A Family Doctor's Tale - SCARLET FEVER

DOC I HAVE SCARLET FEVER

Scarlet Fever is an acute febrile infectious disease of the upper respiratory tract caused by the erythrogenic toxin associated with the bacillus Group A Streptococcus(GAS).

Scarlet Fever is transmitted through the air through
1.droplets from the infected tonsillar or pharyngeal area of infected patients.
2.infected articles or food,
3.infected wounds or
4.infected umbilical stumps of neonates

It is highly infectious, being communicable from 24 hours before onset of symptoms to 2 to 3 weeks after onset of symptoms.

Asymptomatic carriers can also spread the disease.

Incubation period is 2 - 5 days.

The organism enters the blood from the throat and produce an erythrogenic toxin which causes  the symptoms of fever and rash.

The rash is the main symptom which gives rise to the scarlet appearance, hence the name Scarlet Fever.

The infections occur in persons of all ages but peak incidence is 5- 15 years. Males are affected equally as females.

Usually 1 attack will confer permanent immunity to the erythrogenic toxin of GAS streptococcus.

The Signs and Symptoms of Scarlet Fever are:

Symptoms start off with:
1. sudden onset of headache


2. high fever 39-40 degrees centigrades


3. chills and rigors


4. sore throat(infected tonsils)


5. vomiting


6. cervical lymphadenopathy

Subsequent symptoms follows:
1.punctate erythrematous rash appearing 12 to 24 hours later after the fever, starting from the neck and chest then spreads rapidly.

The face is not affected.


2.Facial flushing and pale area around the mouth


3.Dark red lines along skin creases (Pastia's lines)


4.Rash blanches when pressed


5.Tongue coated with white fur with occasional red papillae (white strawberry tongue) The white fur peels on the third day and becomes red by the fourth day (red strawberry tongue)

How to diagnose Scarlet Fever?
-------------------------------------------------------------
1.Symptoms of fever , rash and strawberry tongue


2.ESR raised very high sometimes > 80

3.moderate leucocytosis

4.Throat swab for culture ans sensitivity

The complications of Scarlet Fever are:
1.otitis media


2.rheumatic fever


3.glomerulonephritis


4.henoch-schonlein purpura

The Treatment of Scarlet Fever is:

Isolation in hospital may be needed.
1.Antibiotics (penicillin or amoxicillin) are used in the treatment of Scarlet Fever. Treatment is for at least 10 days.

Alternatives are cephalosporins such as cephelexin in penicillin sensitive patients

2.Paracetamol is given for fever and pain

3.Bed rest , fluids and general supportive care

The Prevention for Scarlet Fever is by:
Avoiding infected patients

Use a mask  in clouded places

General personal hygiene including washing hands after contact with possible contact with mucous discharge from nose, infected items or clothing and after meals


Recently in June 2011 there is an outbreak of  new cases of Scarlet Fever in Hong Kong.

Prognosis of Scarlet Fever is good.


In fact after the introduction of antibiotics, there is very few cases of Scarlet Fever.

Early therapy with antibiotics produce excellent recovery

In rare cases complications such as rheumatic fever and glomerulonephritis can occur

A Family Doctor's Tale - HYPOPARATHYROIDISM

DOC I HAVE HYPOPARATHYROIDISM

Hypoparathyroid disease is a condition when the parathyroid gland produces too little parathyroid hormones resulting in hypocalcemia.

Hypoparathyroid disease is caused by:
Primary
Primary Hypoparathyroid disease is a rare congenital condition which usually occurs in children below the age of sixteen but can persists throughout adult life

Secondary.
Secondary Hypoparathyroid disease is usually related to surgical resection of the thyroid during which partial to total removal of the parthyroid gland occurs.

As a result of better surgical techniques , less permanent loss of the parathyroid glands occurs during throidectomy.

Instead transient deficiency may occur due to injuries to the parathyroid glands during the surgery, temporary reduction of blood supply to the parathyroid gland and hemorrhage during the surgery.

Neither the administration of radfioactive iodine or radiation to the thyroid gland has been known to cause Secondary Hypoparathyroid disease.

Symptoms:
1.tetany from lowered blood calcium

Tetany which appeared in 70 per cent of cases appears as a carpopedal spasm where the stiff hollowed hand with rigid fingers is flexed at the second metacarpal-phalangeal joint, wrist and elbow joints and the legs and feet are extended.

2.epileptic fits and tonic convulsions occurs in 40 per cent of cases

3.laryngeal spasm of muscles (may be dangerous)

4.spasm of the smooth muscle of blood vessel causing numbness due to poor blood circulation

5.diarrhea due to spasm of the smooth muscles of the gastrintestinal tract

6.mental changes including anxiety, depression, psychoses

Signs:
1.neuromuscular excitabilty may show up as contraction of the facial muscles in response to a light tap on the facial nerve in front of the ear(Chvostek's sign)

2.Dorsal flexion and abduction of the foot may occur by a tapping the lateral surface of the fibula just below its heal(Peroneal sign)

3.Inflation of a blood pressure cuff above the systolic pressure may cause the hand the typical position seen in carpopedal spasm(Trousseau's sign)

4.Skin is dry rough and scaly with patchy or generalised erythema

5.Nails may be brittle with transverse ridges

Diagnosis:

1. blood test is done for presence of low  parathyroid hormone levels.

2. Blood calcium is low in hypoparathyroidism

3. Blood phosphate is high in primary

Treatment:
1.Hypocalcemia is treated with intravenous injections of calcium gluconate under cardiac monitoring as excess calcium may affect the heart

2.oral Calcium supplements(Calcium Chloride is the most effective) is given in most cases as a long term treatment usually with improvement of blood Calcium level

3.Large doses of Vitamin D may be necessary in some cases.

4.Treat underlying cause.

5.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
surgery of thyroid gland should be done carefully so as not to remove the parathyroid gland or damage it

A Family Doctor's Tale - HYPERPARATHYROIDISM

DOC I HAVE HYPERPARATHYROIDISM

A Family Doctor's Tale - HYPOCALCEMIA

DOC I HAVE HYPOCALCEMIA

Hypocalcemia is defined as low Calcium (less than 8.4 mg per liter) in the blood.

Normal blood Calcium varies from 8.4 to 10.4 mg per liter.

Calcium and phosphate are interrelated both regulated by the parathyroid hormones and Vitamin D which control the calcium and phosphate exchange between the blood and three important systems in the body:
1.skeletal
2.gastrointestinal
3.renal

Parathyroid hormones acts mainly on the bones and kidney to raise the blood calcium and increase the phosphate excretion.

Vitamin D increases the intestinal absorption of calcium and phosphate.

Hypocalcemia or low calcium level in the blood is caused by:
1.Hypoparathyroidism from surgical removal of parathyroid gland during thyroidectomy

2.Idiopathic hypoparathyroidism from genetic causes, sometimes unknown causes

3.Malabsorption of calcium, Vitamin D or phosphates from diet.

4.Hypoalbuminemia

5.Chronic renal failure

5.Osteomalacia -lack of mineralization of the bone matrix

6.Rickets - abnormal condition of the bones caused by low Vitamin D

7. Hyperventilation- calcium is bonded to the carbonate in the blood. If the carbon dioxide level in the blood is low, then less calcium is present because the carbonate in the blood is low.

Symptoms of hypocalcemia:
1.neuromuscular hyperexcitabilty resulting  in tetany(a cramp condition of the index finger )

2.convulsions

3.stridor -due to tightening of the muscle of vocal cord

4.smooth muscles tightening

5.diarrhea

Signs:
1.Trousseau's sign - Raising the blood pressure to 200 systolic using the blood pressure cuff on the upper arm can cause the typical sign of tetany or obstretician's finger in hypocalcemia


2.Chvostek's sign - tapping the seventh nerve on the same side of the jaw as the tetany sign can cause the finger to jerk confirming hypocalcemia


Diagnosis:
1.Plasma Calcium levels

2.Blood phosphate level

3.Total serum protein levels
low serum calcium in the presence of low albumin allows a higher free cacium concentration making the patient to be normocalcemic. (normal  blood cacium)

4.Bone density test

Treatment:
1.Intravenous calcium carbonate under cardiac monitoring as excessive calcium may affect the heart

2.oral Calcium supplements is given in most cases as a long term treatment usually with improvement of blood Calcium level

3.Large doses of Vitamin D may be necessary in some cases.

4.Treat underlying cause.

5.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate electrolyte replacement after exercise
also after vomiting and diarrhea

A Family Doctor's Tale - HYPERCALCEMIA

DOC I HAVE HYPERCALCEMIA

Hypercalcemia is defined as high calcium(above 10.4 md per liter) in the blood.

Normal blood Calcium varies from 8.4 to 10.4 mg per liter.

Calcium and phosphate are interrelated both regulated by the parathyroid hormones and Vitamin D which control the calcium and phosphate exchange between the blood and three important systems in the body:
1.skeletal
2.gastrointestinal
3.renal

Parathyroid hormones acts mainly on the bones and kidney to raise the blood calcium and increase the phosphate excretion.

Vitamin D increases the intestinal absorption of calcium and phosphate.

Hypercalcemia occurs with high calcium due to:
1.High parathyroid hormones due to parathyoid adenomas

2.Vitamin D excess

3.Various malignancies including myeloma and leukemia.

4.breast tumors and metastases

5.sarcoidosis

Symptoms of Hypercalcemia:
1.weakness

2.lethargy

3.intractable nausea and vomiting

4.dehydration

5.constipation

6.coma

7.cardiac arrthymia

8.calcification of joint or skin

Diagnosis:
1.Plasma calcium and phosphate levels

2.Blood sodium bicarbonate and gases

3.Blood albumin and proteins

4.Joint Xrays in cases of joint calcification

Complications:
1.Calcification of gouty trophi

2.renal stones

3.Cacific tendonitis

4.Myositis ossificans

5.chondrocalcinosis

6.phosphate arthropathy

Treatment:
Acute hypercalcemia is a medical emergency because of its effect on the heart rhythm.
1.Immediate treatment of intravenous isotonic saline and

2.a powerful diuretic such as frusemide to induce excess calcium to pass out through the urine

3.Phosphate intravenously or orally can also be effective to reduce the calcium from the blood although it may cause diarrhea

4.Corticosteroids are also effective in reducing calcium blood levels.

5.Treat underlying cause.

6.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate water replacement after exercise
also after vomiting and diarrhea

A Simple guide to Scarlet Fever

A Simple guide to Scarlet Fever
-----------------------------------------------

What is Scarlet Fever?
------------------------------------
Scarlet Fever is an acute febrile infectious disease of the upper respiratory tract caused by the erythrogenic toxin associated with the bacillus Group A Streptococcus(GAS).

How is Scarlet Fever transmitted?
-----------------------------------------------


Scarlet Fever is transmitted through the air through
1.droplets from the infected tonsillar or pharyngeal area of infected patients.
2.infected articles or food,
3.infected wounds or
4.infected umbilical stumps of neonates 

It is highly infectious, being communicable from 24 hours before onset of symptoms to 2 to 3 weeks after onset of symptoms.

Asymptomatic carriers can also spread the disease.

Incubation period is 2 - 5 days.

The organism enters the blood from the throat and produce an erythrogenic toxin which causes  the symptoms of fever and rash.

The rash is the main symptom which gives rise to the scarlet appearance, hence the name Scarlet Fever.

The infections occur in persons of all ages but peak incidence is 5- 15 years. Males are affected equally as females.

Usually 1 attack will confer permanent immunity to the erythrogenic toxin of GAS streptococcus.

What are the Signs and Symptoms of Scarlet Fever ?
------------------------------------------------------------------------

Symptoms start off with:
1. sudden onset of headache

2. high fever 39-40 degrees centigrade

3. chills and rigors

4. sore throat(infected tonsils)

5. vomiting

6. cervical lymphadenopathy

Subsequent symptoms follows:
1.punctate erythrematous rash appearing 12 to 24 hours later after the fever, starting from the neck and chest then spreads rapidly.
The face is not affected.

2.Facial flushing and pale area around the mouth

3.Dark red lines along skin creases (Pastia's lines)

4.Rash blanches when pressed

5.Tongue coated with white fur with occasional red papillae (white strawberry tongue) The white fur peels on the third day and becomes red by the fourth day (red strawberry tongue)

How to diagnose Scarlet Fever?
-------------------------------------------------------------
1.Symptoms of fever and rash
2.ESR raised very high somtimes > 80
3.moderate leucytosis
4.Throat swab for culture and sensitivity

What are the complications of Scarlet Fever?
----------------------------------------------------------------

1.otitis media

2.rheumatic fever

3.glomerulonephritis

4.henoch-schonlein purpura

What is the Treatment of Scarlet Fever?
------------------------------------------------------------

Isolation in hospital may be needed.
1.Antibiotics (penicillin or amoxicillin) are used in the treatment of Scarlet Fever. Treatment is for at least 10 days.
Alternatives are cephalosporins such as cephelexin in penicillin sensitive patients
2.Paracetamol is given for fever and pain
3.Bed rest , fluids and general supportive care

What is the Prevention for Scarlet Fever?
---------------------------------------------------

Avoiding infected patients
Recently there are new cases of Scarlet Fever in Hong Kong.

What is the Prognosis of Scarlet Fever?
-------------------------------------------------


In fact after the introduction of antibiotics, there is very few cases of Scarlet Fever.
Early therapy with antibiotics produce excellent recovery
In rare cases complications such as rheumatic fever and glomerulonephritis can occur

A Family Doctor's Tale - HYPERNATREMIA

DOC I HAVE HYPERNATREMIA

Hypernatremia is defined as high Sodium in the blood.

Normal blood Sodium varies from 136 to 145 mmol per liter.

Extracellular Sodium level represents only 2 per cent of the total body Sodium.

Sodium is a major determinent of intracellular volume of cells and intracellular osmolarity.

It is a also an important cofactor in many metabolic processes.

The resting membrane potential and excitable tissues like nerves is mainly determined by ratio of intracellular to extracellular Sodium concentrations.

Plasma and extracellular Sodium levels are influenced by many factors particularly acid based balance. Acidosis moves Sodium out of cells while alkalosis shifts Sodium into cells.

Hypernatremia occurs with high sodium due to:
1.dehydration from insufficient water intake or excess water loss

2.impaired renal function cause retention of sodium

3.cardiac disease can cause retention of salt

4.excess intake of salt

Symptoms of Hypernatremia:
1.edema

2.peripheral muscles tetany

Diagnosis:
1.Plasma Sodium levels

2.Blood sodium bicarbonate and gases

3.Urinary electrolytes

Treatment:
1.More intake of water may reduce concentration of sodium

2.diuretic to induce excess sodium to pass out through the urine

3.Infusion of sodium bicarbonate to induce alkalosis

4.Infusion of calcium bicarbonate to induce alkalosis

4.administer Sodium binding resins by mouth

5.Treat underlying cause.

6.Frequent monitoring of progress by blood studies

7.hemodialysis

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate water replacement after exercise
also after vomiting and diarrhea

A Family Doctor's Tale - HYPONATREMIA

DOC I HAVE HYPONATREMIA

Hyponatremia is defined as low Sodium in the blood.

Normal blood Sodium varies from 136 to 145 mmol per liter.

Extracellular Sodium level represents only 2 per cent of the total body Sodium.

Sodium is a major determinant of intracellular volume of cells and intracellular osmolarity.
It is a also an important cofactor in many metabolic processes.
The resting membrane potential and excitable tissues like nerves is mainly determined by ratio of intracellular to extracellular Sodium concentrations.

Plasma and extracellular Sodium levels are influenced by many factors particularly acid based balance. Acidosis moves Sodium out of cells while alkalosis shifts Sodium into cells.

Hyponatremia occurs with loss of salt through:
1.gastrointestinal -vomiting and diarrhea

2.urinary loss especially following use of Sodium wasting diuretics

3.sweating

4.fistula

5.diabetes mellitus.

Symptoms of hyponatremia:
1.lethargy

2.generalized fatigue

3.muscle weakness

4.reduced urination

Diagnosis:
1.Plasma Sodium levels

2.Blood sodium bicarbonate and gases

3.Urinary electrolytes

Treatment:
1.oral Sodium chloride (or salt) is given in most cases with improvement of blood Sodium level

2.Intravenous Sodium chloride dextrose solutionis given in emergency cases.

3.Bicarbonate or lactate infusion may help correct acid base disorders depending on underlying cause.

4.Treat underlying cause.

5.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate electrolyte replacement after exercise
also after vomiting and diarrhea