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I am writing this today because of the article in the Yahoo News article about Hospital deaths of 40 newborns shocking the country of Turkey:
http://news.yahoo.com/s/ap/20080927/ap_on_re_mi_ea/eu_turkey_baby_deaths;_ylt=A0wNcwnPMt5Igh4B3kWs0NUE/
7:22 AM 9/27/2008.
I am thinking of all I have ever learned in regard to preventing infections in any situation but particularly in infants. The article said the doctors thought the infections were transmitted by IV fluids, and that could be the case, of course.Those must be sterile fluids and the needle stick to insert the catheter to administer them must also be a sterile stick with 'cathlons' or large bore needles that are in sterile packages not reused items. Also, the fluids must not have cracked bottles if they are shipped that way or broken seals or if shipped in bags, then the bags must be checked for leaks. If there is moisture present, do not use that bag, since if there was a leak, a break in the integrity of the bag, then bacteria ['germ's] would get in and contaminate the fluids. Also, when the needle or cathlon or IV stick by any method is done it must be done after vigorous handwashing with scrub and soap on the person to do the IV stick. The area of the patient to be stuck, should be swabbed clean with a disinfectant solution that the patient is not allergic too, and strict sterility of the needle apparatus maintained. Also do not use cloudy IV solutions as they most likely are contaminated with large colonies of bacteria seen to the naked eye. I imagine that the nurses and doctors in Turkey know this info, but I learned as an Infection Control Nurse that some times what people know to do and what they actually do, are very different. You have to enforce infection control policies because they are often inconvenient [if contaminated item means a long walk to get another sterile one,] and often expensive too to replace,but less expensive than bacterial infection to the patient. Remember that.
Also, I really want to help them discover what caused those babies to die, so they could prevent any more deaths. One of the reference books I quote from often is old and I know that; but it is relevant especially in the basics. There is an article about how the use of forceps for a birth if not properly sterilized cause infection in the womb with Clostridium Perfringens, the most common form of gas gangrene. That book says that gas gangrene in the womb develops in cases of abortion, in prolonged labor and forceps delivery. Also that the genus Aerobacter and Escherichia may be present. It suggests to culture the os of the cervix to see if typical gram-positive bacilli are present, and that xrays may reveal the presence of gas in the tissues. Of course if these findings exist, antimicrobials and the least expensive is Penicillin, must be given every three hours.
Also, there is the possibility that the babies received via the placenta while in utero, drugs that were administered to the mother for pain or sedation, but harmful to the baby. That possibility has to be included because it is a huge risk to the baby, whatever drug is given to the mother if it crosses the placental barrier. Inhalational anesthesia is still preferred by some women if they consent at all to anesthesia and those are also drugs. The drugs must be analyzed to see if there was a common drug used in each case and then see the stock number, the manufacturer, the pull date [when it goes out of date] and the warnings about contraindications and adverse effects. Some drugs when out of date, become more potent, some less potent.
In pregnancy, there is an impaired drug metabolism by the mother. For instance when demerol [meperidine] or promezine are given more of the drug is excreted than metabolised, but IF the doses are repeated frequently to compensate for that, then possibly there could be a build-up of the drug in the baby, leading to respiratory arrest. Are the babies drugged and their deaths silent from respiratory arrest unwitnessed, as happens in SIDS? According to the book, "Modern Pharmacology"* the drugs that may cause problems during pregnancy are: anti-convulsants, benzodiazephines,catecholamines,doxycyclines,isotretinoin,lidocaine,mebendazole,metronidazole,metyrapone,ribavirin, sulfonamides,tetracyclines,valproic acid, vidarabine. Trimethadione is known to be teratogenic. And also anti-convulsants when suddenly withdrawn run the risk of inducing seizures in the laboring mother and that causes risk of anoxia to the baby in the womb. Also, it says anti-convulsants act as 'competitive inhibitors of Vitamin K-dependent clotting factors", leading to a 'serious,hemorrhagic disorder associated with high infant mortality [25-35%]. This risk could be overcome by administering orally Vitamin K during the 7-10 days before delivery is anticipated. Also it says Ketamine as anesthesia/analgesia, is often used in 'developing countries and under military conditions' and is particularly easy to anesthetize children and even more so, babies. The symptoms of Ketamine's adverse reactions are:
vomiting, screaming, agitation, increased lacrimation and salivation, shivering, skin rash. And if thyroid medications are also given,there is an interaction that causes hypertension and tachycardia. Also particularly important is that is causes intracranial pressure in children who suffered any kind of head injury, [forceps are applied to the head of the baby in the womb]; therefore it seems reasonable that Ketamine should not be used if forceps delivery is planned or anticipated. Also the warning that when Ketamine is used for analgesia or maintenance of pain relief the dose should be halved.
Benzodiazepine administration during pregnancy causes adverse effects on the fetus or newborn. Doxycycline is contraindicated in pregnancy.Isotretinoin for acne vulgaris is contraindicated in pregnancy and women should discontinue it altogether if planning to conceive, since it is known to be teratogenic particularly in the first trimester. It is known also by its trade name of Accutane.
Mebendazole given for treatment of parasites is contraindicated in pregancy because it is known to be teratogenic also, causing defects at the embryo level.
Metronidazole used for treatment of anaerobic bacteria and protozoa including trichomoniasis and giardisis, in high concentrations produced lung cancer in rats, and bacteria exposed to it, had a higher mutation rate suggesting a teratogenic effect in humans therefore should not be given to pregnant women or those planning to be pregnant.
Metyrapone given for causing a decrease in the production and release of cortisol in Cushing's disease [hypercortisolism], when given to pregnant women in the second or third trimester causes impaired bio-synthesis of cortisol in the unborn baby.
Ribavarin, given for the treatment of Lassa fever, influenza, and herpes simplex,and respiratory syncytial is teratogenic and should not be given in pregnancy.
Trimethoprim in combination with sulfamethoxazole increases the hematolic toxicity of sulfamethoxazole, and long-term use of Trimethoprim in folic acid deficient patients [pregnant women are often folic acid deficient] may result in megaloblastic anemia,thrombocytopenia, and granulocytopenia.Therefore increase the folic acid intake of pregnant women--always a good idea since lab studies at the University of Nebraska at Omaha showed that increasing folic acid prevents many birth defects, and also helps heal wounded hearts and kidneys in adults.
Tetracyclines should not be given in pregnancy since the hepatic,and nephrotic toxicity risk is too great, and it causes staining of the teeth of the unborn,and retards bone growth in the baby if given when pregnant in the fourth month of gestation.
Valproic Acid [(Depakene) used for epilepsy should not be given during pregnancy since it is a known teratogenic drug.
Vidarabine, used for DNA viruses of herpes simplex types 1and 2, cytomegalovirus,varicella zoster, and vaccinia virus, encephalitis caused by herpes simplex viruses,kerotoconjunctivitis caused by herpes simplex, should not be used in pregnant patients unless encephalitis is life-threatening. It is known to have oncogenic [cancer producing] and mutagenic [causing genes to mutate] properties.
Barbiturates including thipental when given to hypovolemic [think of dehydrated patients ] patients may cause cardiovascular depression when given as an IV bolus, particularly if there is any cardiac problems of patient or if there are hemodynamic changes of decreased contractility of the heart muscle, hypotension [fall in blood pressure] reduced myocardial blood flow and increased heart rate. Those patients cannot compensate for the hemodynamic shift and may have respiratory depression; and if so, the babies in the womb would also be affected. Did respiratory depression or any of these symptoms occur in the labor and deliveries of those babies who died in hospital in Turkey?
I am going to think on this some more and research some more to see if I could find more info that might help you folks in Turkey solve the mystery and prevent more deaths of neonates there. I am praying for you.
/s/ gloria poole, RN, Denver CO 80203
*footnote: Reference books are:
A Textbook of Medicine, by Cecil & Loeb, and
Modern Pharmacology, by Charles Craig and Robert Stitzel,fourth edition.
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I am posting a link to an article I read today because a quote from it caught my eye. I quote from it:"They are talking about pigs that are going to have mouse genes in them, and this is not going to be labeled?" said Jean Halloran,
director of food policy for Consumers Union. "We are close to speechless on this." Consumers Union publishes Consumer Reports magazine."[ end quote]
This quote is from this article about genetically modified animals:
http://news.yahoo.com/s/ap/20080918/ap_on_he_me/super_chicken;_ylt=AkGd7z55rxFCNPdg4qE9cjus0NUE
4:06 PM 9/18/2008/
Years ago I worked for a world reknown M.D. who was doing a study on high blood pressure at the Medical College of Georgia. I would hear him tell his patients not to eat pork, over and over again, so I asked him why he said that? He said he had not yet established why pork caused high blood pressure but that it did. I remembered that The Bible in Leviticus chapter eleven tells humans NOT to eat scavengers including that disgusting mouse as mentioned above,nor pork [swine], vultures, ravens, catfish, crayfish, camel, coney, hare, fish without scales or fins,eagle, ossifrage,ospray [osprey], owls,swans ,pelicans,gier eagle,stork, heron, lapwing, bats,and any fowl that creep going on all four, and anything that goes on his paws on all four paws at once [dogs] mice, weasels,tortoise,ferret,chameleon,lizard,snails,moles, flying and creeping bugs with four feet. Verses 32-47 of that chapter also tell you to not use for cooking any dish that those things touched until you had cleaned it and it air dried for several hours. These are practical matters because I am convinced that ingesting those scavengers by many groups has caused diseases to be rampant among them. Think about it. If an animal will eat anything even rotting human flesh, would that animal be safe for you to eat? NO! It is easy to see why GOD said not to eat them. I quit eating pork then and there that day the M.D. told me that because I recognized that advice was from GOD's Word.
Also GOD warned not to ever eat blood. It is written, 'it shall be a perpetual statute [law of GOD] for your generations throughout all your dwellings, that ye eat neither fat nor blood." Leviticus 3:17
The risk for genetically modified foods is as the quote points out, what is it modified with? Would you eat a dead rat under any circumstances? I would not! Because I know what GOD said about it. Therefore it makes no sense to eat part of a dead rat either, incorporated into the flesh of an animal that GOD said humans could eat. Don't be deceived by those who would sell their souls to the devil for a buck! Avoid genetically modified foods especially if you don't know how they are modified. GOD's wisdom is perfect whereas humans are imperfect. Trust GOD and do not try to outsmart GOD.
All entries to this site are written by Ms Gloria Poole,RN |
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Today's lesson is about Tuberculosis often abbreviated as TB. It is much in the news and has existed from antiquity and was once called "consumption" because it consumes the lungs with abscesses and holes if left untreated.
A brief history of the medical advances that have led to a greater understanding of that disease is: in 1882,Koch isolated the Tuberculosis causing bacillus. In 1890, Mafucci isolated the avian [bird] bacillus that produced TB in birds and occasionally in humans. In 1898, Theobald Smith isolated the bovine [cow] form of bacillus that produces TB in cows and could be transmitted to humans in some cases. In 1895, Roentgen discovered xrays that produced the anatomic discoveries of what TB does to lungs and bowels, that was indispensible information in the understanding of how TB progressed. In 1944, Waksman developed a TB-specific antibiotic that was very successful in treating TB.
Tuberculosis exists in these animals in certain conditions: some fish, amphibians, some fowls, some mammals, and reptiles. Animals in captivity fall prey to it more easily than animals in the wild.Among domesticated animals TB appears in swine, some cattle [cattle usually eat grains so if fed other than grains,there is a risk] and gallinaceous birds. [hens, turkeys, partridges]. For those residing in the US, the likelihood of getting TB from cattle is very rare, because of meat-packing standards.
In humans, there is no ethnic group that is immune naturally to Tuberculosis. The severity and morbidity of it varies greatly and seems to be related to factors such as closeness of living quarters, how often exposed to active TB bacillus, nutrition, [diets high in protein and vitamins are body-building and help prevent disease] and hygiene of the individuals and the environments. Tuberculosis is widely prevalent in many nations of the world still,and must be considered a risk if you travel to some countries. The nations where TB is widely prevalent are the Asian countries, Eastern Europe, Latin America, Alaskan Indians, Greenland, Newfoundland and Labrador,some African nations, and the Phillippines. Several million deaths annually are attributed to Tuberculosis. The group most likely to die from Tuberculosis is elderly men, though the very young are also susceptible.
In most cases [92%] if a person dies from TB,it is because of the pulmonary form of TB with non-pulmonary TB accounting for less than 10 % of the deaths.
In humans, the source of the tuberculosis bacilli is usually traced to another human who was actively infected or to a tuberculous animal. Milk contaminated with Tuberculosis is rare in the US because of pasteurization but in other nations, it is not as uncommon. Most of the time, human TB is caused by inhaling air contaminated [that is air breathed out by an person who has active TB] with the bacilli. Tuberculosis is air-borne and is transmitted if an actively diseased person breathes, coughs, sneezes, or spits, regardless of the level of hygiene available.
In cases, where very young children are in the household with an active case of Tuberculosis, their being inoculated [inhaling the active TB] is almost inevitable. That is why TB must be quaratined from the home to prevent the rest of the family from getting it. Also the urine and feces of a person infected carries the active Tuberculous bacilli, and must handled with special precautions. Also direct mouth to mouth transmission of the bacillus occurs, and occasionally a baby in the womb will contract active disease from a tuberculous placenta or amniotic fluid being aspirated into the lungs.
There are three known Tuberculosis bacilli: 1)mycobacterium tuberculosis var hominus [humans], 2) mycobacterium tuberculosis var bovis [cows], and 3) mycobacterium tuberculosis var avium [fowl]. Humans may be infected by any of these. Guinea pigs often used in so-called research labs are easily infected with any of these and transmit the disease also. Rabbits do also. The tuberculosis bacilli is a rod-shaped organism distinquished by its acid-fastness to staining in the medical lab. The TB bacillus grows slowly and aerobically [in the presence of air] on various culture mediums. There is no capsule to it. The TB bacillus is tenacious [tough to exterminate] and may survive many months in the dark, or even when refrigerated,but dies fairly quickly when exposed to bright sunlight and is killed by boiling in water for two minutes or pasteurization at 60 degrees centigrade.
Infection is common but deaths do not always occur. In fact, deaths are becoming less common with chemotherapy [drug treatments] and isolation, and quarantine. In other words, active tuberculosis is not automatically a death sentence though where you contract it, certainly makes a huge difference in your survival rate.
What is labeled the Koch phenomenon is that the first inoculation with active TB [the first time a human is exposed to active disease] causes a tissue reaction to tuberculin, or tissue hypersensitivity or allergy to it. The second inoculation of disease to the same person, [the second exposure to it] produces a more rapid, and intense response with a tendency to abscess formation, ulceration, extrusion of necrotic [dead] matter and then subsequent healing. The phagocytes in the blood mobilize to defeat the tuberculosis bacilli at the site of infection, and in certain conditions form an effective barrier against further invasion. If there is no more inoculation [no more exposure to active TB] then the person is not likely to contract the active disease. In humans that first tissue hypersensitivity could take 5 or 6 weeks to develop, and and may produce serious inflammatory reactions such as serous pleurisy. Acquired immunity may take up to a year to acquire and though the allergy to the tuberculous bacilli is not an indicator of immunity, it is believed to be a factor in developing immunity. Some groups such as the Jews, seem to have a higher natural immunity to tuberculosis than other groups. Black people seem to have a lower resistance to it than other groups.The cause for this is not known as yet,whether it is genetic or environmentally produced. Deaths from tuberculosis is about three times higher for black races than for white races, with no real explanation except possibly that many of the "black" or non-white races are in countries where crowded living conditions prevail and exposure is more likely to occur.
Generally, tuberculosis is more prevalent in childhood. Males are more likely to have it and that is thought to be due to their greater likelihood of seeking sex behaviours that expose them to the active disease more often. Other factors that may predispose to acquiring active Tuberculosis are pregnancy while being exposed to TB at the same time since pregnancy puts more demands on the circulatory system and requires that the mother increase her calorie intake and in some countries that is not as readily easy to do as in other countries. Also poor diets or starvation certainly reduce the natural immunity, and anxiety and aggravated stress also lowers the immunity. For centuries TB was prevalent among schizophrenics that are institutionalized and that is thought to be because of crowded conditions with air-borne TB in the air and decreased immunity from other drugs and isolation from family[ stress]and lack of hygiene by those not in a reality mode of thinking. Those type of institutions as well as acute care hospitals are learning that noso-comial infections must be tracked and treated at the institutional level and not allowed to breed/multiply unchecked.
Those populations with serious numbers of infections include Puerto Ricans, Alaskan Indians, certain African nations, Phillippines, and not as much in the Arabic nations. The Arabic people are generally very aware of meticulous hand-washing and cleaning of themselves. Certain occupations contribute to the likelihood of disease and those include exposure to silicous dust, [metal moulding, sandblasting, mining, stone-cutting, polishing stones, and manufacturing abrasive soaps]. Also trauma to the chest contributes by producing hemoptysis [blood being spilled into the chest cavity then coughed up] which creates an excellent culture medium for the bacilli to grow on. Bronchial dissemination of infection with TB, and pleural rupture with spreading of empyema [pus filled cavities] results in the case of trauma if the active disease was present and chest trauma occurred. That happens if the impact of the trauma was enough to break open lesions and spill the pus into the surrounding areas. Concurrent diabetes increases the risk of infection but hyperthyroidism does not. Hyperthyroidism seems to increase the native resistance to Tuberculosis bacilli, and that is not yet understood why.
Pulmonary TB is a likely development in a child born with congenital [acquired in the womb] pulmonic stenosis [the valve to the pulmonary artery becomes sort of stuck with strictures] . Patients with pneumococcal pneumonia are usually able to survive TB unless their fuctional lung reserve is almost depleted. Necrosing pnuemonia and/or abscess from it, may lead to a subsequent expansion of TB into other areas, and a lengthening treatment of medical interventions.
The way tuberculosis advances is that at first the cells infected aggregate at the site of infection. Then the vascular [blood supply] congests, [fills with more blood trying to bring phagocytes in increases to the area to fight it off] then fluid may accumulate in the cells. Neutrophilic leukocytes predominate there. Depending upon how fast the bacilli multiples at that site, [including how effective the body's own resistance and ability to fight off disease is] if the leukocytes continue to accumulate they will form an abscess, trying to seal off the infection. If the abscess liquifies and drains off, then the infection is probably contained. Caseation as it is called is a change in the early stages of inflammation. That word means a coagulative [produced from clotting blood] necrosis [the blood clot deadens surrounding tissue if infected] occurs. It looks sort of like a dry, consistency of cheese. That may remain for months, but eventually liquifies and will break its boundaries, draining to the outside if located on the skin's surface, and to the inside if inside the body. If that occurs in the lungs, the exudate [pus] will drain into the bronchi,and if in the renal [kidney TB] it will drain into the ureters that empty the urine to the outside. If is superficial and necrotic it will appear as an abscess, and probably will break and drain. If the abscess is in the vertebral column, it will likely form an abscess in the psoas sheath and appear in the groin and rupture there. Whereever it finds an outlet,the sloughing off of tissue and evacuation of that is accomplished. If this caseation occurs in the wall of a pulmonary vein it creates a channel for the Tuberculosis bacilli to enter the blood stream. That is not good. If that does not occur, after the abscess drains, there may be a residual defect in the form of a change to the previous structure. For instance if the abscess occurs in the middle ear, a perforated ear drum may be left in its place. If it occurs in the lung, a parenchymal cavity may be left there. If the abscess does not completely drain off the bacilli,then reinfection of tuberculosis is likely. Healing and repair are possible before caseation occurs. If caseation occurs, as it does in most lesions of any size and duration, then resolution of the surrounding non-necrotic [living tissue in other words] exudate may occur, but the areas with necrotic [dying tissues] will still harbor active TB. In certain conditions there would then develop a slow, fibrin accumulation that would cause drying of the membranes and shrinking of tissue. Eventually the lesion may be converted into a fibrocaseous mass, or a wholly encapsulated mess,extending beyond the center of the lesion. Then in time it accumulates mineral salts particularly calcium phosphate leading to a "chalky" phase leading to complete calcification of the lesion or ossification. By this time the contained bacilli frequently die. If however, they do not, then reinfection may occur. It is possible for one lesion to heal while another one could become deadly. Ulcers and cavities [holes] in the lungs result. Mucous membranes may grow back when effectively treated, but destroyed alveoli do not grow back. Large cavities seldom heal completely by natural processes. Healing usually takes months if not years. In many cases, there is no real healing only arresting the disease so that more damage to the lungs does not occur.
Chemotherapy [treatment with prescribed medicines] may halt or slow the development of the disease. but the essential processes of resolution of abscesses and fibrous repair of the tissue by the body, are not otherwise altered.
The Tuberculosis bacilli are spread by the lymph nodes from the primary site of infection and also by the blood stream if it advances to that stage, and via intracanicular canals, [the gastrointestinal tract, respiratory bronchi, lymph system, circulatory system.] Remember that the heart is a pump and will also pump infected blood throughout the body so it is important to treat TB early on. Tuberculosis bacilli have been isolated from bone, eyes, kidneys, skin, lungs,prostate gland in men and their epididymis,joints of bones, etc. The term 'bronchial dissemination' means that the active TB bacilli was inhaled into previously healthy alveoli of one or both lungs from an infected person or animal.
Large and abrupt disseminations of TB such as occur during hemorrage from an infected cavity, may produce confluent tuberculous lobular or lobar pneumonia, but the more common pattern is several smaller secondary lesions forming. [reactivation and spreading of it]. The bronchi, trachea, and larynx are common sites of infection; and also the middle ear which transmits the bacilli via the eustachian tube instead of the blood supply, and the tongue and lip through the mucuous membranes, usually if abrasions are present. If pus is coughed up from the lungs and then swallowed, Tuberculosis will take root in the gastrointestinal tract.Rectal crypts and ischiorectal abscesses usually form in the lower bowel in that case.This fact is also the reason why homosexual men are more likely to contract Tuberculosis than heterosexual men.
The lung is the primary site in 90% or more of cases of Tuberculosis. The primary site is called the 'Ghon'. Menigitis is a usual complication and also generalized miliary tuberculosis if TB is contracted in early childhood.
Testing for Tuberculosis is diagnostic some of the time, but it is possible to have false negatives. The test does not measure immunity nor does it indicate the severity of disease, if disease is present. A positive reaction may not occur when it should if these conditions exist: 1) if it has been less than 5 or 6 weeks since the inoculation with active TB bacilli occurred, 2) if TB was present but healed, 3)if TB is in terminal stages, 4)if sarcoidosis is also present, 5)if the dose of TB test is inadequate, 6) if person to be tested was recently given cortisone or corticotropin.
If these conditions exist and the signs and symptoms of TB exist, then sputum [produced from the lungs by deep coughing up, not saliva] must be tested, and in some cases, a surgical biopsy may be indicated to rule out other lung diseases. Tuberculosis may mimic fungus infections of the lungs, sarcoidosis,and beryllium granulomatosis.However the presence of caseation is usually believed to be positive proof of TB. Aspiration of abscesses and cavities may not be a good idea as it could spread the infection through the tissues when the aspirating needle is pulled back out. If pus is present in the sputum, aspiration would be a bad idea. In that case, a surgical incision to remove specimens is probably the better method.
Lab testing indicates that the polymorphonuclear leukocytes will rise to 12,000 to 18,000 per cu mm; and the sed rate will be elevated in almost all febrile [with fever] cases. An elevated sed rate is not specific to TB however and is not diagnostic of TB by itself. The gamma globulin factor will also rise and the albumin decreases in active disease. There may also be an increase in the alpha fractions of proteins, and also in the protein-bound carbohydrates, and in the C-reactive proteins. In later stages of TB, there is a lowering of circulating blood volume, and content of mineral salts, enzymes and vitamins in the body,and bacteremia [infected blood ] may also occur. Other signs and symptoms of active Tuberculosis are weight loss without dieting, malaise [generalized feeling of not being well] and fever. The disproportion of active disease to symptoms [meaning that a person could be very sick with TB before symptoms occur] is almost unique to TB and often gives a clue to the presence of disease.
Chemotherapy is always indicated, with different drugs. Streptomycin is often successful as well as combination of that with isoniazid, and other newer drugs if those prove ineffective. Also quarantine of the infected person is essential to containing the disease and eradicating it. Streptomycin is usually given by injection. Any drug produces a chemical change in your body.If you are allergic to it, or chemically susceptible to small doses of any drug or chemical there are risks to treatment. However the benefits of eradicating TB often outweigh the risks. Streptomycin is known to be damaging to the vestibule in the middle ear, in some people, and there is a risk of permanent damage to the auditory nerve leading to deafness in the affected ear. Other drugs used to treat it are Para-aminosalicyclic acid [PAS or Rezipas] is more tolerable by some patients. Cycloserine is another drug used to treat TB. Also there is often a combined approach to multiple drugs being prescribed.
This is not a comprehensive lesson in Tuberculosis but hopefully gives you enough info that if you are having any of these symptoms you should see a Medical Doctor immediately.
I referred to the textbook, A Textbook of Medicine, by Cecil & Loeb for this information.
This entry and all so far, was added here by Ms Gloria Poole, RN licensed in Colorado and previously licensed in GA and the UK also.
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Meningitis, or inflammation or infection of the meninges of the brain occurs after becoming contaminated with bacteria, viruses, spirochetes, parasites or fungi. The meninges is the thin covering of the brain. The clinical features depend somewhat on where the infection is located, whether in the basal or cortical area of the brain. Infection may also be in the spinal cord which is part of the central nervous system.
The most common microorganisms [think germs for layman's word] are tubercle bacillus [the one that causes tuberculosis], meningococcus, the influenza bacillus, the pnemococcus [causing pneumonia], the hemolytic streptococcus, and the staphylococcus. Others that also infect the meninges are: nonhemolytic streptococcus, including enterococci, the colon bacillus, and the pyocyaneus bacillus, which commonly infects after a spinal or lumbar puncture and spinal anesthesia; and Friedlander's bacillus, Aerobacter aerogenes, proteus vulgaris, salmonellae, Alcaligenes [aecalis, Pasteurella tularensis,] the gonococcus [that causes gonorrhea], the Brucella melitensis and the Bacillus antracis which causes anthrax, are occasional causes of meningitis also. The spirochetes that cause meningitis are Treponema pallidum, that causes syphilis. It is a thin actively motile [moving about] spiral organism. Spirochetes must have a liquid environment to survive and multiply and cause infection, therefore the genitals during coitus are likely to allow transmission of bacteria and produce infection if one of the partners in the sex act is infected with T.Pallidum. The other spirochete that causes meningitis is Leptospira icterohemorrhagica come from rats,mice dogs, cats,cattle and swine and is transmitted when a human comes into contact with an infected animal's urine, or by swimming in infected waters. The fungi that cause meningitis are the mycoses Torula histolytica, that is the agent that causes blastomycosis, and has been isolated from contaminated fruit juices, milk from cows if they have infected teats, and pigeon manure [from handling pigeons].
In the case of meningitis from any causative infection it is essential to determine what organism [germ, bacteria, spirochete, parasite, fungus, or virus] caused it, because the treatment is critical and the treatment is different depending on what the cause was. The viruses that causes meningitis usually also cause encephalitis or myelitis simultaneously. Encephalitis is the infection of the central nervous system [spinal cord, fluid, and brain] and may occur after a vaccination for viral diseases such as smallpox,measles, German measles,varicella,mumps, influenza [flu] or rabies. Also mumps virus, the virus of acute lymphocytic choriomeningitis,and the poliomyelities virus all may cause meningitis, and they must be ruled out in determining a cause of the meningitis.
Of the parasites that cause meningitis Trichinella spiralis and trypanosomes are the most prevalent cause. Trichinella spiralis is the larvae of the roundworm 'trichinella spiralis' that is transmitted by inadequately cooked pork and is one of the greatest uncontrolled problems of the public health.
Meningitis may also occur after an ear infection of the middle ear, or mastoid process but it is not as common as in previous decades because pediatricians treat those quickly generally.
The meninges of the brain becomes infected through the blood stream of blood circulating through the brain, or through direct contact with one of the germs or viruses, or spirochetes or parasites or funguses. The causative agent is transmitted through the middle ear if that is where the original infection began or through the lip,nose, or eyelids, or through lumbar puncture, or spinal anesthesia, or surgery on the face, brain or nose, laminectomy, repair of spina bifida or brain tumors or meningoele. The orginal spot where the infection began must be determined and treated and drained if an abscess there, and then the blood treated for infection.
Meningitis may also be caused by the person's own body seeding the bacteria elsewhere, and the causative agent could begin in the lungs, or endocardium. Not all people who have those bacteria [mentioned previously] present will develop meningitis however. Chronic meningitis coudl occur as reinfestation from the nasal cavity.
Meningitis may occur alone or with thrombophlebitis [a clot forming] of the one of the intracranial sinuses, an extradural or subdural abscess, or a brain abscess. The ear and mastoid are the most common cause of pyogenic meningitis and the paranasal sinus is the second most common cause of that particular type of meningitis. Meningitis that occurs from the sinuses most frequently is from the frontal sinuses, then the sphenoid and ethmoid cells, then rarely the maxillary sinus. Meningitis may occur as a complication of surgery on the sinuses or from head injury.
It is imperative to culture the blood of any patient suspected of meningitis before treatment begins to find out what is causing it. It is probably also necessary to xray the head and ears and mastoids as well. Diagnosis depends on the history given by the patient, the signs and symptoms of infection and clinical tests, including testing the cerebrospinal fluid [the fluid surrounding the spinal cord and brain].
These events that a patient relates to you should be considered significant to point to the possibility of meningitis:
1) if there was a recent infection of nose, throat or sinuses,
2) recent surgery in those areas;
3) head trauma,
4) recent lumbar puncture and/or spinal anesthesia; [because a needle is introduced into tthe spinal sac]
5) history of contact with infected person
6) previous or active signs of pulmonary infection
7)herpes
8)hemorragic skin eruptions.
The signs and symptoms of meningitis are:
fever, headache, prostration [not being able to get up], pain in the back, or neck, nausea and vomiting, and may also be associated with stupor, coma or convulsions, and if so, then meningitis must be suspected. The localized signs are increased intracranial pressure [measured by MD or staff] and spasm of the neck muscles causing stiff neck and spasm of the erector spinae muscle of the back with opisthotonus, and spasm of the hamstring muscle causing a positive Kernig's sign. Also, if menigococcus is the cause, then sepsis and rash will occur. In all meningitis the common symptoms are pain in the neck and back when the head if flexed forward on the chest, hyperesthesia, hyperirratability and exaggerated reflexes. Inequality of reflexive movement is not unusual. If the cranial nerves are infected, there may also be strabismus and deafness. If the intracranial pressure is increased, there will be nausea and vomiting, dilated or irregular pupils of the eye, engorgement of the veins of fundi of the eye,choking of the disk, irregular slow pulse and moderately elevated blood pressure. In severe cases, Cheyne-stokes breathing will be present. Fever may not be consistent. If not treated, restlessness, irritability, may be succeeded by delirium, generalized convulsions, deep depression, and somnolence, [sleepiness] followed by stupor [near unconscious state] and then coma. In infants the first signs may be refusal of feedings, vomiting or regurgitation, diarrhea, irritability, and fever, and may also present convulsions and bulging of the fontanelles, which is very indicative of meningitis. Death is a common result of untreated meningitis, and also chronic meningitis for those who did not die, and delayed death from other complications and sequalae of disease.
The treatment of meningitis depends on what caused it. Sulfonamides [sulfadiazine] are the preferred drug for meningococcal meningitis.Penicillin may also help but is not as effective as sulfonamides but may be preferred if allergic to sulfonamide drugs. Streptomycin is the correct drug for tuberculous meningitis.For pneumococcal, hemolytic streptococcal, and stapylococcal meningitis, both Penicillin and sulfadiazine are given. In the gram negative bacterias, of hemophilus influenza, pseudomonas aeruginosa, and Klebsiella pneumonia, streptomycin is preferred drug. Other drugs including chloramphenicol, polymyxin,and newer generations of drugs may be used. It is important to pay attention to the nutrition of the patient because typically they lose a great deal of weight.
Of course, the patient needs to be hospitalized. Bacterial meningitis in an infant less than two years old is more serious than at any other time of life, and must be treated immediately, regardless of what caused it. It is life-threatening quickly in other words. It is also life-threatening in adults but usually there is more time to intervene in adults before death occurs.
This "lesson" is to help you gain some understanding of what causes meningitis and what to look for and what to be alarmed about, and what to do. If you see any of these symptoms in others or yourself, get them or yourself to a Medical doctor immediately, or to the most educated health care licensed person available to you. This is not a comprehensive lesson on meningitis but sort of hits the highlights of a very serious disease.
I referred to "A Textbook of Medicine" by Cecil and Loeb for this lesson.
signed Ms Gloria Poole, RN, licensed in Colorado with active and current license. |
No courses in this category
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I am writing this today because of the article in the Yahoo News article about Hospital deaths of 40 newborns shocking the country of Turkey:
http://news.yahoo.com/s/ap/20080927/ap_on_re_mi_ea/eu_turkey_baby_deaths;_ylt=A0wNcwnPMt5Igh4B3kWs0NUE/
7:22 AM 9/27/2008.
I am thinking of all I have ever learned in regard to preventing infections in any situation but particularly in infants. The article said the doctors thought the infections were transmitted by IV fluids, and that could be the case, of course.Those must be sterile fluids and the needle stick to insert the catheter to administer them must also be a sterile stick with 'cathlons' or large bore needles that are in sterile packages not reused items. Also, the fluids must not have cracked bottles if they are shipped that way or broken seals or if shipped in bags, then the bags must be checked for leaks. If there is moisture present, do not use that bag, since if there was a leak, a break in the integrity of the bag, then bacteria ['germ's] would get in and contaminate the fluids. Also, when the needle or cathlon or IV stick by any method is done it must be done after vigorous handwashing with scrub and soap on the person to do the IV stick. The area of the patient to be stuck, should be swabbed clean with a disinfectant solution that the patient is not allergic too, and strict sterility of the needle apparatus maintained. Also do not use cloudy IV solutions as they most likely are contaminated with large colonies of bacteria seen to the naked eye. I imagine that the nurses and doctors in Turkey know this info, but I learned as an Infection Control Nurse that some times what people know to do and what they actually do, are very different. You have to enforce infection control policies because they are often inconvenient [if contaminated item means a long walk to get another sterile one,] and often expensive too to replace,but less expensive than bacterial infection to the patient. Remember that.
Also, I really want to help them discover what caused those babies to die, so they could prevent any more deaths. One of the reference books I quote from often is old and I know that; but it is relevant especially in the basics. There is an article about how the use of forceps for a birth if not properly sterilized cause infection in the womb with Clostridium Perfringens, the most common form of gas gangrene. That book says that gas gangrene in the womb develops in cases of abortion, in prolonged labor and forceps delivery. Also that the genus Aerobacter and Escherichia may be present. It suggests to culture the os of the cervix to see if typical gram-positive bacilli are present, and that xrays may reveal the presence of gas in the tissues. Of course if these findings exist, antimicrobials and the least expensive is Penicillin, must be given every three hours.
Also, there is the possibility that the babies received via the placenta while in utero, drugs that were administered to the mother for pain or sedation, but harmful to the baby. That possibility has to be included because it is a huge risk to the baby, whatever drug is given to the mother if it crosses the placental barrier. Inhalational anesthesia is still preferred by some women if they consent at all to anesthesia and those are also drugs. The drugs must be analyzed to see if there was a common drug used in each case and then see the stock number, the manufacturer, the pull date [when it goes out of date] and the warnings about contraindications and adverse effects. Some drugs when out of date, become more potent, some less potent.
In pregnancy, there is an impaired drug metabolism by the mother. For instance when demerol [meperidine] or promezine are given more of the drug is excreted than metabolised, but IF the doses are repeated frequently to compensate for that, then possibly there could be a build-up of the drug in the baby, leading to respiratory arrest. Are the babies drugged and their deaths silent from respiratory arrest unwitnessed, as happens in SIDS? According to the book, "Modern Pharmacology"* the drugs that may cause problems during pregnancy are: anti-convulsants, benzodiazephines,catecholamines,doxycyclines,isotretinoin,lidocaine,mebendazole,metronidazole,metyrapone,ribavirin, sulfonamides,tetracyclines,valproic acid, vidarabine. Trimethadione is known to be teratogenic. And also anti-convulsants when suddenly withdrawn run the risk of inducing seizures in the laboring mother and that causes risk of anoxia to the baby in the womb. Also, it says anti-convulsants act as 'competitive inhibitors of Vitamin K-dependent clotting factors", leading to a 'serious,hemorrhagic disorder associated with high infant mortality [25-35%]. This risk could be overcome by administering orally Vitamin K during the 7-10 days before delivery is anticipated. Also it says Ketamine as anesthesia/analgesia, is often used in 'developing countries and under military conditions' and is particularly easy to anesthetize children and even more so, babies. The symptoms of Ketamine's adverse reactions are:
vomiting, screaming, agitation, increased lacrimation and salivation, shivering, skin rash. And if thyroid medications are also given,there is an interaction that causes hypertension and tachycardia. Also particularly important is that is causes intracranial pressure in children who suffered any kind of head injury, [forceps are applied to the head of the baby in the womb]; therefore it seems reasonable that Ketamine should not be used if forceps delivery is planned or anticipated. Also the warning that when Ketamine is used for analgesia or maintenance of pain relief the dose should be halved.
Benzodiazepine administration during pregnancy causes adverse effects on the fetus or newborn. Doxycycline is contraindicated in pregnancy.Isotretinoin for acne vulgaris is contraindicated in pregnancy and women should discontinue it altogether if planning to conceive, since it is known to be teratogenic particularly in the first trimester. It is known also by its trade name of Accutane.
Mebendazole given for treatment of parasites is contraindicated in pregancy because it is known to be teratogenic also, causing defects at the embryo level.
Metronidazole used for treatment of anaerobic bacteria and protozoa including trichomoniasis and giardisis, in high concentrations produced lung cancer in rats, and bacteria exposed to it, had a higher mutation rate suggesting a teratogenic effect in humans therefore should not be given to pregnant women or those planning to be pregnant.
Metyrapone given for causing a decrease in the production and release of cortisol in Cushing's disease [hypercortisolism], when given to pregnant women in the second or third trimester causes impaired bio-synthesis of cortisol in the unborn baby.
Ribavarin, given for the treatment of Lassa fever, influenza, and herpes simplex,and respiratory syncytial is teratogenic and should not be given in pregnancy.
Trimethoprim in combination with sulfamethoxazole increases the hematolic toxicity of sulfamethoxazole, and long-term use of Trimethoprim in folic acid deficient patients [pregnant women are often folic acid deficient] may result in megaloblastic anemia,thrombocytopenia, and granulocytopenia.Therefore increase the folic acid intake of pregnant women--always a good idea since lab studies at the University of Nebraska at Omaha showed that increasing folic acid prevents many birth defects, and also helps heal wounded hearts and kidneys in adults.
Tetracyclines should not be given in pregnancy since the hepatic,and nephrotic toxicity risk is too great, and it causes staining of the teeth of the unborn,and retards bone growth in the baby if given when pregnant in the fourth month of gestation.
Valproic Acid [(Depakene) used for epilepsy should not be given during pregnancy since it is a known teratogenic drug.
Vidarabine, used for DNA viruses of herpes simplex types 1and 2, cytomegalovirus,varicella zoster, and vaccinia virus, encephalitis caused by herpes simplex viruses,kerotoconjunctivitis caused by herpes simplex, should not be used in pregnant patients unless encephalitis is life-threatening. It is known to have oncogenic [cancer producing] and mutagenic [causing genes to mutate] properties.
Barbiturates including thipental when given to hypovolemic [think of dehydrated patients ] patients may cause cardiovascular depression when given as an IV bolus, particularly if there is any cardiac problems of patient or if there are hemodynamic changes of decreased contractility of the heart muscle, hypotension [fall in blood pressure] reduced myocardial blood flow and increased heart rate. Those patients cannot compensate for the hemodynamic shift and may have respiratory depression; and if so, the babies in the womb would also be affected. Did respiratory depression or any of these symptoms occur in the labor and deliveries of those babies who died in hospital in Turkey?
I am going to think on this some more and research some more to see if I could find more info that might help you folks in Turkey solve the mystery and prevent more deaths of neonates there. I am praying for you.
/s/ gloria poole, RN, Denver CO 80203
*footnote: Reference books are:
A Textbook of Medicine, by Cecil & Loeb, and
Modern Pharmacology, by Charles Craig and Robert Stitzel,fourth edition.
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I am posting a link to an article I read today because a quote from it caught my eye. I quote from it:"They are talking about pigs that are going to have mouse genes in them, and this is not going to be labeled?" said Jean Halloran,
director of food policy for Consumers Union. "We are close to speechless on this." Consumers Union publishes Consumer Reports magazine."[ end quote]
This quote is from this article about genetically modified animals:
http://news.yahoo.com/s/ap/20080918/ap_on_he_me/super_chicken;_ylt=AkGd7z55rxFCNPdg4qE9cjus0NUE
4:06 PM 9/18/2008/
Years ago I worked for a world reknown M.D. who was doing a study on high blood pressure at the Medical College of Georgia. I would hear him tell his patients not to eat pork, over and over again, so I asked him why he said that? He said he had not yet established why pork caused high blood pressure but that it did. I remembered that The Bible in Leviticus chapter eleven tells humans NOT to eat scavengers including that disgusting mouse as mentioned above,nor pork [swine], vultures, ravens, catfish, crayfish, camel, coney, hare, fish without scales or fins,eagle, ossifrage,ospray [osprey], owls,swans ,pelicans,gier eagle,stork, heron, lapwing, bats,and any fowl that creep going on all four, and anything that goes on his paws on all four paws at once [dogs] mice, weasels,tortoise,ferret,chameleon,lizard,snails,moles, flying and creeping bugs with four feet. Verses 32-47 of that chapter also tell you to not use for cooking any dish that those things touched until you had cleaned it and it air dried for several hours. These are practical matters because I am convinced that ingesting those scavengers by many groups has caused diseases to be rampant among them. Think about it. If an animal will eat anything even rotting human flesh, would that animal be safe for you to eat? NO! It is easy to see why GOD said not to eat them. I quit eating pork then and there that day the M.D. told me that because I recognized that advice was from GOD's Word.
Also GOD warned not to ever eat blood. It is written, 'it shall be a perpetual statute [law of GOD] for your generations throughout all your dwellings, that ye eat neither fat nor blood." Leviticus 3:17
The risk for genetically modified foods is as the quote points out, what is it modified with? Would you eat a dead rat under any circumstances? I would not! Because I know what GOD said about it. Therefore it makes no sense to eat part of a dead rat either, incorporated into the flesh of an animal that GOD said humans could eat. Don't be deceived by those who would sell their souls to the devil for a buck! Avoid genetically modified foods especially if you don't know how they are modified. GOD's wisdom is perfect whereas humans are imperfect. Trust GOD and do not try to outsmart GOD.
All entries to this site are written by Ms Gloria Poole,RN |
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Today's lesson is about Tuberculosis often abbreviated as TB. It is much in the news and has existed from antiquity and was once called "consumption" because it consumes the lungs with abscesses and holes if left untreated.
A brief history of the medical advances that have led to a greater understanding of that disease is: in 1882,Koch isolated the Tuberculosis causing bacillus. In 1890, Mafucci isolated the avian [bird] bacillus that produced TB in birds and occasionally in humans. In 1898, Theobald Smith isolated the bovine [cow] form of bacillus that produces TB in cows and could be transmitted to humans in some cases. In 1895, Roentgen discovered xrays that produced the anatomic discoveries of what TB does to lungs and bowels, that was indispensible information in the understanding of how TB progressed. In 1944, Waksman developed a TB-specific antibiotic that was very successful in treating TB.
Tuberculosis exists in these animals in certain conditions: some fish, amphibians, some fowls, some mammals, and reptiles. Animals in captivity fall prey to it more easily than animals in the wild.Among domesticated animals TB appears in swine, some cattle [cattle usually eat grains so if fed other than grains,there is a risk] and gallinaceous birds. [hens, turkeys, partridges]. For those residing in the US, the likelihood of getting TB from cattle is very rare, because of meat-packing standards.
In humans, there is no ethnic group that is immune naturally to Tuberculosis. The severity and morbidity of it varies greatly and seems to be related to factors such as closeness of living quarters, how often exposed to active TB bacillus, nutrition, [diets high in protein and vitamins are body-building and help prevent disease] and hygiene of the individuals and the environments. Tuberculosis is widely prevalent in many nations of the world still,and must be considered a risk if you travel to some countries. The nations where TB is widely prevalent are the Asian countries, Eastern Europe, Latin America, Alaskan Indians, Greenland, Newfoundland and Labrador,some African nations, and the Phillippines. Several million deaths annually are attributed to Tuberculosis. The group most likely to die from Tuberculosis is elderly men, though the very young are also susceptible.
In most cases [92%] if a person dies from TB,it is because of the pulmonary form of TB with non-pulmonary TB accounting for less than 10 % of the deaths.
In humans, the source of the tuberculosis bacilli is usually traced to another human who was actively infected or to a tuberculous animal. Milk contaminated with Tuberculosis is rare in the US because of pasteurization but in other nations, it is not as uncommon. Most of the time, human TB is caused by inhaling air contaminated [that is air breathed out by an person who has active TB] with the bacilli. Tuberculosis is air-borne and is transmitted if an actively diseased person breathes, coughs, sneezes, or spits, regardless of the level of hygiene available.
In cases, where very young children are in the household with an active case of Tuberculosis, their being inoculated [inhaling the active TB] is almost inevitable. That is why TB must be quaratined from the home to prevent the rest of the family from getting it. Also the urine and feces of a person infected carries the active Tuberculous bacilli, and must handled with special precautions. Also direct mouth to mouth transmission of the bacillus occurs, and occasionally a baby in the womb will contract active disease from a tuberculous placenta or amniotic fluid being aspirated into the lungs.
There are three known Tuberculosis bacilli: 1)mycobacterium tuberculosis var hominus [humans], 2) mycobacterium tuberculosis var bovis [cows], and 3) mycobacterium tuberculosis var avium [fowl]. Humans may be infected by any of these. Guinea pigs often used in so-called research labs are easily infected with any of these and transmit the disease also. Rabbits do also. The tuberculosis bacilli is a rod-shaped organism distinquished by its acid-fastness to staining in the medical lab. The TB bacillus grows slowly and aerobically [in the presence of air] on various culture mediums. There is no capsule to it. The TB bacillus is tenacious [tough to exterminate] and may survive many months in the dark, or even when refrigerated,but dies fairly quickly when exposed to bright sunlight and is killed by boiling in water for two minutes or pasteurization at 60 degrees centigrade.
Infection is common but deaths do not always occur. In fact, deaths are becoming less common with chemotherapy [drug treatments] and isolation, and quarantine. In other words, active tuberculosis is not automatically a death sentence though where you contract it, certainly makes a huge difference in your survival rate.
What is labeled the Koch phenomenon is that the first inoculation with active TB [the first time a human is exposed to active disease] causes a tissue reaction to tuberculin, or tissue hypersensitivity or allergy to it. The second inoculation of disease to the same person, [the second exposure to it] produces a more rapid, and intense response with a tendency to abscess formation, ulceration, extrusion of necrotic [dead] matter and then subsequent healing. The phagocytes in the blood mobilize to defeat the tuberculosis bacilli at the site of infection, and in certain conditions form an effective barrier against further invasion. If there is no more inoculation [no more exposure to active TB] then the person is not likely to contract the active disease. In humans that first tissue hypersensitivity could take 5 or 6 weeks to develop, and and may produce serious inflammatory reactions such as serous pleurisy. Acquired immunity may take up to a year to acquire and though the allergy to the tuberculous bacilli is not an indicator of immunity, it is believed to be a factor in developing immunity. Some groups such as the Jews, seem to have a higher natural immunity to tuberculosis than other groups. Black people seem to have a lower resistance to it than other groups.The cause for this is not known as yet,whether it is genetic or environmentally produced. Deaths from tuberculosis is about three times higher for black races than for white races, with no real explanation except possibly that many of the "black" or non-white races are in countries where crowded living conditions prevail and exposure is more likely to occur.
Generally, tuberculosis is more prevalent in childhood. Males are more likely to have it and that is thought to be due to their greater likelihood of seeking sex behaviours that expose them to the active disease more often. Other factors that may predispose to acquiring active Tuberculosis are pregnancy while being exposed to TB at the same time since pregnancy puts more demands on the circulatory system and requires that the mother increase her calorie intake and in some countries that is not as readily easy to do as in other countries. Also poor diets or starvation certainly reduce the natural immunity, and anxiety and aggravated stress also lowers the immunity. For centuries TB was prevalent among schizophrenics that are institutionalized and that is thought to be because of crowded conditions with air-borne TB in the air and decreased immunity from other drugs and isolation from family[ stress]and lack of hygiene by those not in a reality mode of thinking. Those type of institutions as well as acute care hospitals are learning that noso-comial infections must be tracked and treated at the institutional level and not allowed to breed/multiply unchecked.
Those populations with serious numbers of infections include Puerto Ricans, Alaskan Indians, certain African nations, Phillippines, and not as much in the Arabic nations. The Arabic people are generally very aware of meticulous hand-washing and cleaning of themselves. Certain occupations contribute to the likelihood of disease and those include exposure to silicous dust, [metal moulding, sandblasting, mining, stone-cutting, polishing stones, and manufacturing abrasive soaps]. Also trauma to the chest contributes by producing hemoptysis [blood being spilled into the chest cavity then coughed up] which creates an excellent culture medium for the bacilli to grow on. Bronchial dissemination of infection with TB, and pleural rupture with spreading of empyema [pus filled cavities] results in the case of trauma if the active disease was present and chest trauma occurred. That happens if the impact of the trauma was enough to break open lesions and spill the pus into the surrounding areas. Concurrent diabetes increases the risk of infection but hyperthyroidism does not. Hyperthyroidism seems to increase the native resistance to Tuberculosis bacilli, and that is not yet understood why.
Pulmonary TB is a likely development in a child born with congenital [acquired in the womb] pulmonic stenosis [the valve to the pulmonary artery becomes sort of stuck with strictures] . Patients with pneumococcal pneumonia are usually able to survive TB unless their fuctional lung reserve is almost depleted. Necrosing pnuemonia and/or abscess from it, may lead to a subsequent expansion of TB into other areas, and a lengthening treatment of medical interventions.
The way tuberculosis advances is that at first the cells infected aggregate at the site of infection. Then the vascular [blood supply] congests, [fills with more blood trying to bring phagocytes in increases to the area to fight it off] then fluid may accumulate in the cells. Neutrophilic leukocytes predominate there. Depending upon how fast the bacilli multiples at that site, [including how effective the body's own resistance and ability to fight off disease is] if the leukocytes continue to accumulate they will form an abscess, trying to seal off the infection. If the abscess liquifies and drains off, then the infection is probably contained. Caseation as it is called is a change in the early stages of inflammation. That word means a coagulative [produced from clotting blood] necrosis [the blood clot deadens surrounding tissue if infected] occurs. It looks sort of like a dry, consistency of cheese. That may remain for months, but eventually liquifies and will break its boundaries, draining to the outside if located on the skin's surface, and to the inside if inside the body. If that occurs in the lungs, the exudate [pus] will drain into the bronchi,and if in the renal [kidney TB] it will drain into the ureters that empty the urine to the outside. If is superficial and necrotic it will appear as an abscess, and probably will break and drain. If the abscess is in the vertebral column, it will likely form an abscess in the psoas sheath and appear in the groin and rupture there. Whereever it finds an outlet,the sloughing off of tissue and evacuation of that is accomplished. If this caseation occurs in the wall of a pulmonary vein it creates a channel for the Tuberculosis bacilli to enter the blood stream. That is not good. If that does not occur, after the abscess drains, there may be a residual defect in the form of a change to the previous structure. For instance if the abscess occurs in the middle ear, a perforated ear drum may be left in its place. If it occurs in the lung, a parenchymal cavity may be left there. If the abscess does not completely drain off the bacilli,then reinfection of tuberculosis is likely. Healing and repair are possible before caseation occurs. If caseation occurs, as it does in most lesions of any size and duration, then resolution of the surrounding non-necrotic [living tissue in other words] exudate may occur, but the areas with necrotic [dying tissues] will still harbor active TB. In certain conditions there would then develop a slow, fibrin accumulation that would cause drying of the membranes and shrinking of tissue. Eventually the lesion may be converted into a fibrocaseous mass, or a wholly encapsulated mess,extending beyond the center of the lesion. Then in time it accumulates mineral salts particularly calcium phosphate leading to a "chalky" phase leading to complete calcification of the lesion or ossification. By this time the contained bacilli frequently die. If however, they do not, then reinfection may occur. It is possible for one lesion to heal while another one could become deadly. Ulcers and cavities [holes] in the lungs result. Mucous membranes may grow back when effectively treated, but destroyed alveoli do not grow back. Large cavities seldom heal completely by natural processes. Healing usually takes months if not years. In many cases, there is no real healing only arresting the disease so that more damage to the lungs does not occur.
Chemotherapy [treatment with prescribed medicines] may halt or slow the development of the disease. but the essential processes of resolution of abscesses and fibrous repair of the tissue by the body, are not otherwise altered.
The Tuberculosis bacilli are spread by the lymph nodes from the primary site of infection and also by the blood stream if it advances to that stage, and via intracanicular canals, [the gastrointestinal tract, respiratory bronchi, lymph system, circulatory system.] Remember that the heart is a pump and will also pump infected blood throughout the body so it is important to treat TB early on. Tuberculosis bacilli have been isolated from bone, eyes, kidneys, skin, lungs,prostate gland in men and their epididymis,joints of bones, etc. The term 'bronchial dissemination' means that the active TB bacilli was inhaled into previously healthy alveoli of one or both lungs from an infected person or animal.
Large and abrupt disseminations of TB such as occur during hemorrage from an infected cavity, may produce confluent tuberculous lobular or lobar pneumonia, but the more common pattern is several smaller secondary lesions forming. [reactivation and spreading of it]. The bronchi, trachea, and larynx are common sites of infection; and also the middle ear which transmits the bacilli via the eustachian tube instead of the blood supply, and the tongue and lip through the mucuous membranes, usually if abrasions are present. If pus is coughed up from the lungs and then swallowed, Tuberculosis will take root in the gastrointestinal tract.Rectal crypts and ischiorectal abscesses usually form in the lower bowel in that case.This fact is also the reason why homosexual men are more likely to contract Tuberculosis than heterosexual men.
The lung is the primary site in 90% or more of cases of Tuberculosis. The primary site is called the 'Ghon'. Menigitis is a usual complication and also generalized miliary tuberculosis if TB is contracted in early childhood.
Testing for Tuberculosis is diagnostic some of the time, but it is possible to have false negatives. The test does not measure immunity nor does it indicate the severity of disease, if disease is present. A positive reaction may not occur when it should if these conditions exist: 1) if it has been less than 5 or 6 weeks since the inoculation with active TB bacilli occurred, 2) if TB was present but healed, 3)if TB is in terminal stages, 4)if sarcoidosis is also present, 5)if the dose of TB test is inadequate, 6) if person to be tested was recently given cortisone or corticotropin.
If these conditions exist and the signs and symptoms of TB exist, then sputum [produced from the lungs by deep coughing up, not saliva] must be tested, and in some cases, a surgical biopsy may be indicated to rule out other lung diseases. Tuberculosis may mimic fungus infections of the lungs, sarcoidosis,and beryllium granulomatosis.However the presence of caseation is usually believed to be positive proof of TB. Aspiration of abscesses and cavities may not be a good idea as it could spread the infection through the tissues when the aspirating needle is pulled back out. If pus is present in the sputum, aspiration would be a bad idea. In that case, a surgical incision to remove specimens is probably the better method.
Lab testing indicates that the polymorphonuclear leukocytes will rise to 12,000 to 18,000 per cu mm; and the sed rate will be elevated in almost all febrile [with fever] cases. An elevated sed rate is not specific to TB however and is not diagnostic of TB by itself. The gamma globulin factor will also rise and the albumin decreases in active disease. There may also be an increase in the alpha fractions of proteins, and also in the protein-bound carbohydrates, and in the C-reactive proteins. In later stages of TB, there is a lowering of circulating blood volume, and content of mineral salts, enzymes and vitamins in the body,and bacteremia [infected blood ] may also occur. Other signs and symptoms of active Tuberculosis are weight loss without dieting, malaise [generalized feeling of not being well] and fever. The disproportion of active disease to symptoms [meaning that a person could be very sick with TB before symptoms occur] is almost unique to TB and often gives a clue to the presence of disease.
Chemotherapy is always indicated, with different drugs. Streptomycin is often successful as well as combination of that with isoniazid, and other newer drugs if those prove ineffective. Also quarantine of the infected person is essential to containing the disease and eradicating it. Streptomycin is usually given by injection. Any drug produces a chemical change in your body.If you are allergic to it, or chemically susceptible to small doses of any drug or chemical there are risks to treatment. However the benefits of eradicating TB often outweigh the risks. Streptomycin is known to be damaging to the vestibule in the middle ear, in some people, and there is a risk of permanent damage to the auditory nerve leading to deafness in the affected ear. Other drugs used to treat it are Para-aminosalicyclic acid [PAS or Rezipas] is more tolerable by some patients. Cycloserine is another drug used to treat TB. Also there is often a combined approach to multiple drugs being prescribed.
This is not a comprehensive lesson in Tuberculosis but hopefully gives you enough info that if you are having any of these symptoms you should see a Medical Doctor immediately.
I referred to the textbook, A Textbook of Medicine, by Cecil & Loeb for this information.
This entry and all so far, was added here by Ms Gloria Poole, RN licensed in Colorado and previously licensed in GA and the UK also.
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Meningitis, or inflammation or infection of the meninges of the brain occurs after becoming contaminated with bacteria, viruses, spirochetes, parasites or fungi. The meninges is the thin covering of the brain. The clinical features depend somewhat on where the infection is located, whether in the basal or cortical area of the brain. Infection may also be in the spinal cord which is part of the central nervous system.
The most common microorganisms [think germs for layman's word] are tubercle bacillus [the one that causes tuberculosis], meningococcus, the influenza bacillus, the pnemococcus [causing pneumonia], the hemolytic streptococcus, and the staphylococcus. Others that also infect the meninges are: nonhemolytic streptococcus, including enterococci, the colon bacillus, and the pyocyaneus bacillus, which commonly infects after a spinal or lumbar puncture and spinal anesthesia; and Friedlander's bacillus, Aerobacter aerogenes, proteus vulgaris, salmonellae, Alcaligenes [aecalis, Pasteurella tularensis,] the gonococcus [that causes gonorrhea], the Brucella melitensis and the Bacillus antracis which causes anthrax, are occasional causes of meningitis also. The spirochetes that cause meningitis are Treponema pallidum, that causes syphilis. It is a thin actively motile [moving about] spiral organism. Spirochetes must have a liquid environment to survive and multiply and cause infection, therefore the genitals during coitus are likely to allow transmission of bacteria and produce infection if one of the partners in the sex act is infected with T.Pallidum. The other spirochete that causes meningitis is Leptospira icterohemorrhagica come from rats,mice dogs, cats,cattle and swine and is transmitted when a human comes into contact with an infected animal's urine, or by swimming in infected waters. The fungi that cause meningitis are the mycoses Torula histolytica, that is the agent that causes blastomycosis, and has been isolated from contaminated fruit juices, milk from cows if they have infected teats, and pigeon manure [from handling pigeons].
In the case of meningitis from any causative infection it is essential to determine what organism [germ, bacteria, spirochete, parasite, fungus, or virus] caused it, because the treatment is critical and the treatment is different depending on what the cause was. The viruses that causes meningitis usually also cause encephalitis or myelitis simultaneously. Encephalitis is the infection of the central nervous system [spinal cord, fluid, and brain] and may occur after a vaccination for viral diseases such as smallpox,measles, German measles,varicella,mumps, influenza [flu] or rabies. Also mumps virus, the virus of acute lymphocytic choriomeningitis,and the poliomyelities virus all may cause meningitis, and they must be ruled out in determining a cause of the meningitis.
Of the parasites that cause meningitis Trichinella spiralis and trypanosomes are the most prevalent cause. Trichinella spiralis is the larvae of the roundworm 'trichinella spiralis' that is transmitted by inadequately cooked pork and is one of the greatest uncontrolled problems of the public health.
Meningitis may also occur after an ear infection of the middle ear, or mastoid process but it is not as common as in previous decades because pediatricians treat those quickly generally.
The meninges of the brain becomes infected through the blood stream of blood circulating through the brain, or through direct contact with one of the germs or viruses, or spirochetes or parasites or funguses. The causative agent is transmitted through the middle ear if that is where the original infection began or through the lip,nose, or eyelids, or through lumbar puncture, or spinal anesthesia, or surgery on the face, brain or nose, laminectomy, repair of spina bifida or brain tumors or meningoele. The orginal spot where the infection began must be determined and treated and drained if an abscess there, and then the blood treated for infection.
Meningitis may also be caused by the person's own body seeding the bacteria elsewhere, and the causative agent could begin in the lungs, or endocardium. Not all people who have those bacteria [mentioned previously] present will develop meningitis however. Chronic meningitis coudl occur as reinfestation from the nasal cavity.
Meningitis may occur alone or with thrombophlebitis [a clot forming] of the one of the intracranial sinuses, an extradural or subdural abscess, or a brain abscess. The ear and mastoid are the most common cause of pyogenic meningitis and the paranasal sinus is the second most common cause of that particular type of meningitis. Meningitis that occurs from the sinuses most frequently is from the frontal sinuses, then the sphenoid and ethmoid cells, then rarely the maxillary sinus. Meningitis may occur as a complication of surgery on the sinuses or from head injury.
It is imperative to culture the blood of any patient suspected of meningitis before treatment begins to find out what is causing it. It is probably also necessary to xray the head and ears and mastoids as well. Diagnosis depends on the history given by the patient, the signs and symptoms of infection and clinical tests, including testing the cerebrospinal fluid [the fluid surrounding the spinal cord and brain].
These events that a patient relates to you should be considered significant to point to the possibility of meningitis:
1) if there was a recent infection of nose, throat or sinuses,
2) recent surgery in those areas;
3) head trauma,
4) recent lumbar puncture and/or spinal anesthesia; [because a needle is introduced into tthe spinal sac]
5) history of contact with infected person
6) previous or active signs of pulmonary infection
7)herpes
8)hemorragic skin eruptions.
The signs and symptoms of meningitis are:
fever, headache, prostration [not being able to get up], pain in the back, or neck, nausea and vomiting, and may also be associated with stupor, coma or convulsions, and if so, then meningitis must be suspected. The localized signs are increased intracranial pressure [measured by MD or staff] and spasm of the neck muscles causing stiff neck and spasm of the erector spinae muscle of the back with opisthotonus, and spasm of the hamstring muscle causing a positive Kernig's sign. Also, if menigococcus is the cause, then sepsis and rash will occur. In all meningitis the common symptoms are pain in the neck and back when the head if flexed forward on the chest, hyperesthesia, hyperirratability and exaggerated reflexes. Inequality of reflexive movement is not unusual. If the cranial nerves are infected, there may also be strabismus and deafness. If the intracranial pressure is increased, there will be nausea and vomiting, dilated or irregular pupils of the eye, engorgement of the veins of fundi of the eye,choking of the disk, irregular slow pulse and moderately elevated blood pressure. In severe cases, Cheyne-stokes breathing will be present. Fever may not be consistent. If not treated, restlessness, irritability, may be succeeded by delirium, generalized convulsions, deep depression, and somnolence, [sleepiness] followed by stupor [near unconscious state] and then coma. In infants the first signs may be refusal of feedings, vomiting or regurgitation, diarrhea, irritability, and fever, and may also present convulsions and bulging of the fontanelles, which is very indicative of meningitis. Death is a common result of untreated meningitis, and also chronic meningitis for those who did not die, and delayed death from other complications and sequalae of disease.
The treatment of meningitis depends on what caused it. Sulfonamides [sulfadiazine] are the preferred drug for meningococcal meningitis.Penicillin may also help but is not as effective as sulfonamides but may be preferred if allergic to sulfonamide drugs. Streptomycin is the correct drug for tuberculous meningitis.For pneumococcal, hemolytic streptococcal, and stapylococcal meningitis, both Penicillin and sulfadiazine are given. In the gram negative bacterias, of hemophilus influenza, pseudomonas aeruginosa, and Klebsiella pneumonia, streptomycin is preferred drug. Other drugs including chloramphenicol, polymyxin,and newer generations of drugs may be used. It is important to pay attention to the nutrition of the patient because typically they lose a great deal of weight.
Of course, the patient needs to be hospitalized. Bacterial meningitis in an infant less than two years old is more serious than at any other time of life, and must be treated immediately, regardless of what caused it. It is life-threatening quickly in other words. It is also life-threatening in adults but usually there is more time to intervene in adults before death occurs.
This "lesson" is to help you gain some understanding of what causes meningitis and what to look for and what to be alarmed about, and what to do. If you see any of these symptoms in others or yourself, get them or yourself to a Medical doctor immediately, or to the most educated health care licensed person available to you. This is not a comprehensive lesson on meningitis but sort of hits the highlights of a very serious disease.
I referred to "A Textbook of Medicine" by Cecil and Loeb for this lesson.
signed Ms Gloria Poole, RN, licensed in Colorado with active and current license. |
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