Transcript TSS

Brucellosis
Clinical features
*The incubation period of brucellosis is 1-3 weeks.The onset
is insidious , with malaise , headache, weakness, generalized
myalgia and night sweats.
*The fever pattern is classically undulant , although
continuous and intermittent patterns are also
seen.Lymphadenopathy, hepatosplenomegaly and spinal
tenderness sacro-iliitis(20-30%) may be present ;arthritis ,
osteomyelitis ,epididimo-orchitis (up to 40% ) ,
meningoencephalitis and endocarditis have all been described.
*Untreated brucellosis can give rise to chronic infection,
lasting a year or more.This is characterized by easy
fatiguability , myalgia , and occasional bouts of fever and
depression.
*Splenomegaly is usually present.Occasionally infection can
lead to localized brucellosis.Bones and joints , spleen
,endocardium , lungs , urinary tract and nervous system may
be involved.Systemic symptoms occur in less than one
third.
DIAGNOSIS
*Blood ( or bone marrow ) cultures are positive during the
acute phase of illness in 50% of patients ( higher in
B.meitensis ) , but prolonged culture is required .
*If using automated blood culture systems (BACTEC)
incubate longer than the usual5-7 days.This is less helpful in
chronic disease where serological tests of greater value.
*The brucella agglutination test , which demonstrates a
fourfold or greater rise in titre (>1 in 160 ) over a 4-weeks
period , is highly suggestive of brucellosis .
N.B…..non – agglutinating IgG and IgA molecules can block
the agglutinating reaction ( prozone phenomenon ) and the
test should be carried out to a high dilution to avoid this.
*An elevated serum IgG level is evidence of current or
recent ; a negative test excludes chronic brucellosis.
*In localized brucellosis antibody titres are low , and diagnosis
is usually established by culturing organisms from the
involved site.
*PCR for the detection of Brucella in blood gives a rapid
diagnosis ,and along with the measurement of IgG and IgM
antibodies by ELISA , are highly sensitive and specific
Management
*Brucellosis is treated with a combination of doxycycline
200mg daily and rifampicin 600_900 mg daily for 6
weeks, but relapses occur.
*Alternatively tetracycline can be combined with
streptomycin , which is usually given for only the first 2
weeks of treatment.
Prevention
*Prevention and control involve careful attention to hygiene
when handling infected animals.
, vaccination with the eradication of infection in animals , and
pasteurization of milk.
*No vaccine is available for use in humans.
Scarlet fever
Occurs when the infectious organism ( usually a
group A streptoccocus ) produces erythrogenic
toxin in an individual who does not posses
neutralizing antitoxin antibody
CLINICL FEATURES
*The incubation period of this relatively mild
disease, which mainly affects children , is 2-4
days following streptoccocal infection , usually
in the pharynx.
*Regional lymphadenopathy , fever,, rigors ,
headache and vomiting are present.
*The rash, which blanches on pressure, usually
appears on the second day of illness ; it
initially occurs on the neck but rapidly
becomes punctate, erythematous and
generalized.
*The rash is typically absent from the face , palms and
soles, and is prominent in the flexures .It usually
lasts about 5 days and is followed by extensive
desquamation of the skin.
*The face is flushed, with characteristic circumoral
pallor.Early in the disease the tongue has a with
coating through which prominent bright red papillae
can be seen (‘ strawberry tongue ‘) .Later the white
coating disappears, leaving a raw-looking , bright
red colour (‘raspaberry tongue ‘)
*The patient is ineffective for 10-21 days after the onset of
rash , unless treated with penicillin.
*Scarlet fever may be complicated by peritonsillar or
retropharyngeal abscesses and otitis media.
Diagnosis
The diagnosis is established by typical clinical
features and culture of a throat swab.Elevated
antistreptolysin O and anti-DNase B levels in
convalescent serum are indicative of
streptoccocal infection
Treatment
*Penicillin is the drug of choice and is given orally
as phenoxymethylpenicillin 500 mg four times
daily for 10 days .Individuals allergic to penicillin
can be treated effectively with erythromycin 250
mg four times daily for 10 days.
*Treatment is usually effective in preventing
rheumatic fever and acute glomerulonephritis,
which are non-suppurative complications of
streptococcal pharyngitis.Unlike acute rheumatic
fever,streptococcal nephritis may also complicate
streptococcal skin infection.
Staphylococcal toxic shock syndrome (TSS)
Serious and life-threatening disease associated
with infection by Staph. aureus which is
producing toxic shock syndrome toxin I (TSST
I).
*It is most commonly seen in young women
during , or immediately after , menustration
and is associated with the use of highly
absorbent intravaginal tampons.
*Staph. aureus has been shown to grow in and
around the tampon with the liberation of
TSSTI.TSS has also been described in both
sexes in any age group associated with toxinproducing staphylococcal infections.
*The toxin acts as a’ super-antigen’ , triggering
significant T- helper cell activation and very
high peripheral polymorphonuclear leucocyte
numbers.
*TSS has an abrupt onset with high fever ,
generalized systemic upset ( myalgia ,
headache , sore throat and vomiting), a
generalized erythematous blanching rash
resembling scarlet fever ,and hypotension.
*It rapidly progresses over a matter of hours to
multisystem involvement with cardiac , renal
and hepatic compromise , leading to death in
10-20%.Recovery is accompanied at 7-10 days
by desquamation.
Diagnosis
*Is clinical ( fever ,rash,hypotension plus
systemic upset in any person with distant
staphylococcal infection).
*It may be confirmed in menstrual cases by
vaginal examination , the finding of a retained
tampon and microbiological examination by
Gram stain demonstrating typical
staphylococci.Subsequent culture and
demonstration of toxin production are
confirmatory.
Management
*Immediate and aggressive fluid resuscitation
with an intravenous antistaphylococcal
antibiotics ( flucloxacillin or vancomycin) is
required.
*The rapid progression of symptoms and signs
may require intensive care .Women who
recover should be advised not to use tampons
for at least 1 year and should also be warned
that due to an inadequate antibody response to
TSSTI ,the condition can recur.
Streptococcal toxic shock syndrome
This is associated with severe group A
streptococcal skin infections producing
pyogenic exotoxin A.Initially , an influenza- like
illness occurs with , in 50% of cases, signs of
necrotizing fasciitis.A faint erythematous rash ,
mainly on the chest , rapidly progresses to a
toxic multisystem shock-like state.
*N.B…..without aggressive management , multiorgan failure will develop.
*Management includes fluid resuscitation ,linked
to parenteral antistreptococcal antibiotic
therapy , usually with benzylpenicillin with or
without clindamycin.