use cocaine or other illicit drugs.


There are three stages of syphilis:

• The first (primary) stage (1-5 weeks): This involves the formation of the chancre,a classic painless ulcer of syphilis. At this stage, syphilis is highly contagious.

• The second (secondary) stage (4-6 weeks): However, 25 percent of cases will proceed to the secondary stage of syphilis.

This phase can include hair loss; a sore throat; white patches in the nose, mouth, and vagina; fever; headaches; and a skin rash. There can be lesions on the genitals that look like genital warts, but are caused by spirochetes rather than the wart virus. These wart-like lesions, as well as the skin rash, are highly contagious. The rash can occur on the palms of the hands, and the infection can be transmitted by casual contact.

• The third (tertiary) stage: This final stage of the disease involves the brain and heart, and is usually no longer contagious. At this point, however, the infection can cause extensive damage to the internal organs and the brain, and can lead to death.

Diagnosis :
Is by following blood tests

• Rapid plasma reagin (RPR)
• Venereal Disease Research Laboratory (VDRL) test.
• Fluorescent treponemal antibody absorbed (FTA-ABS) test.

Treatment :
Syphilis is treated with penicillin, administered by injection.
Other antibiotics can be used for patients allergic to penicillin.

A small percentage of patients do not respond to the usual doses of penicillin. Therefore, it is important that patients have periodic repeat blood tests to make sure that the infectious agent has been completely destroyed and there is no further evidence of the disease.

In all stages of syphilis, proper treatment will cure the disease, but in late syphilis, damage already done to body organs cannot be reversed.

Prevention of Syphilis:

Patients with infectious syphilis should abstain from sexual activity until rendered noninfectious by antibiotic therapy.

Talk openly with your partner about STDs, HIV, and hepatitis B infection, and the use of contraception. All sexually active persons should consider using latex condoms to prevent STDs and HIV infection, even if they are using another form of contraception.

Latex condoms used consistently and correctly are an effective means for preventing disease (and pregnancy). Since latent condoms protect covered parts only, the exposed parts should be washed with soap and water as soon after contact as possible. This applies to men and women.

Mouth ulcers

What are Mouth Ulcers?

Mouth ulcers are small oval sores, red in colour, which develop inside the mouth. They are commonly found in the inner part of the cheeks, inside the lips, under the tongue or on the soft palate. This type of ulcer is not contagious unlike cold sores and usually disappears after a couple of weeks.

These are also known as ‘canker sores’ or ‘aphthous ulcers’.

Mouth ulcers affect both men and women although women are more commonly affected. Teenagers are especially prone to developing these which can often be a result of stress, poor diet or a lack of sleep!

You may find that you develop mouth ulcers if you are ‘run down’ or have high stress levels.

What does a mouth ulcer look like?

It is a round or oval type of swelling with a yellow or white coloured centre. It may have a ‘crater-like’ appearance and is often red and painful. Most people experience a single mouth ulcer but it is not uncommon to develop several ulcers at once.

You may experience pain when you eat or drink anything hot or cold. For those suffering with chronic mouth ulcers, they can expect to see as many 15 or 20 at a time.

Types of mouth ulcers

There are three types of mouth ulcers which are as follows:

• Minor ulcers
• Major ulcers
• Herpetiform ulcers

Minor ulcers

Around 80% of all mouth ulcers are the minor type. They are oval or round in shape and are no bigger than 10mm in size. They have a pale yellow colour but often look red and swollen although they are not usually painful.

Usually just the one ulcer appears but up to five can appear at the same time.

This type of ulcer lasts for a week to ten days and disappears without any scarring.

Major ulcers

This type of ulcer is bigger and deeper than a minor ulcer and tends to occur in about 1 out of 10 cases. Usually one ulcer develops although two can appear at the same time. This ulcer lasts from ten days to several months but in some cases, they can remain for a year or two. These painful ulcers leave a scar after they have disappeared.

Herpetiform ulcers

Also known as ‘pinpoint’ulcers: these tiny ulcers are no bigger than 3mm in size and appear as clusters. These clusters can contain from four or five ulcers up to 100. In some cases they can combine together to form large, irregular shaped groups of ulcers.

This type of ulcer appears in 10% of cases.

They usually take a week to ten days to clear and don’t result in any scarring.

Mouth ulcers are more common in people aged between 10 and 40. After that they tend to appear on occasions but this is less likely over time. Basically the older you get the less chance you have of developing mouth ulcers.

At some point you may stop developing mouth ulcers altogether.

Are mouth ulcers contagious?

No. You cannot get mouth ulcers from kissing or sharing a glass which has been used by someone with a mouth ulcer.

But what are contagious are cold sores which are formed from the herpes virus and can be transmitted via personal contact, e.g. kissing.

Some people rarely develop mouth ulcers but there are others who suffer from these on a regular basis. Around 1 in five people experience ‘recurring’mouth ulcers which can be a miserable experience.

If you are one of these unlucky sufferers then find out more in our persistent mouth ulcers section.

DIARRHOEA

What is diarrhoea?

Diarrhoea is loose, watery stools occurring more than three times in one day. Diarrhoea is a common problem that usually lasts a day or two and goes away on its own without any special treatment. However, prolonged diarrhoea can be a sign of other problems. People with diarrhoea may pass more than a quart of stool a day.

Diarrhoea can cause dehydration, which means the body lacks enough fluid to function properly. Dehydration is particularly dangerous in children and the elderly, and it must be treated promptly to avoid serious health problems.

People of all ages can get diarrhoea. The average adult has a bout of diarrhoea about four times a year.

What causes diarrhoea?

Diarrhoea may be caused by a temporary problem, like an infection, or a chronic problem, like an intestinal disease. A few of the more common causes of diarrhoea are

• Bacterial infections. Several types of bacteria, consumed through contaminated food or water, can cause diarrhoea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli.


• Viral infections. Many viruses cause diarrhoea, including rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis.


• Food intolerances. Some people are unable to digest some component of food, such as lactose, the sugar found in milk.


• Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhoea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.


• Reaction to medicines, such as antibiotics, blood pressure medications, and antacids containing magnesium.


• Intestinal diseases, like inflammatory bowel disease or coeliac disease.


• Functional bowel disorders, such as irritable bowel syndrome, in which the intestines do not work normally.

Some people develop diarrhoea after stomach surgery or removal of the gallbladder. The reason may be a change in how quickly food moves through the digestive system after stomach surgery or an increase in bile in the colon that can occur after gallbladder surgery.

In many cases, the cause of diarrhoea cannot be found. As long as diarrhoea goes away on its own, an extensive search for the cause is not usually necessary.

People who visit foreign countries are at risk for traveller's diarrhoea, which is caused by eating food or drinking water contaminated with bacteria, viruses, or, sometimes, parasites. Traveller's diarrhoea is a particular problem for people visiting developing countries. Visitors to the United States, Canada, most European countries, Japan, Australia, and New Zealand do not face much risk for traveller's diarrhoea. (See "Preventing Traveller's Diarrhoea" below)

What are the symptoms?

Diarrhoea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to use the bathroom. Depending on the cause, a person may have a fever or bloody stools.

Diarrhoea can be either acute (short-term) or chronic (long-term). The acute form, which lasts less than 4 weeks, is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhoea lasts more than 4 weeks and is usually related to functional disorders like irritable bowel syndrome or inflammatory bowel diseases like coeliac disease.

Diarrhoea in Children

Children can have acute or chronic forms of diarrhoea. Causes include bacteria, viruses, parasites, medications, functional disorders, and food sensitivities. Infection with the rotavirus is the most common cause of acute childhood diarrhoea. Rotavirus diarrhoea usually resolves in 3 to 9 days.

Medications to treat diarrhoea in adults can be dangerous to children and should be given only under a doctor's guidance.

Diarrhoea can be dangerous in newborns and infants. In small children, severe diarrhoea lasting just a day or two can lead to dehydration. Because a child can die from dehydration within a few days, the main treatment for diarrhoea in children is rehydration. (See "Preventing Dehydration" below .)

What is dehydration?

General signs of dehydration include

• thirst
• less frequent urination
• dry skin
• fatigue
• light-headedness
• dark colored urine

Signs of dehydration in children include

• dry mouth and tongue
• no tears when crying
• no wet nappies (diapers) for 3 hours or more
• sunken abdomen, eyes, or cheeks
• high fever
• listlessness or irritability
• skin that does not flatten when pinched and released

If you suspect that you or your child is dehydrated, call the doctor immediately. Severe dehydration may require hospitalization.

When should a doctor be consulted?

Although usually not harmful, diarrhoea can become dangerous or signal a more serious problem. You should see the doctor if any of the following is true:

• You have diarrhoea for more than 3 days.
• You have severe pain in the abdomen or rectum.
• You have a fever of 102 degrees Fahrenheit or higher.
• You see blood in your stool or have black, tarry stools.
• You have signs of dehydration.

If your child has diarrhoea, do not hesitate to call the doctor for advice. Diarrhoea can be dangerous in children if too much fluid is lost and not replaced quickly.

What tests might the doctor do?

Diagnostic tests to find the cause of diarrhoea include the following:

• Medical history and physical examination. The doctor will need to know about your eating habits and medication use and will examine you for signs of illness.


• Stool culture. Lab technicians analyze a sample of stool to check for bacteria, parasites, or other signs of disease or infection.


• Blood tests. Blood tests can be helpful in ruling out certain diseases.


• Fasting tests. To find out if a food intolerance or allergy is causing the diarrhoea, the doctor may ask you to avoid lactose (found in milk products), carbohydrates, wheat, or other foods to see whether the diarrhoea responds to a change in diet.


• Sigmoidoscopy. For this test, the doctor uses a special instrument to look at the inside of the rectum and lower part of the colon.


• Colonoscopy. This test is similar to sigmoidoscopy, but the doctor looks at the entire colon.

What is the treatment?

In most cases, replacing lost fluid to prevent dehydration is the only treatment necessary. (See "Preventing Dehydration" below.) Medicines that stop diarrhoea may be helpful in some cases, but they are not recommended for people whose diarrhoea is caused by a bacterial infection or parasite - stopping the diarrhoea traps the organism in the intestines, prolonging the problem. Instead, doctors usually prescribe antibiotics. Viral causes are either treated with medication or left to run their course, depending on the severity and type of the virus.

Preventing Dehydration

Dehydration occurs when the body has lost too much fluid and electrolytes (the salts potassium and sodium). The fluid and electrolytes lost during diarrhoea need to be replaced promptly - the body cannot function properly without them. Dehydration is particularly dangerous for children, who can die from it within a matter of days.

Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, you could have broth or soups, which contain sodium, and fruit juices, soft fruits, or vegetables, which contain potassium.

For children, doctors often recommend a special rehydration solution that contains the nutrients they need. You can buy this solution in the grocery store without a prescription. Examples include Pedialyte, Ceralyte, and Infalyte.

Tips About Food

Until diarrhoea subsides, try to avoid milk products and foods that are greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhoea.

As you improve, you can add soft, bland foods to your diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or fat. For children, the paediatrician may recommend what is called the BRAT diet: bananas, rice, applesauce, and toast.

Preventing Traveller's Diarrhoea

Traveller's diarrhoea happens when you consume food or water contaminated with bacteria, viruses, or parasites. You can take the following precautions to prevent traveller's diarrhoea when you go abroad:

• Do not drink any tap water, not even when brushing your teeth.


• Do not drink unpasteurized milk or dairy products.


• Do not use ice made from tap water.


• Avoid all raw fruits and vegetables (including lettuce and fruit salad) unless they can be peeled and you peel them yourself.


• Do not eat raw or rare meat and fish.


• Do not eat meat or shellfish that is not hot when served to you.


• Do not eat food from street vendors.

You can safely drink bottled water (if you are the one to break the seal), carbonated soft drinks, and hot drinks like coffee or tea.

Depending on where you are going and how long you are staying, your doctor may recommend that you take antibiotics before leaving to protect you from possible infection.

Points to Remember

• Diarrhoea is a common problem that usually resolves on its own.


• Diarrhoea is dangerous if a person becomes dehydrated.


• Causes include viral, bacterial, or parasitic infections; food intolerance; reactions to medicine; intestinal diseases; and functional bowel disorders.


• Treatment involves replacing lost fluids and electrolytes. Depending on the cause of the problem, a person might also need medication to stop the diarrhoea or treat an infection. Children may need an oral rehydration solution to replace lost fluids and electrolytes.


• Call the doctor if a person with diarrhoea has severe pain in the abdomen or rectum, a fever of 102 degrees Fahrenheit or higher, blood in the stool, signs of dehydration, or diarrhoea for more than 3 days.

Rickets

Osteomalacia in children; Vitamin D deficiency; Renal rickets; Hepatic rickets

Last reviewed: August 3, 2010.

Rickets is a disorder caused by a lack of vitamin D, calcium, or phosphate. It leads to softening and weakening of the bones.

Causes, incidence, and risk factors

Vitamin D helps the body control calcium and phosphate levels. If the blood levels of these minerals become too low, the body may produce hormones that cause calcium and phosphate to be released from the bones. This leads to weak and soft bones.

Vitamin D is absorbed from food or produced by the skin when exposed to sunlight. Lack of vitamin D production by the skin may occur in people who:

• Live in climates with little exposure to sunlight

• Must stay indoors

• Work indoors during the daylight hours

You may not get enough vitamin D from your diet if you:

• Are lactose intolerant (have trouble digesting milk products)

• Do not drink milk products

• Follow a vegetarian diet

Infants who are breastfed only may develop vitamin D deficiency. Human breast milk does not supply the proper amount of vitamin D. This can be a particular problem for darker-skinned children in winter months (when there are lower levels of sunlight).

Not getting enough calcium and phosphorous in your diet can also lead to rickets. Rickets caused by a lack of these minerals in diet is rare in developed countries, because calcium and phosphorous are found in milk and green vegetables.

Your genes may increase your risk of rickets. Hereditary rickets is a form of the disease that is passed down through families. It occurs when the kidneys are unable to hold onto the mineral phosphate. Rickets may also be caused by kidney disorders that involve renal tubular acidosis.

Disorders that reduce the digestion or absorption of fats will make it more difficult for vitamin D to be absorbed into the body.

Occasionally, rickets may occur in children who have disorders of the liver, or who cannot convert vitamin D to its active form.

Rickets is rare in the United States. It is most likely to occur in children during periods of rapid growth, when the body needs high levels of calcium and phosphate. Rickets may be seen in children ages 6 - 24 months. It is uncommon in newborns.

Symptoms

• Bone pain or tenderness

  • Arms

  • Legs

  • Pelvis

  • Spine

• Dental deformities

  • Delayed formation of teeth

  • Decreased muscle tone (loss of muscle strength)

  • Defects in the structure of teeth; holes in the enamel

  • Increased cavities in the teeth (dental caries)

  • Progressive weakness

• Impaired growth

• Increased bone fractures

• Muscle cramps

• Short stature (adults less than 5 feet tall)

• Skeletal deformities

  • Asymmetrical or odd-shaped skull

  • Bowlegs

  • Bumps in the ribcage (rachitic rosary)

  • Breastbone pushed forward (pigeon chest)

  • Pelvic deformities

  • Spine deformities (spine curves abnormally, including scoliosis or kyphosis)

Signs and tests

A physical exam reveals tenderness or pain in the bones, rather than in the joints or muscles.

The following tests may help diagnose rickets:

• Arterial blood gases

• Blood tests (serum calcium)

• Bone biopsy (rarely done)

• Bone x-rays

• Serum alkaline phosphatase

• Serum phosphorus

Other tests and procedures include the following:

• ALP (alkaline phosphatase) isoenzyme

• Calcium (ionized)

• PTH

• Urine calcium

Treatment

The goals of treatment are to relieve symptoms and correct the cause of the condition. The cause must be treated to prevent the disease from returning.

Replacing calcium, phosphorus, or vitamin D that is lacking will eliminate most symptoms of rickets. Dietary sources of vitamin D include fish, liver, and processed milk. Exposure to moderate amounts of sunlight is encouraged. If rickets is caused by a metabolic problem, a prescription for vitamin D supplements may be needed.

Positioning or bracing may be used to reduce or prevent deformities. Some skeletal deformities may require corrective surgery.

Expectations (prognosis)

The disorder may be corrected by replacing vitamin D and minerals. Laboratory values and x-rays usually improve after about 1 week, although some cases may require large doses of minerals and vitamin D.

If rickets is not corrected while the child is still growing, skeletal deformities and short stature may be permanent. If it is corrected while the child is young, skeletal deformities often improve or disappear with time.

Complications

• Chronic skeletal pain

• Skeletal deformities

• Skeletal fractures, may occur without cause

Calling your health care provider

Call your child's health care provider if you notice symptoms of rickets.

Prevention

You can prevent rickets by making sure that your child gets enough calcium, phosphorus, and vitamin D in the diet. People who have gastrointestinal or other disorders may need to take supplements. Ask your child's health care provider.

Kidney (renal) causes of poor vitamin D absorption should be treated right away. People who have renal disorders should have their calcium and phosphorus levels monitored regularly.

Genetic counseling may help people who have a family history of inherited disorders that can cause rickets.

Malaria

Malaria
Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitoes. In the human body, the parasites multiply in the liver, and then infect red blood cells.

Causes, incidence, and risk factors

Malaria is caused by a parasite that is transmitted from one human to another by the bite of infected Anopheles mosquitoes. In humans, the parasites (called sporozoites) travel to the liver, where they mature and release another form, the merozoites. These enter the bloodstream and infect the red blood cells.

The parasites multiply inside the red blood cells, which then rupture within 48 to 72 hours, infecting more red blood cells. The first symptoms usually occur 10 days to 4 weeks after infection, though they can appear as early as 8 days or as long as a year after infection. Then the symptoms occur in cycles of 48 to 72 hours.

The majority of symptoms are caused by the massive release of merozoites into the bloodstream, the anemia resulting from the destruction of the red blood cells, and the problems caused by large amounts of free hemoglobin released into circulation after red blood cells rupture.

Malaria can also be transmitted from a mother to her unborn baby (congenitally) and by blood transfusions. Malaria can be carried by mosquitoes in temperate climates, but the parasite disappears over the winter.

The disease is a major health problem in much of the tropics and subtropics. The CDC estimates that there are 300-500 million cases of malaria each year, and more than 1 million people die. It presents a major disease hazard for travelers to warm climates.

In some areas of the world, mosquitoes that carry malaria have developed resistance to insecticides. In addition, the parasites have developed resistance to some antibiotics. This has led to difficulty in controlling both the rate of infection and spread of this disease.

Figure 1: CDC illustration of the life cycles of malaria parasites, Plasmodium spp. SOURCE: CDC

Falciparum malaria, one of four different types of malaria, affects a greater proportion of the red blood cells than the other types and is much more serious. It can be fatal within a few hours of the first symptoms.

Symptoms

• Anemia

• Chills

• Coma

• Convulsion

• Fever

• Headache

• Jaundice

• Muscle pain

• Nausea

• Stools, bloody

• Sweating

• Vomiting

Signs and tests

During a physical examination, the doctor may identify an enlarged liver or an enlarged spleen. Malaria blood smears taken at 6 to 12 hour intervals confirm the diagnosis.

Treatment

Malaria, especially Falciparum malaria, is a medical emergency requiring hospitalization. Chloroquine is a frequently used anti-malarial medication, but quinidine or quinine plus doxycycline, tetracycline, or clindamycin; or atovaquone plus proguanil (Malarone); or mefloquine or artesunate; or the combination of pyrimethamine and sulfadoxine, are given for chloroquine-resistant infections. The choice of medication depends in part on where you were when you were infected.

Aggressive supportive medical care, including intravenous (IV) fluids and other medications and breathing (respiratory) support may be needed.

Expectations (prognosis)

The outcome is expected to be good in most cases of malaria with treatment, but poor in Falciparum infection with complications.

Complications

• Destruction of blood cells (hemolytic anemia)

• Liver failure and kidney failure

• Meningitis

• Respiratory failure from fluid in the lungs (pulmonary edema)

• Rupture of the spleen leading to massive internal bleeding (hemorrhage)

Calling your health care provider

Call your health care provider if you develop fever and headache after visiting the tropics.

Prevention

Most people living in areas where malaria is common have acquired some immunity to the disease. Visitors will not have immunity, and should take preventive medications. It is important to see your health care provider well before your trip, because treatment may begin is long as 2 weeks before travel to the area, and continue for a month after you leave the area. The types of anti-malarial medications prescribed will depend on the area you visit. According to the CDC, travelers to South America, Africa, the Indian subcontinent, Asia, and the South Pacific should take one of the following drugs: mefloquine, doxycycline, choroquine, hydroxychoroquine, or Malarone.

Even pregnant women should take preventive medications because the risk to the fetus from the medication is less than the risk of acquiring a congenital infection.

People on anti-malarial medications may still become infected. Avoid mosquito bites by wearing protective clothing over the arms and legs, using screens on windows, and using insect repellent.

Chloroquine has been the drug of choice for protection from malaria. But because of resistance, it is now only suggested for use in areas where Plasmodium vivax, P. oval, and P. malariae are present. Falciparum malaria is becoming increasingly resistant to anti-malarial medications.

For travelers going to areas where Falciparum malaria is known to occur, there are several options for malaria prevention, including mefloquine, atovaquone/Proguanil (Malarone), and doxycycline.

Travelers can call the CDC for information on types of malaria in a given geographical area, preventive drugs, and times of the year to avoid travel. See: www.cdc.gov

Diagnostic Approach of Insomnia

Diagnostic Approach of Insomnia

1. How long have you had problems with insomnia?

   Why: to determine if acute or chronic. Transient insomnia can last up to 3-4 weeks and after that it is considered to be chronic.

2. Is the sleep disturbance problem with sleep onset (initial insomnia), sleep maintenance (middle insomnia) or premature awakening (late insomnia)?
3. What is the sleeping environment?

   Why: Common problems with the sleeping environment that may contribute to insomnia and sleep disturbance include noise, extreme temperatures, poorly ventilated room, hot bedroom, cold bedroom, mattress that is too soft or hard, too much light in bedroom.

4. Do you take day time naps?

   Why: may cause or prolong the problem of insomnia.

5. What is the age of the person with insomnia?

   Why: a reduction in sleep requirements often accompanies aging. If the sleep disturbance is in a child or infant must consider hunger, colic, indigestion, dirty diaper, too hot, too cold, teething.

6. Are there simple reasons for sleep disturbance?

   Why: e.g. overeating before bedtime, sugar snack before bedtime, environment change (in an unfamiliar hotel or hospital bed), sleep schedule change, jet lag, shift work, mental stimulation before bedtime, sex at bedtime (some people become stimulated after sex), lack of exercise, partner who has restless legs syndrome or who snores loudly.

7. What are your stressors at the moment?

   Why: questions specifically about relationship, family, children, social support, occupation, general physical health and financial stresses. Stressors are a common cause of insomnia such as a change of occupation, loss of a loved one, illness, anxiety over a deadline or examination.

8. Previous or current use of sedatives or hypnotics?

   Why: The regular use of sedatives or hypnotics will interfere with sleep patterns and lead to chronic insomnia. Often the dosage of these medications will have been increased in the past so as to maintain hypnotic effectiveness after tolerance begins to develop. In cases of withdrawal, individuals may sleep only 1-4 hours each night ("rebound insomnia") for several weeks and will also experience an increase in anxious dr and nightmares and awakenings through the night.

9. Past medical history?

   Why: many medical problems may increase the risk of insomnia such as hyperthyroidism, kidney disease, Parkinson's disease, asthma, congestive cardiac failure, emphysema, chronic bronchitis, Addison's disease, Cushing's disease.

10. Past psychiatric history?

    Why: certain mental illnesses are well known to cause insomnia such as depression, anxiety, schizophrenia, mania.

11. Medications?

    Why: Some medications may cause insomnia including thyroid hormones, certain weight loss drugs, phenylpropanolamine (PPA), nasal decongestants, diuretics (due to night urination), high-potency vitamins, certain antidepressants (e.g. SSRIs and also MAOs). Withdrawal of some medications may also cause insomnia such as severe rebound insomnia with benzodiazepine sleeping pills.

12. Cigarette smoking?

    Why: may cause insomnia especially at bedtime. The use of nicotine patches for smoking cessation may cause vivid dreams and disturbed sleep in some people.

13. Alcohol history?

    Why: excessive alcohol before bedtime may cause insomnia. Typically alcohol causes increased drowsiness and reduced time to fall to sleep but even moderate amounts of alcohol can increase awakenings after sleep onset by interfering with the ability of the brain to maintain sleep.

14. Caffeine intake?

    Why: including coffee, tea, cola, chocolate (especially before bedtime but even in the afternoon in some people) may cause insomnia. It causes an increased time to fall to sleep, more frequent arousals during sleep, and a reduction in total sleep time for up to 8-14 hours after caffeine ingestion.

15. Illicit drug use?

    Why: e.g. amphetamine and cocaine usage may cause insomnia.

Sometimes, other symptoms may be present and may help your doctor analyse your condition. These may include:

1. Night urination?

   Why: causes of night time urination such as cystitis, prostatitis, benign enlargement of the prostate, prostate cancer, diuretic usage and diabetes may effectively cause insomnia due to the practical need to urinate.

2. Pain or physical discomfort?

   Why: any disease that causes any discomfort may interfere with sleep such as chronic back pain, arthritis pain, peptic ulcer pain, angina chest pain, skin ulcer pain, ear ache, tooth ache, anal itch, leg cramps.

3. Shortness of breath at night?

   Why: any disease that causes shortness of breath especially at night may interfere with sleep such as congestive heart failure, asthma, emphysema.

4. Symptoms of hyperthyroidism?

   Why: e.g. loose bowel motions, intolerance to heat, sweating of hands, muscle weakness, increased appetite, weight loss, heart palpitations, emotional disturbance, sleep disturbance.

5. Symptoms of menopause?

   Why: e.g. hot flushes, night sweats, heart palpitations, lightheadedness, dry vaginal, dry skin, headaches, disturbed sleep due to night sweats and hot flushes.

6. Symptoms of depression?

   Why: e.g. depressed mood, crying spells, anhedonia (loss of interest or pleasure), increase or decrease in appetite (usually decreased), weight loss or gain, insomnia or increased sleeping, fatigue, loss of energy, feelings of worthlessness, feelings of excessive guilt, poor concentration, difficulty making decisions, low libido, thoughts of death or suicide attempt. The great majority of individuals who experience major depression will suffer form insomnia, usually early morning wakening (usually around 3am) with difficulty returning to sleep.

7. Symptoms of anxiety?

   Why: e.g. nervousness, shakiness, tremor, restlessness, irritability, insomnia, poor concentration, heart palpitations, racing heart, sweating, dizziness, diarrhea, lump in throat and frequency of urination. Difficulty with getting to sleep (both at the beginning of the night and following night time awakenings) is a common feature of generalized anxiety disorder, due to increased autonomic arousal and worry.

8. Symptoms of Manic-depression?

   Why: e.g. episodes of depression (often psychotic in intensity) and at other times episodes of psychotic excitement (mania or hypomania). Symptoms of psychotic excitement may include elevation of mood, increased activity, insomnia, decreased need for sleep, grandiose ideas, irritability, disinhibition (which affects social, sexual and financial behavior), rapid speech and racing thought, delusions (persecutory or grandiose) and sometimes hallucinations.

9. Symptoms of restless leg syndrome?

   Why: e.g. irresistible urge to move their legs when awake and inactive, especially when lying in bed just prior to sleep. This interferes with the ability to fall asleep. People experience a creeping, crawling sensation deep in their calves that is only relieved by movement, particularly walking.

10. Symptoms of obstructive sleep apnea?

    Why: e.g. loud snoring, disturbed nocturnal sleep, daytime sleepiness, unrefreshed sleep, restless sleep, morning headache, nocturnal choking, reduced libido.

11. Symptoms of narcolepsy?

    Why: e.g. excessive daytime sleepiness wit involuntary daytime sleep episodes, disturbed nocturnal sleep and cataplexy (sudden weakness or loss of muscle tome, often elicited by emotion).

12. Symptoms of Parkinson's disease?

    Why: e.g. coarse hand tremor most marked at rest, rigidity of limbs, slowness in initiating and executing movements and speech, expressionless mask-like face and dementia. Sufferers of Parkinson's disease frequently complain of difficulty getting to sleep and increased awake time during the night.

Pneumothorax

Pneumothorax

What is a pneumothorax?

A pneumothorax is a collection of free air in the chest outside the lung that causes the lung to collapse.

Types of pneumothorax

A spontaneous pneumothorax, also referred to as a primary pneumothorax, occurs in the absence of a traumatic injury to the chest or a known lung disease. A secondary (also termed complicated) pneumothorax occurs as a result of an underlying condition.

Causes

• Spontaneously (more commonly in tall slim young males and in Marfan syndrome)
• Following a penetrating chest wound
• Following barotrauma to the lungs^[2][3]

It may also be due to:

• Chronic lung pathologies including emphysema, asthma
• Acute infections
• Chronic infections, such as tuberculosis
• Lung damage caused by cystic fibrosis
• Lung Cancer
• Rare diseases that are unique to women such as Catamenial pneumothorax (due to endometriosis in the chest cavity) and lymphangioleiomyomatosis (LAM).

Symptoms

Almost everyone who has a collapsed lung has the following symptoms:

• Sharp chest pain, made worse by a deep breath or a cough
• Shortness of breath

A larger pneumothorax will cause more severe symptoms, including:

• Chest tightness
• Easy fatigue
• Rapid heart rate
• Bluish color of the skin caused by lack of oxygen

Note: Symptoms may begin during rest or sleep.

Other symptoms that can occur with a collapsed lung include:

• Nasal flaring
• Low blood pressure (hypotension)

Investigations

• Chest x-ray to tell whether there is air outside the lung
• Arterial blood gases

Treatment

A small pneumothorax may go away on its own. You may only need oxygen and rest. The health care provider may use a needle to pull the extra air out from around the lung so it can expand more fully. You may be allowed to go home if you live near the hospital.

If you have a large pneumothorax, a chest tube will be placed between the ribs into the space around the lungs to help drain the air and allows the lung to re-expand.

The chest tube can be left in place for several days. You must stay in the hospital while the chest tube is in place.

Some patients with a collapsed lung need extra oxygen, which helps the air around the lung be reabsorbed more quickly.

Lung surgery may be needed to treat your pneumothorax or to prevent future episodes. The area where the leak occurred may be repaired. Sometimes, a special chemical is placed into the area of the collapsed lung. This chemical causes a scar to form.

Expectations (prognosis)

If you have a collapsed lung, you are more likely to have another one in the future if you:

• Are tall and thin

• Continue to smoke

• Have had two collapsed lungs in the past

How well a person does after having a collapsed lung depends on what caused it.

Complications

• Another collapsed lung in the future

• Shock

Pleural effusion

What is a pleural effusion?

A pleural effusion is an excess accumulation of fluid in the pleural space around the lungs. The pleura are thin membranes that enclose the lungs and line the inside of the chest cavity. The 'pleural space' describes the small space between the inner and outer layers of pleura, which normally contains a small volume of lubricating pleural fluid to allow the lungs to expand without friction. This fluid is constantly being formed through leakage of fluid from nearby capillaries and then re-absorbed by the body's lymphatic system. With a pleural effusion, some imbalance between production and reabsorption of pleural fluid leads to excess fluid building up in the pleural space.

There are two major types of pleural effusion:

• Transudative effusions, where the excess pleural fluid is low in protein; and
• Exudative effusions, where the excess pleural fluid is high in protein

Types of fluids

Four types of fluids can accumulate in the pleural space:

• Serous fluid (hydrothorax)
• Blood ([haemothorax])
• Chyle (chylothorax)
• Pus (pyothorax or empyema)

Causes of Pleural Effusions

Anything that causes an imbalance between production and reabsorption of pleural fluid can lead to development of a pleural effusion. Transudative pleural effusions (those low in protein) usually form as a result of excess capillary fluid leakage into the pleural space. Common causes of transudative effusions include:

• Congestive heart failure;
• Nephrotic syndrome;
• Cirrhosis of the liver;
• Pulmonary embolism; and
• Hypothyroidism.

Exudative effusions, which are high in protein, are often more serious than transudative effusions. They are formed as a result of inflammation of the pleura, which might happen for example in lung disease. Common causes of exudative effusions include:

• Pneumonia;
• Lung cancer, or other cancers;
• Connective tissue diseases, including rheumatoid arthritis and systemic lupus erythematosus;
• Pulmonary embolism;
• Asbestosis;
• Tuberculosis; and
• Radiotherapy.

Clinical Diagniosis;

Physical findings are variable and depend on the volume of the pleural effusion. Generally, there are no physical findings for effusions smaller than 300 mL. With effusions larger than 300 mL, findings may include the following:

• Dullness to percussion
• Decreased tactile fremitus
• Asymmetric chest expansion, with diminished or delayed expansion on the side of the effusion: Dullness to percussion, decreased tactile fremitus, and asymmetric chest expansion are the most reliable physical findings of pleural effusion.
• Diminished or inaudible breath sounds
• Egophony ("e" to "a" changes) at the most superior aspect of the pleural effusion
• Pleural friction rub
• Other findings that provide clues to the etiology of the effusion include the following:
  • Peripheral edema, distended neck veins, and S ₃ gallop, suggestive of congestive heart failure
  • Edema may also be a manifestation of nephrotic syndrome; pericardial disease; or, combined with yellow nails, the yellow nail syndrome.
  • Cutaneous changes with ascites, suggestive of liver disease
  • Evidence of malignancy such as lymphadenopathy or palpable mass

Investigations

During a physical examination, the doctor will listen to the sound of your breathing with a stethoscope and may tap on your chest to listen for dullness.

The following tests may help to confirm a diagnosis:

• Chest x-ray
• Pleural fluid analysis (examining the fluid under a microscope to look for bacteria, amount of protein, and presence of cancerous cells)
• Thoracentesis (a sample of fluid is removed with a needle inserted between the ribs)
• Thoracic CT
• Ultrasound of the chest

Treatment

Treatment may be directed at removing the fluid, preventing it from accumulating again, or addressing the underlying cause of the fluid buildup.

Therapeutic thoracentesis may be done if the fluid collection is large and causing pressure, shortness of breath, or other breathing problems, such as low oxygen levels. Removing the fluid allows the lung to expand, making breathing easier. Treating the underlying cause of the effusion then becomes the goal.

For example, pleural effusions caused by congestive heart failure are treated with diuretics (water pills) and other medications that treat heart failure. Pleural effusions caused by infection are treated with appropriate antibiotics. In people with cancer or infections, the effusion is often treated by using a chest tube for several days to drain the fluid. Chemotherapy, radiation therapy, surgery, or instilling medication into the chest that prevents re-accumulation of fluid after drainage may be used in some cases.

Cutaneous Abnormalities

Cutaneous Abnormalities

Macule -

A small localized change in the color of skin that is neither raised (elevated) nor depressed. Macules are never large. They are basically little spots or blemishes in the skin. They are entirely flat and can only be appreciated by visual inspection; they cannot be seen from the side, just from above.

Papule

A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated) and may be associated with secondary features such as crusts or scales.

Nodule-

A small solid collection of tissue, a nodule is palpable (can be felt). It may range in size from greater than 1.0 cm (3/8 inch) to somewhat less than 2 cm (13/16 inch) in diameter. A nodule may be present in the epidermis, dermis or subcutis (at any level in the skin).

Vesicle:

A vesicle is a circumscribed, fluid-containing, epidermal elevation generally considered less than either 5or 10mm in diameter at the widest point.

Bulla :

A fluid-filled blister more than 5 mm (about 3/16 inch) in diameter with thin walls.

A bulla on the skin is a blister. A bulla on the pleura (the membrane covering the lung) is also called a bleb.

In Latin a bulla was a "bubble, stud or knob." It referred to any rounded protrusion, particularly one that was hollow or cystic.

Cyst:

A cyst is a growth containing liquid that appears inside your body or under your skin.

Pustule

pustule is a small collection of pus in the top layer of skin (epidermis) or beneath it in the dermis. Pustules frequently form in sweat glands or hair follicles. Pus is a mixture of inflammatory cells and liquid.

Scabies

What is scabies?

Human scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies.

Scabies occurs worldwide and affects people of all races and social classes. Scabies can spread rapidly under crowded conditions where close body contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks.

Transmission

Human scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The adult female scabies mites burrow into the upper layer of the skin (epidermis) where they live and deposit their eggs. The microscopic scabies mite almost always is passed by direct, prolonged, skin-to-skin contact with a person who already is infested. An infested person can spread scabies even if he or she has no symptoms. Humans are the source of infestation; animals do not spread human scabies.

Persons At Risk

Scabies can be passed easily by an infested person to his or her household members and sexual partners. Scabies in adults frequently is sexually acquired.

Scabies is a common condition found worldwide; it affects people of all races and social classes. Scabies can spread easily under crowded conditions where close body and skin contact is common. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks. Child care facilities also are a common site of scabies infestations.

Symptoms

When a person is infested with scabies mites the first time, symptoms usually do not appear for up to two months (2-6 weeks) after being infested; however, an infested person still can spread scabies during this time even though he/she does not have symptoms.

If a person has had scabies before, symptoms appear much sooner (1-4 days) after exposure. An infested person can transmit scabies, even if they do not have symptoms, until they are successfully treated and the mites and eggs are destroyed.

Common Symptoms

The most common symptoms of scabies, itching and a skin rash, are caused by sensitization (a type of “allergic” reaction) to the proteins and feces of the parasite. Severe itching (pruritus), especially at night, is the earliest and most common symptom of scabies. A pimple-like (papular) itchy (pruritic) “scabies rash” is also common. Itching and rash may affect much of the body or be limited to common sites such as:

• between the fingers,
• wrist,
• elbow,
• armpit,
• penis,
• nipple,
• waist,
• buttocks,
• shoulder blades.

The head, face, neck, palms, and soles often are involved in infants and very young children, but usually not adults and older children.

Tiny burrows sometimes are seen on the skin; these are caused by the female scabies mite tunneling just beneath the surface of the skin. These burrows appear as tiny raised and crooked (serpiginous) grayish-white or skin-colored lines on the skin surface. Because mites are often few in number (only 10-15 mites per person), these burrows may be difficult to find. They are found most often in the webbing between the fingers, in the skin folds on the wrist, elbow, or knee, and on the penis, breast, or shoulder blades.

Medications

• Sulphur has been used since around 25 AD to treat Scabies. You can find bar soap with sulfur in the ranges of 1%-10% to kill scabies, it's recommended you go with 6% or above. Wash whole body once daily for 4 days. It is still recommended that you wash all clothing and bedclothes in hot water and tumble dry on hot as with Permethrin. However, this treatment is largely ineffective.

Topical drugs

• Permethrin 5% is topical medication of choice. Toxicity may resemble allergic reactions. It is usually applied to the skin before bedtime and left on for about 8 to 14 hours, then showered off in the morning. Package directions or doctor's instructions should be followed, but one application is normally sufficient to cure an infection
• Eurax (USP Crotamiton) This is not a cure but helps to relieve itch (pruritis)
• Malathion: Applied for 24 hours; effective in killing both adults and eggs.
• Lindane lotion is approved in the U.S. for use as a second-line treatment where first-line medications like permethrin have either failed, are not well tolerated or otherwise contraindicated It is illegal in 17 other countries, and 33 more countries have restricted its use. Though rare, serious side effects have resulted from product misuse.The FDA has confirmed 3 deaths that all involved use of lindane not in accordance with the label, including excessive topical applications and oral ingestions.
• There is some evidence that a 10% sulfur ointment in petroleum jelly applied topically is effective. It is cheap and readily available over-the-counter. It also has the advantage of being able to be used in pregnant women and infants under two months of age.
• Neem oil is deemed very effective in the treatment of scabies although only preliminary scientific proof exists which still has to be corroborated, and is recommended for those who are sensitive to permethrin, a known insecticide which might be an irritant. Also, the scabies mite has yet to become resistant to neem, so in persistent cases neem has been shown to be very effective.
• Tea tree oil at 5% was only partially effective and does not seem to be a viable solution for treatment. In one study, it was more effective than commercial medications against the scabies mite in an in vitro situation.

Oral

A single dose of Ivermectin has been reported to reduce the load of scabies but another dose is required after 2 weeks for full eradication. In 1999, a small scale test comparing topically applied Lindane to orally administered Ivermectin found no statistically significant differences between the two treatments. As Ivermectin is easily administered (not requiring a rub down of the whole body like lindane or permethrin twice per treatment), compliance is much better. Ivermectin is used in eradication programs of many parasites of both human and animal. Side effects may include mild abdominal pain, nausea, vomiting, myalgia and/or arthralgia, which subside. The product is considered safe for use in children over five months of age.

Public health and prevention strategies

There is no vaccine available for scabies, nor are there any proven causative risk factors. Therefore, most strategies focus on preventing re-infection. All family and close contacts should be treated at the same time, even if asymptomatic. Cleaning of environment should occur simultaneously, as there is a risk of reinfection. Therefore it is recommended to wash and hot iron all material (such as clothes, bedding, and towels) that has been in contact with scabies infestation.

Cleaning the environment should include:

• Treatment of furniture and bedding.
• Vacuuming floors, carpets, and rugs.
• Disinfecting floor and bathroom surfaces by mopping.
• Cleaning the shower/bath tub after each use.
• Daily washing of recently worn clothes, towels and bedding in hot water, drying in a hot dryer and steam ironing.

Itchiness during treatment

Options to combat itchiness include antihistamines such as chlorpheniramine. Prescription: Hydroxyzine (Atarax).

Cholecystitis

Cholecystitis

Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct.

• Gallbladder inflammation usually results from a gallstone blocking the flow of bile.
• Typically, people have abdominal pain that lasts more than 6 hours, fever, and nausea.
• Ultrasonography can usually detect signs of gallbladder inflammation.
• The gallbladder is removed, often using a laparoscope.

Cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the gallbladder.

Cholecystitis is classified as acute or chronic.

Acute Cholecystitis: Acute cholecystitis begins suddenly, resulting in severe, steady pain in the upper abdomen. At least 95% of people with acute cholecystitis have gallstones. The inflammation almost always begins without infection, although infection may follow later. Inflammation may cause the gallbladder to fill with fluid and its walls to thicken.

Rarely, a form of acute cholecystitis without gallstones (acalculous cholecystitis) occurs. Acalculous cholecystitis is more serious than other types of cholecystitis. It tends to occur after the following:

• Major surgery
• Critical illnesses such as serious injuries, major burns, and bodywide infections (sepsis)
• Intravenous feedings for a long time
• Fasting for a prolonged time
• A deficiency in the immune system

It can occur in young children, perhaps developing from a viral or another infection.

Chronic Cholecystitis: Chronic cholecystitis is gallbladder inflammation that has lasted a long time. It almost always results from gallstones. It is characterized by repeated attacks of pain (biliary colic). In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually due to gallstones, and may become thick-walled, scarred, and small. The gallbladder usually contains sludge (microscopic particles of materials similar to those in gallstones), or gallstones that either block its opening into the cystic duct or reside in the cystic duct itself.

Symptoms of Cholecystitis

The list of signs and symptoms mentioned in various sources for Cholecystitis includes the 21 symptoms listed below:

• Upper right-side abdominal pain
• Biliary colic - spasmodic upper abdominal pain
• Biliary colic after a fatty meal
• Abdominal discomfort
• Pain under right shoulder blade
• Fever
• Nausea
• Vomiting
• Flatulence
• Jaundice
• Itching skin
• Pale stool
• Thickening of gallbladder
• Shrinking of gallbladder
• Gallbladder inflammation
• Back pain
• Indigestion
• Yellow skin
• Yellow membranes
• Yellow whites of the eyes

Diagnosis

Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:

• fever (usually low grade in uncomplicated cases)
• tender right upper quadrant +/- Murphy's sign

Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes.

Ultrasound can assist in the differential.

Differential diagnosis

Acute cholecystitis

• This should be suspected whenever there is acute right upper quadrant or epigastric pain.
  • Other possible causes include:
    • Perforated peptic ulcer
    • Acute peptic ulcer exacerbation
    • Amoebic liver abscess
    • Acute amoebic liver colitis
    • Acute pancreatitis
    • Acute intestinal obstruction
    • Renal colic
    • Acute retrocolic appendicitis

Chronic cholecystitis

• The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:
  • Peptic ulcer
  • Hiatus hernia
  • Colitis
  • Functional bowel syndrome

It is defined pathologically by the columnar epithelium has reached down the muscular layer.

Treatment

People with acute or chronic cholecystitis need to be hospitalized. They are not allowed to eat or drink and are given fluids and electrolytes intravenously. A doctor may pass a tube through the nose and into the stomach, so that suctioning can be used to keep the stomach empty and reduce fluid accumulating in the intestine if the intestine is not contracting normally. Usually, antibiotics are given intravenously, and pain relievers are given.

If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder is usually removed within 24 to 48 hours after symptoms start. If necessary, surgery can be delayed for 6 weeks or more while the attack subsides. Delay is often necessary for people with a disorder that makes surgery too risky (such as a heart, lung, or kidney disorder). If a complication such as an abscess, gangrene, or perforated gallbladder is suspected, immediate surgery is necessary.

In chronic cholecystitis, the gallbladder is usually removed after the acute episode subsides.

In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder.

Surgical removal of the gallbladder (cholecystectomy) is usually done using a flexible viewing tube called a laparoscope. After small incisions are made in the abdomen, the laparoscope and other tubes are inserted, and surgical tools are passed through the incisions and used to remove the gallbladder.

Systemic lupus erythematosus

Systemic lupus erythematosus

Systemic Lupus Erythematosus

Systemic lupus erythematosus is a chronic (persistent) disease that causes inflammation in various parts of the body. It is commonly just called SLE or 'lupus'. The severity of SLE ranges from mild to severe. There are two main forms of lupus. Discoid lupus only affects only the skin . The other form is systemic lupus erythematosus which involves the skin and joints and may involve internal organs such as the heart or kidney as well

Pathophysiology

SLE is an autoimmune disorder characterized by multisystem microvascular inflammation with the generation of autoantibodies. Although the specific cause of SLE is unknown, multiple factors are associated with the development of the disease, including genetic, racial, hormonal, and environmental factors.Many immune disturbances, both innate and acquired, occur in SLE, as illustrated in below.

In systemic lupus erythematosus (SLE), many genetic-susceptibility factors, environmental triggers, antigen-antibody responses, B-cell and T-cell interactions, and immune clearance processes interact to generate and perpetuate autoimmunity.

One proposed mechanism for the development of autoantibodies involves a defect in apoptosis that causes increased cell death and a disturbance in immune tolerance.The redistribution of cellular antigens during apoptosis leads to a cell-surface display of plasma and nuclear antigens in the form of nucleosomes. Thus, dysregulated (intolerant) lymphocytes begin targeting normally protected intracellular antigens.

Immune complexes form in the microvasculature, leading to complement activation and inflammation. Moreover, antibody-antigen complexes deposit on the basement membranes of skin and kidneys. In active SLE, this process has been confirmed based on the presence of complexes of nuclear antigens such as DNA, immunoglobulins, and complement proteins at these sites. Serum antinuclear antibodies (ANAs) are found in virtually all individuals with active SLE, and antibodies to native double-stranded DNA (dsDNA) are relatively specific for the diagnosis of SLE.

History

A detailed and accurate history is crucial to aid in diagnosing the type of AKI and in determining its subsequent treatment. A detailed history and a physical examination in combination with routine laboratory tests are useful in making a correct diagnosis .

• Distinguishing AKI from chronic renal failure is important, yet making the distinction can be difficult. A history of chronic symptoms — fatigue, weight loss, anorexia, nocturia, and pruritus — suggests chronic renal failure.
• Take note of the following findings during the physical examination:
  • Hypotension
  • Volume contraction
  • Congestive heart failure
  • Nephrotoxic drug ingestion
  • History of trauma or unaccustomed exertion
  • Blood loss or transfusions
  • Evidence of connective tissue disorders or autoimmune diseases
  • Exposure to toxic substances, such as ethyl alcohol or ethylene glycol
  • Exposure to mercury vapors, lead, cadmium, or other heavy metals, which can be encountered in welders and miners
• People with the following comorbid conditions are at a higher risk for developing AKI:
  • Hypertension
  • Congestive cardiac failure
  • Diabetes
  • Multiple myeloma
  • Chronic infection
  • Myeloproliferative disorder
• Urine output history can be useful. Oliguria generally favors AKI. Abrupt anuria suggests acute urinary obstruction, acute and severe glomerulonephritis, or embolic renal artery occlusion. A gradually diminishing urine output may indicate a urethral stricture or bladder outlet obstruction due to prostate enlargement.
• Because of a decrease in functioning nephrons, even a trivial nephrotoxic insult may cause AKI to be superimposed on chronic renal insufficiency.

Signs and symptoms

Common initial and chronic complaints include fever, malaise, joint pains, myalgias, fatigue, and temporary loss of cognitive abilities. Because they are so often seen with other diseases, these signs and symptoms are not part of the diagnostic criteria for SLE.


Dermatological manifestations

• Malar rash describes an erythematous rash over the cheeks and nasal bridge, with classic nasolabial fold sparing, as seen in the image below.
  

  

  The classic malar rash, also known as a butterfly rash, with distribution over the cheeks and nasal bridge. Note that the fixed erythema, sometimes with mild induration as seen here, characteristically spares the nasolabial folds.

• Photosensitive rash is often macular or diffusely erythematous in sun-exposed areas of the face, arms, or hands, as in the image below.
  
  

  

  Photosensitive systemic lupus erythematosus (SLE) rashes typically occur on the face or extremities, which are sun-exposed regions. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic.

Musculoskeletal manifestations
Joint symptoms, ranging from intermittent joint pains (arthralgias) to sudden inflammation of multiple joints (acute polyarthritis), occur in about 90% of people and may exist for years before other symptoms appear. In long-standing disease, marked joint deformity may occur (Jaccoud's arthropathy) but is rare. However, joint inflammation is generally intermittent and usually does not damage the joints.

Hematological manifestations
Anemia and iron deficiency may develop in up to 50% of cases. Low platelet and white blood cell counts may be due to the disease or a side-effect of pharmacological treatment. People with SLE may have an association with antiphospholipid antibody syndrome(a thrombotic disorder), wherein autoantibodies to phospholipids are present in their serum. Abnormalities associated with antiphospholipid antibody syndrome include a paradoxical prolonged PTT Partial thromboplastin time (which usually occurs in hemorrhagic disorders) and a positive test for antiphospholipid antibodies; the combination of such findings have earned the term lupus anticoagulant-positive. Another autoantibody finding in SLE is the anticardiolipin antibody, which can cause a false positive test for syphilis.

Renal manifestations
Hypertension or hematuria may signal nephritic SLE. Edema of periorbital or peripheral regions and anasarca are common physical findings related to nephrotic syndrome or volume overload with renal failure.

Pulmonary manifestations

Lung and pleura inflammation can cause pleuritis, pleural effusion, lupus pneumonitis, chronic diffuse interstitial lung disease, pulmonary hypertension, pulmonary emboli, pulmonary hemorrhage, and shrinking lung syndrome.

Lymph Node and Spleen Problems

Wide-spread enlargement of the lymph nodes is common, particularly among children, young adults, and blacks of all ages. Enlargement of the spleen (splenomegaly) occurs in about 10% of people. People may experience nausea, diarrhea, and vague abdominal discomfort. The occurrence of these symptoms may be the forewarning of a flare-up.

Nervous System Problems

Involvement of the brain (neuropsychiatric lupus) can cause headaches, mild impairment of thinking, personality changes, stroke, epilepsy, severe mental disorders (psychoses), or a condition in which a number of physical changes may occur in the brain, resulting in disorders such as dementia. The nerves in the body or spinal cord may also be damaged.

Kidney Problems

Kidney involvement may be minor and without symptoms or may be relentlessly progressive and fatal. The most common result of this impairment is protein in the urine that leads to swelling (edema) in the legs.

Blood Problems The numbers of red blood cells, white blood cells, and platelets may decrease. Platelets assist in blood clotting, so if these numbers decrease greatly, bleeding may occur. Also, and for other reasons, the blood may clot too easily, which accounts for many of the problems that can affect other organs (such as strokes and blood clots to the lungs or recurrent miscarriages).

Gastrointestinal Tract Problems

Impairment of blood supply to various parts of the gastrointestinal tract may result in abdominal pain, damage to the liver or pancreas (pancreatitis), or a blockage or tear (perforation) of the gastrointestinal tract.

Pregnancy Problems

Pregnant women have a higher-than-normal risk of miscarriage and stillbirth.

Diagnostic criteria

Some physicians make a diagnosis on the basis of the American College of Rheumatology (ACR) classification criteria. The criteria, however, were established mainly for use in scientific research including use in randomized controlled trials which require higher confidence levels, so some people with SLE may not pass the full criteria.

The American College of Rheumatology established eleven criteria in 1982, which were revised in 1997 as a classificatory instrument to operationalise the definition of SLE in clinical trials. They were not intended to be used to diagnose individuals and do not do well in that capacity. For the purpose of identifying patients for clinical studies, a person has SLE if any 4 out of 11 symptoms are present simultaneously or serially on two separate occasions.

1. Serositis: Pleuritis (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart); sensitivity = 56%; specificity = 86% (pleural is more sensitive; cardiac is more specific).
2. Oral ulcers (includes oral or nasopharyngeal ulcers).
3. Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion; sensitivity = 86%; specificity = 37%.
4. Photosensitivity (exposure to ultraviolet light causes skin rash, or other symptoms of SLE flareups); sensitivity = 43%; specificity = 96%.
5. Blood—hematologic disorder—hemolytic anemia (low red blood cell count) or leukopenia (white blood cell count<4000/µl), class="mw-redirect">lymphopenia (<1500/µl) sensitivity =" 59%;" specificity =" 89%.Hypocomplementemia is also seen, due to either consumption of C3 and C4 by immune complex-induced inflammation or to congenitally complement deficiency, which may predispose to SLE.
6. Renal disorder: More than 0.5g per day protein in urine or cellular casts seen in urine under a microscope; sensitivity = 51%; specificity = 94%.
7. Antinuclear antibody test positive; sensitivity = 99%; specificity = 49%.
8. Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody, and/or false positive serological test for syphilis; sensitivity = 85%; specificity = 93%.Presence of anti-ss DNA in 70% of cases (though also positive with rheumatic disease and healthy persons)^[45]).
9. Neurologic disorder: Seizures or psychosis; sensitivity = 20%; specificity = 98%.
10. Malar rash (rash on cheeks); sensitivity = 57%; specificity = 96%.^[44]
11. Discoid rash (red, scaly patches on skin that cause scarring); sensitivity = 18%; specificity = 99%.

The mnemonic to remember the 11 symptoms is 'SOAP BRAIN MD'.

Some people, especially those with antiphospholipid syndrome, may have SLE without four criteria, and also SLE may present with features other than those listed in the criteria.

Recursive partitioning has been used to identify more parsimonious criteria. This analysis presented two diagnostic classification trees:

1. Simplest classification tree: SLE is diagnosed if a person has an immunologic disorder (anti-DNA antibody, anti-Smith antibody, false positive syphilis test, or LE cells) or malar rash.
   • sensitivity = 92%
   • specificity = 92%
2. Full classification tree: Uses 6 criteria.
   • sensitivity = 97%
   • specificity = 95%

Other alternative criteria have been suggested.

Treatment

Treatment depends on which organs are affected and how active the inflammation of lupus is. The severity of the lupus is not necessarily the same as the activity of the inflammation. For example, organs may be permanently damaged and scarred from lupus that caused inflammation in the past. Such damage may be referred to as “severe,” even if the lupus is not active (that is, it is not causing any inflammation or any further damage at this time). The goal of treatment is to decrease the activity of lupus—that is, to decrease inflammation, which in turn should prevent damage.

If lupus is not very active (sometimes called mild lupus), treatment may not need to be intensive. Nonsteroidal anti-inflammatory drugs (NSAIDs—see Pain: Nonsteroidal Anti-Inflammatory Drugs) often can relieve joint pain. Hydroxychloroquine Some Trade Names
PLAQUENIL
, chloroquine Some Trade Names
ARALEN
, or quinacrine Some Trade Names
ATABRINE
, sometimes taken in combination, helps relieve joint and skin symptoms. Sunscreen lotions (with a sun protection factor of at least 30) should be used, especially by people who have skin rashes.

Very active lupus (sometimes called severe lupus) is treated immediately with a corticosteroid such as prednisone (see Joint Disorders: Corticosteroids: Uses and Side Effects. The dose and duration of treatment depend on which organs are affected. Sometimes an immunosuppressive drug such as azathioprine Some Trade Names
IMURAN
or cyclophosphamide Some Trade Names
LYOPHILIZED CYTOXAN
is given to suppress the body's autoimmune attack. Mycophenolate mofetil Some Trade Names
CELLCEPT
is an alternative immunosuppressive drug. The combination of a corticosteroid and an immunosuppressive drug is most often used for severe kidney disease or nervous system disease and for vasculitis.

Once the initial inflammation is controlled, a doctor determines the dose that most effectively suppresses inflammation over the long term. Usually, the dose of prednisone is gradually decreased when symptoms are controlled and laboratory test results show improvement. Relapses or flare-ups can occur during this process. For most people who have lupus, the dose of prednisone can eventually be decreased or occasionally discontinued.

Surgical procedures and pregnancy may be more complicated for people who have lupus, and they require close medical supervision. Miscarriages and flare-ups during pregnancy are common. Pregnancy should be avoided during a flare-up, and conception should be delayed until the disease seems likely to be inactive.

People who take corticosteroids should be tested periodically and, if necessary, treated for osteoporosis (thinning of the bones), which can occur with chronic corticosteroid use. People should be monitored closely by a doctor for coronary artery disease. Other risk factors for coronary artery disease (for example, high blood pressure and high cholesterol levels) should be controlled as well as possible.