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<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="02c285a1erlcgo.png"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>usmle med 6</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="usmle med 6"><U><B>home</B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="pearls 1"><U>pearls 1</U></A>   |   <B>pearls 2</B>   |   <A HREF="id21.htm" TARGET="_top" TITLE="pearls 3"><U>pearls 3</U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="pearls 4"><U>pearls 4</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="pearls 5"><U>pearls 5</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="qcm"><U>qcm</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="answers"><U>answers</U></A>   |   <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="02ad2c00dkelyh.png"> <bR> <div>   <a href="http://counter.mycomputer.com/"><img alt="Counter" src="http://counter.mycomputer.com/c.count?u=DHAMMOUD&c=1" border=0></a>   </div> <div> danil hammoudi.md</div> <div>  <img src="HTMLobj-95/aniGif.gif" border="0" align="bottom" width="120" height="80">   <img src="HTMLobj-96/aniGif.gif" border="0" align="bottom" width="175" height="240">  <A HREF="http://dir.yahoo.com/Arts/Artists/Masters/Picasso__Pablo__1882_1973_/" TARGET="_top" TITLE="http://dir.yahoo.com/Arts/Artists/Master"><U><IMG SRC="06500900.png" border=0 width="256" height="400" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="pearls 1"><U>pearls 1</U></A></div> <div> pearls 2</div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="pearls 3"><U>pearls 3</U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="pearls 4"><U>pearls 4</U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="pearls 5"><U>pearls 5</U></A></div> <div> <A HREF="id18.htm" TARGET="_top" TITLE="qcm"><U>qcm</U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="answers"><U>answers</U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> http://www.medical-<A HREF="http://www.medical-library.org/journals/secure/peds_id/secure/Cytomegalovirus_EBV_HHV.pdf" TARGET="_top" TITLE="http://www.medical-library.org/journals/"><U>library.org/journals/secure/peds_id/secure/Cytomegalovirus_EBV_HHV.pd</U></A>f</div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>pearls 2</I></div> <bR> <div> <A HREF="http://sinoemedicalassociation.com" TARGET="_top" TITLE="http://sinoemedicalassociation.com"><U> <img src="HTMLobj-122/aniGif.gif" border="0" align="bottom" width="340" height="60">  </U></A></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="564" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 76 WIDTH="560"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A human immunodeficiency virus (HIV)-positive patient presents with fever, dyspnea, tachypnea, and peripheral cyanosis. The chest x-ray reveals extensive "ground-glass" opacities in the lower zones of both lungs. The physician would expect which of the following?</div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <B>organism to respond to trimethoprim-sulfamethoxazole (TMP-SMX)</B></div> <bR> <bR> <bR> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" ><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient has a </FONT><I><B>Pneumocystis carinii</B></I><B> pneumonitis with the characteristic chest x-ray findings of "ground-glass" opacities in the lungs.</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Methenamine silver stains [not Gram's stains  of lung tissue or bronchoalveolar lavage specimens frequently demonstrate densely clustered cysts that resemble crushed Ping-Pong balls. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Because the patient is human immunodeficiency virus (HIV) positive and has an opportunistic infection, the patient qualifies as having acquired immune deficiency syndrome (AIDS). </div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">P. carinii</I> is the most common initial manifestation and cause of death in patients with AIDS. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Once considered a protozoan, DNA analysis now shows that the organism is more closely related to a fungus. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The organism cannot be cultured.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients are generally susceptible to infection when their CD4 helper T cell count approaches 200 cells/mm<FONT SIZE="1" COLOR="#000000" FACE="Arial" >3</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is contracted in immunosuppressed patients by inhalation and produces an interstitial pneumonitis with extreme hypoxia. <I>Pneumocystis</I> predominantly affects the lungs, but it can also involve other head and neck organs, such as the thyroid, or the skin.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The treatment for <I>P. carinii</I> is trimethoprim-sulfamethoxazole (TMP-SMX) or pentamidine. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aerosolized pentamidine or low-dose sulfonamides are useful as prophylaxis against the infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is a 20% fatality rate with each infection; therefore, lifetime prophylaxis is needed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The infection does not respond to amphotericin B  or erythromycin </div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">P. carinii</I> is easily confused with <I>Histoplasma capsulatum</I>, but <I>Histoplasma</I> organisms are located in macrophages. Disseminated histoplasmosis could present with granulomas in the bone marrow . </div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">P. carinii</I> does not produce granulomatous inflammation. Amphotericin B is the treatment of choice for histoplasmosis.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">PCP is the most common life-threatening opportunistic infection occurring in patients with HIV disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the era of PCP prophylaxis and highly-active antiretroviral therapy, the incidence of PCP is decreasing. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The incidence of PCP has declined steadily from 50% in 1987 to 25% currently.</div> <bR> <bR> <div> <B>Risk factors for Pneumocystis carinii pneumonia</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with CD4 counts of 200 cells/<FONT SIZE="3" COLOR="#000000" FACE="WP MathA" >F</FONT>L or less are 4.9 times more likely to develop PCP compared with patients with CD4 counts of more than 200 cells/<FONT SIZE="3" COLOR="#000000" FACE="WP MathA" >F</FONT>L.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Candidates for PCP prophylaxis include: patients with a prior history of PCP, patients with a CD4 cell count of less than 200 cells/<FONT SIZE="3" COLOR="#000000" FACE="WP MathA" >F</FONT>L, and HIV-infected patients with thrush or persistent fevers.</div> <bR> <div> <B>Clinical presentation</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">PCP usually presents with fever, dry cough, and shortness of breath or dyspnea on exertion with a gradual onset over several weeks.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Physical findings are often minimal; however, tachypnea may be pronounced, and patients may be so dyspneic that they are unable to speak without stopping to rest.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Circumoral, acral, and mucous membrane cyanosis may be evident.</div> <bR> <bR> <div> <B>Laboratory findings</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete blood counts and sedimentation rates</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> show no characteristic pattern in patients with PCP.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Serum chemistries are not particularly helpful; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">however, the serum LDH concentration is frequently increased.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arterial blood gas</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> measurements generally show increases in P(A-a)O<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">although PaO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT> values vary widely depending on disease severity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Up to 25% of patients may have a PaO2 of 80 mm Hg or above while breathing room air.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulmonary function tests</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients with PCP usually have a decrease in diffusing capacity for carbon monoxide (DLCO).</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Radiographic presentation</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">PCP in AIDS patients usually causes a diffuse interstitial infiltrate. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">High resolution computerized tomography (HRCT) may be helpful for those patients who have normal chest radiographic findings.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pneumatoceles (cavities, cysts, blebs, or bullae) and spontaneous pneumothoraces in patients with PCP are common.</div> <bR> <bR> <bR> <div> <B>Laboratory diagnosis</B></div> <div> <B>Sputum induction.</B> The least invasive means of establishing a specific diagnosis is the examination of sputum induced by inhalation of a 3 to 5% saline mist. The sensitivity of induced sputum examination for PCP is 74 to 77% and the negative predictive value is 58 to 64%. If the sputum tests negative, an invasive diagnostic procedure is required to confirm the diagnosis of PCP.</div> <div> <B>Transbronchial biopsy and bronchoalveolar lavage</B>. The sensitivity of transbronchial biopsy for PCP is 98%. The sensitivity of bronchoalveolar is 90%.</div> <div> <B>Open lung biopsy</B> should be reserved for patients with progressive pulmonary disease in whom the less invasive procedures are nondiagnostic.</div> <div> <B>Diagnostic algorithm</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If the chest radiograph of a symptomatic patient appears normal, a DLCO should be performed. Patients with significant symptoms, a normal-appearing chest radiograph, and a normal DLCO should undergo high-resolution CT. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with abnormal findings at any of these steps should proceed to sputum induction or bronchoscopy. Sputum specimens collected by induction that reveal P. carinii should also be stained for acid-fast organisms and fungi, and the specimen should be cultured for mycobacteria and fungi.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients whose sputum examinations do not show P. carinii or another pathogen should undergo bronchoscopy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lavage fluid is stained for P. carinii, acid-fast organisms, and fungi. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Also, lavage fluid is cultured for mycobacteria and fungi and inoculated onto cell culture for viral isolation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Touch imprints are made from tissue specimens and stained for P. carinii.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Tissue is cultured for mycobacteria and fungi, and stained for P. carinii, acid-fast organisms, and fungi.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> If all procedures are nondiagnostic and the lung disease is progressive, clinicians open lung biopsy may be considered.</div> <div> <B>Therapy and prophylaxis</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trimethoprim-sulfamethoxazole (</B> <B>Bactrim, Septra) </B>is the recommended initial therapy for PCP. Dosage is 15 mg/kg/day of TMP and 75 mg/kg/day of SMX divided every 8 hours for 14 to 21 days. Adverse effects include rash (33%), elevation of liver enzymes (44%), nausea and vomiting (50%), anemia (40%), creatinine elevation (33%), and hyponatremia (94%). The most common adverse reactions that necessitated a change in therapy were neutropenia (15%) and severe rash (15%).</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pentamidine</B> is an alternative in patients who have adverse reactions or fail to respond to TMP-SMX. The dosage is 3 mg/kg/day for 14 to 21 days. Adverse effects include anemia (33%), creatinine elevation (60%), LFT elevation (63%), and hyponatremia (56%). The most common adverse effect requiring a change in therapy is neutropenia (32%). Pancreatitis, hypoglycemia, and hyperglycemia are common side effects of pentamidine. Hypoglycemia or hyperglycemia occurs in 57% of all patients.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Corticosteroids</B>. Adjunctive corticosteroid treatment is beneficial with anti-PCP therapy in patients with a partial pressure of oxygen (PaO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>) less than 70 mm Hg, (A-a)DO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT> greater than 35 mm Hg, or oxygen saturation less than 90% on room air. Contraindications include suspected tuberculosis or disseminated fungal infection. Treatment with prednisone (40 mg twice daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily until day 21 of therapy) should begin at the same time as anti-PCP therapy.</div> <bR> <div> <B>Prophylaxis</B></div> <bR> <div> PCP is the most common life-threatening opportunistic infection in HIV-infected patients. HIV-infected patients who have CD4 counts less than 200 cells per microliter or who have survived an episode of PCP should receive prophylaxis against PCP.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trimethoprim</B> <B>-sulfamethoxazole </B>(once daily to thrice weekly) is the preferred regimen for PCP prophylaxis because of efficacy and simultaneous efficacy in prophylaxis against toxoplasmosis.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dapsone</B> (100 mg daily or twice weekly) is a prophylactic regimen for patients who can not tolerate TMP-SMX. Adverse reactions included anemia, LDH elevation, methemoglobinemia, nausea, and skin rash. §</div> <div> ====================================================================================================</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>Calcium channel blockers (e.g., verapamil, nifedipine) are used commonly in <B>mild-to-moderate hypertension and in all forms of angina. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nifedipine blocks L-type calcium channels in vascular smooth muscle at plasma levels below those required for significant effects on atrioventricular (AV) nodal conduction; therefore, it is safer than verapamil in patients with AV conduction abnormalities. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, the rapid onset, short-acting formulations should be avoided, and nifedipine capsules should not be used for the emergency treatment of hypertension because of an increased risk of myocardial infarct and stroke.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Nimodipine is also a calcium channel blocker, but it is used clinically to reduce the severity and incidence of ischemic defects in patients with subarachnoid hemorrhage from ruptured congenital aneurysms who are in good neurologic condition postictus. Nimodipine's hemodynamic effects are not marked. </div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B><B>Diazoxide and minoxidil are both potent arteriolar vasodilators used for severe hypertension</B> in combination with <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >b</FONT>-blockers or diuretics to offset compensatory fluid retention and/or reflex tachycardia. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The two drugs have similar side effects, including increased hair growth. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, diazoxide has the unusual characteristic of causing hyperglycemia, which has led to its therapeutic use in the management of hypoglycemia of hyperinsulinism.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Diazoxide is chemically related to thiazides, and concomitant use of such diuretics may increase its effects. </div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The potent vasodilator hydralazine (used in moderate-to-severe hypertension) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and the antiarrhythmic drug procainamide are both known to cause systemic lupus erythematosus (SLE). </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Although classified as a sodium channel blocker, procainamide also blocks potassium channels, leading to prolongation of the cardiac action potential. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bretylium  and sotalol  also prolong the duration of the cardiac action potential. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hydralazine  has no direct effect on the heart, but due to its potent hypotensive effects may cause severe reflex tachycardia.</div> <div> ======================================================================================================</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urethritis is the most common sexually transmitted disease (STD) in men.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is most commonly caused by <I>Neisseria gonorrhoeae</I> or <I>Chlamydia trachomatis</I>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> However, <I>Trichomonas vaginalis</I> or the herpes simplex virus (HSV) can also be causative agents of nongonococcal urethritis (NGU). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> At one time, the standard treatment would have been penicillin .</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> However, because of increasing resistance, penicillin is no longer recommended for gonorrhea.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Ceftriaxone  and cefixime are drugs that inhibit cell wall synthesis but are not susceptible to <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >b</FONT>-lactase hydrolysis; therefore, they are recommended replacements for penicillin in the treatment of gonorrhea.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The quinolones, ciprofloxacin and ofloxacin, inhibit bacterial DNA gyrase and have a relatively broad spectrum of activity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They too are effective against gonorrhea. However, because chlamydial infections so often accompany gonococcal infections, the Centers for Disease Control (CDC) recommends that all patients with suspected or proved gonococcal urethritis also be treated as if they had chlamydial NGU. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Although the quinolones have antichlamydial activity in vitro, they have not been recommended for clinical infections. <I>C. trachomatis</I> is susceptible to tetracyclines such as doxycycline, but strains of tetracycline-resistant <I>N. gonorrhoeae</I> have also become too common to recommend its use. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Therefore, combined therapy, such as ceftriaxone and doxycycline, is required to treat both infections. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alternatively, because both organisms are still susceptible to the relatively new drug azithromycin, it can be used alone.</div> <div> <IMG SRC="06bd33b0.jpg" border=0 width="211" height="59" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">gonorrhea and chlamydia are not only often transmitted together but also very, very difficult to differentiate in terms of the syndromes they produce. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They are the two most common bacterial sexually transmitted diseases in the United States and they are fairly common. Interestingly,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> it has been a race, with gonorrhea way ahead and that was because the methods for detecting chlamydia were not nearly as good. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Then chlamydia started catching up and as our methodology has gotten better and better, chlamydia has become more common than gonorrhea. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It probably always was, but we just weren't able to demonstrate it.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> They produce similar syndromes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They can both produce </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">urethritis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> mucopurulent cervicitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">anorectal infections, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">conjunctivitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">epididymitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pelvic inflammatory disease,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> the Fitz-Hugh-Curtis syndrome,[ Perihepatitis in women with gonococcal inflammation of the pelvic organs resulting from the spread of gonococci to the upper abdomen].</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> perihepatitis and they both can produce arthritis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">although the arthritis with chlamydia is not a true infectious arthritis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> it is Reiter's syndrome or host chlamydial infection arthritis, which at one time was also attributed to the gonococcus.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This is just like what we spoke about yesterday in terms of gastrointestinal infections.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This is a post infectious arthritis and is presumably immunologic and one of the things that can trigger it is chlamydial infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is most commonly seen in people with HLAB27 tissue type, but can be seen with other tissue types also. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gonorrhea is a disease of the young - 15 to 25 years as defined by the CDC.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is more common in urban blacks of low socioeconomic status. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <B>We see a lot more gonorrhea in people in lower socioeconomic groups and more chlamydia in people of upper socioeconomic groups - college students, for example.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Females who develop gonorrhea are usually asymptomatic and males are usually symptomatic.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> As a matter of fact, the figure is that after contracting the gonococcus, over ninety percent of males will become symptomatic within five days;</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the others will not become symptomatic at all, ever. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rectal infection is common in women and in male homosexuals.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Twenty percent of male homosexuals who practice anal receptive intercourse develop gonorrhea.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Rectal infection is usually asymptomatic.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Pharyngeal infection is common in women practicing fellatio - the figure if twenty percent - and male homosexuals.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Pharyngeal infection is usually asymptomatic. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They can produce symptomatic infection, but it serves as a mucosal site from which dissemination can occur and certainly from which spread of infection can occur to another individual.</div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Females are less effective transmitters of gonorrhea than male.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> One-third of males will be infected by one exposure, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sixty percent by three exposures and in males it is fifty percent of females who will be affected by one exposure and ninety percent of females will be affected by <B><U>three exposures. </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">So males are far more effective in terms of transmission;</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> it is thirty-three percent with one exposure versus fifty percent and sixty percent with one exposure versus ninety. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is a repetitive theme that you will see with HIV infection,  with chlamydia infection and probably, with virtually any sexually transmitted disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Males are more effective in transmission.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The gonorrhea germs are found in the mucous areas of the body (the vagina, penis, genital tract, throat and rectum).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In women, the opening (cervix) to the womb (uterus) from the birth canal is the first place of infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The disease however can spread into the womb and fallopian tubes, resulting in pelvic inflammatory disease (PID) which can cause infertility ( in up to 10%) of infected women and tubal (ectopic) pregnancy.<FONT SIZE="3" COLOR="#FF00FF" FACE="Verdana" > </FONT></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With regard to gonorrhea, you must treat the partners because of not, the partner will re-infect the individual you are treating in the first place and is free to go around infecting other people in the community</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Much of the approach to sexually transmitted diseases is to prevent further spread of infection, not only to treat the patient that you are dealing with but also to prevent further spread. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With melas there is</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> urethritis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> dysuria, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">discharge.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Spread can occur to the prostate,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> seminal vesicles and epididymis and produce epididymitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> With epididymitis, you usually have unilateral pain and swelling of the testicle.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epididymitis is caused by Enterobacteriaceae as well as by chlamydia and prostatitis is usually not a gonococcal infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As a matter of fact, it is really quite uncommon to get symptomatic gonococcal prostatitis. </div> <div> <IMG SRC="061b65f0.jpg" border=0 width="438" height="351" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="06282900.png" border=0 width="130" height="144" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="06368900.png" border=0 width="104" height="144" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="064b0200.jpg" border=0 width="432" height="288" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="066d38d0.png" border=0 width="211" height="141" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0674ae70.jpg" border=0 width="330" height="231" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0682cda0.jpg" border=0 width="300" height="218" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With females, there is cervicitis, discharge and an inflamed, nontender cervix. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Spread can occur to the rectum, which is usually totally asymptomatic.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Then spread can occur beyond the mucosa of the urethra, of the cervix, of the rectum and of the pharynx.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These can be totally asymptomatic and then spread can occur either via the bloodstream or by direct extension.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In the female, </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">contiguous spread can occur and produce pelvic inflammatory disease</B>, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">salpingitis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> or can actually go all the way through the fallopian tube into the peritoneal cavity and produce the syndrome called Fitz-Hugh-Curtis syndrome. [see below and my pathology pages women disease]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It can produce perihepatitis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> occasionally perisplenitis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> then there may be bacteremic spread. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bacteremia can produce</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> skin lesions and arthritis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Endocarditis at one time was fairly common from the gonococcus; five percent of all cases of endocarditis were caused by the gonococcus back before antibiotics.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Now, it is a rare occasion to see gonococcal endocarditis; it almost doesn't happen anymore. The explanation is absolutely lacking - nobody understands it, because it is not related to antibiotic therapy and it may well be that the gonococcus has evolved and changed in nature so that it is far less prone to cause endocarditis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occasionally, the gonococcus can cause meningitis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some of the cases of apparent meningococcal meningitis, when looked at carefully, turned out to be a gonococcus and not meningococcus.</div> <bR> <div> <B>One can acquire gonorrhea easily from:</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701680000ff00.png" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">penis to vagina sex</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701680000ff00.png" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">penis to mouth "oral" sex</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701680000ff00.png" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">penis to rectum "anal" sex</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701680000ff00.png" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mouth to vagina contact</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG SRC="07272620.gif" border=0 width="114" height="98" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="073d7c40.jpg" border=0 width="471" height="196" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>A </B><FONT SIZE="4" COLOR="#000080" FACE="Arial" ><B>baby can get it from an infected mother during birth</B></FONT><B>. Very rarely, gonorrhea can be transmitted through kissing (if there is a cut on the lip or some other opening that comes in contact)</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG SRC="06dc8c30.jpg" border=0 width="200" height="195" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="06ec2c80.jpg" border=0 width="194" height="200" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="06fc89a0.jpg" border=0 width="200" height="154" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07002c10.jpg" border=0 width="258" height="193" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07112f20.jpg" border=0 width="274" height="242" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <FONT SIZE="5" COLOR="#FF00FF" FACE="Verdana" > <A NAME="symptoms"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></FONT>Symptoms of Gonorrhea</div> <bR> <div> <B>Gonorrhea</B><B> in Men:</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Creamy or green, pus-like penile discharge<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Painful urination<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Testicular pain<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <bR> <div> <B>Gonorrhea</B><B> in Women:</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Creamy or green, pus-like vaginal discharge<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Painful urination<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bleeding between periods<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Painful intercourse<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excessive bleeding during menstrual period<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lower abdominal pain<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <bR> <div> <B>Rectal infection:</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Itching<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Constipation<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rectal bleeding<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Creamy, pus-like discharge<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pain<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" > </FONT></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Men infected with </B><B>gonorrhea</B><B> will experience a burning sensation while urinating with a yellowish white discharge from the penis and pain in the testicles.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In rectal infection symptoms include </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">creamy pus-like discharge,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> rectal bleeding,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> itching anus,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> constipation and painful bowel movements with blood in the feces.</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Those few women with symptoms have a  </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">possibly some burning while urinating, painful intercourse, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">excessive bleeding during menstrual period,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> bleeding between periods,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> lower abdominal pain, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">irritation of the vulva and a yellow or bloody vaginal discharge. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women often have no symptoms but those that do get a vaginal discharge and discomfort and burning when urinating.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Infections in the throat and rectum can also occur.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Symptoms usually appear two to seven days after infection in males (sometimes it can take up to 30 days for symptoms to appear) and often there are no symptoms at all (in 10 to 15 percent of men and about 80 percent of women).</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> People with no symptoms are at risk for developing complications from </B><B>gonorrhea</B><B> and can unknowingly spread the infection.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B><B>From the time of infection </B><B>gonorrhea</B><B> can be spread and will continue to be spread until properly treated.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Past infection does not make a person immune to </B><B>gonorrhea</B><B>. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous infections with </B><B>gonorrhea</B><B> may allow complications to occur more rapidly and increase your risk of getting HIV increases. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Long term complications</B><B> </B></div> <bR> <div> <B>Men</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epididymitis - an inflammation of the testicles that can cause sterility</B><B> </B></div> <bR> <div> <B><IMG SRC="06900000.jpg" border=0 width="768" height="512" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>Women</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pelvic Inflammatory Disease - an ascending infection that spreads from the vagina and cervix to the uterus and fallopian tubes. PID can lead to sterility.</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ectopic pregnancy - a pregnancy outside of the uterus</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perihepatitis - an infection around the liver</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gonorrhea</B><B> can be transmitted to newborns.</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abscesses</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sterility</B><B> </B></div> <bR> <div> <B>Laboratory Testing for Gonorrhea</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The laboratory is challenged with the task of rapidly and accurately detecting the presence of <I>N. gonorrhoeae</I> in submitted genital specimens. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The optimal specimen for males is a urethral swab and a direct smear made at the time of collection.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> For females, a swab of the endocervical canal provides the best recovery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anorectal swabs may also be useful when sampling for test of cure or culturing patients who practice anal sex.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Vaginal specimens often result in falsely negative culture results, and should only be accepted for culture from children. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rayon or dacron swabs should be used for collection since cotton swabs may contain agents that are toxic to gonococci. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The organism is very fastidious and susceptible to drying, it is therefore important to transport the specimens to the laboratory in charcoal transport media and without delay.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For male patients, a gram stained smear prepared from the urethral discharge is particularly useful in making a presumptive diagnosis of gonorrhea. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The presence of gram negative cocci in pairs displaying a typical kidney bean shape, and located inside the neutrophils is virtually diagnostic of infection with <I>N. gonorrhoeae</I>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A direct smear is not, however, reliable for diagnosis of female patients. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In both, confirmatory testing is essential. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This diagnosis can have substantial emotional and practical impact and should only be made when the laboratory is absolutely certain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intra-cellular gram-negative diplococci </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gram-stained smear of urethral discharge </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Confirmatory testing consists of growing the bacteria on enriched culture media, performing various biochemical tests and fluorescent staining using a monoclonal antibody specific for <I>N. gonorrhoeae</I>. The tests are necessary to distinguish <I>N. gonorrhoeae</I> from non-pathogenic species of the same genus that may be isolated from genital sites.</div> <bR> <div> <B> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="845" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 509 WIDTH="833"><div> <B>INVESTIGATIONS</B> </div> <div> 1) <B>Smear</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">of exudate typically shows polymorphs with intracellular gram-negative diplococci. This is very reliable (95% detection rate) in symptomatic urethritis in male patients and give a rapid presumptive diagnosis in clinics. For cervical, rectal or asymptomatic urethral infection, smear detects only about 50 percent of cases. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The following points should be noted in order to obtain a smear of better yield: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use a sterile 3mm-small-diameter platinum complete loop for secretion sampling. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In male, retract the prepuce and wipe the glans to remove any secretion before taking urethral specimens. The loop is inserted into the everted external meatus and the terminal cm of the urethra gently scraped. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In patient who have no urethral discharge, or who have just passed urine, repeat tests after the urine has been held for overnight, i.e. early morning smear. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anal smears are best taken after passage of a proctoscope. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Oropharyngeal smear is not useful for pharyngeal infection as commensal Neisseria is commonly present. Just do a culture. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For accurate diagnosis in female, smear must be taken from the urethra, cervix and preferably anorectum.</div> <div> 2)<B> Culture</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">, for example in Thayer-Martin medium, detects 95-100 percent of symptomatic male urethral infections and 80-90 percent of cervical, rectal or pharyngeal infections. Immediate direct inoculation to culture plate is routinely practised in Social Hygiene Clinics. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Besides giving a confirmatory diagnosis especially in women, oral and rectal infection or in disseminated disease, culture allows drug sensitivity testing, checking on the effects of treatment & test of cure, and documentation and subtyping of infection in legal proceedings such as sexual assault or rape. </div> <bR> <div> 3) There is no useful serological test for gonorrhoea. Previous complement fixation test for gonorrhoea is obsolete.</div> <bR> </tD> </tR> </TABLE></B></div> <div> <B><U>COMPLICATIONS</U></B><U> </U></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complication of gonorrhoea in man,</U></B></div> <div>  which are now rare because of the availability of effective antibiotics, include: </div> <bR> <div> <B>Cowperitis</B> presents as fever, malaise and severe pain in the perineum with frequency, urgency, painful defecation, and sometime acute urinary retention. Rectal examination is agonizingly painful. </div> <bR> <div> <B>Periurethral abscess</B> presents as painful local swelling in the bulb or the fossa navicularis in the penis. </div> <bR> <div> <B>Urethral stricture</B> could lead to obstructive symptoms and damages as well as recurrent urinary infection, leading to renal failure. Stricture may occur anywhere in the urethra but most commonly in the bulb. It is diagnosed by anterior urethroscopy or by urethrogram. Urologist's help is valuable in the management. </div> <bR> <div> <B>Prostatitis</B> is uncommon as attacks are cut short by the use of antibiotics. Symptoms include fever, perineal discomfort, pain on defecation and variable urinary complaints. Rectal examination may show a large, tense and fluctuant mass bulging into the rectum. </div> <bR> <div> <B>Epididymitis</B>, affecting 1% of patients, usually presented with acute onset of unilateral painful scrotal swelling. Examination showed inflamed epididymis with hydrocele and tender thickened vas. The epididymis is destroyed and bilateral disease result in sterility.</div> <bR> <bR> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complications in female patients include: </U></B></div> <bR> <div> <B>Bartholinitis and abscess</B> usually causes difficulty in walking because of the painful genital swelling. Pus can be expressed from the tender inflammed spherical fluctuant bartholin gland in the lower third of the labia. </div> <bR> <div> <B>Pelvic infection</B> occurs in about 10% of female with gonorrhoea and causes acute attacks of bilateral lower abdominal pain with fever, nausea, vomiting, deep dyspareunia, vaginal discharge, dysuria and menstrual abnormalities. Pelvic examination reveals forniceal tenderness, cervical tenderness on movement and adnexal masses. Long term sequelae include chronic pelvic inflammatory disease, infertility and increase risk of ectopic pregnancy. </div> <bR> <div> <FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>Fitz-Hugh-Curtis</B></FONT><B> syndrome </B>(acute gonococcal perihepatitis) consists of acute onset of upper right-quadrant abdominal pain and tenderness aggravated by breathing, coughing or movement, and referred to the right shoulder accompanying an attack of gonococcal PID. Laparoscopy, occasionally needed to exclude other acute abdominal conditions, show typical "violin string" adhesions. </div> <bR> <div> <B>Disseminated gonococcal infection</B>, which affects less than 1% of patients, is seen more frequently in women, especially during menstruation and pregnancy. It is characterised by fever, skin rash and arthritis, rarely meningitis, endocarditis and hepatitis. Typical skin rash consists of a few painful crops of erythematous papules which become vesicopustular and haemorrhagic with necrotic centres, especially common on extremities associated with arthritis. Joint involvement can be an additive asymmetrical arthritis affecting the knees and the small joints on hands and feet, with tenosynovitis of the wrist; or mono/oligoarthritis affecting the knee, wrist or ankle simulating acute septic arthritis. The diagnosis is clinical plus demonstrating the presence of gonococci in oral, rectal or genital sites, or by blood culture, synovial fluid culture</div> <bR> <div> <B>TREATMENT</B> </div> <div> There are mutant types of Gonorrhea that resists certain antibiotics. Penicillin is no longer used. The disease can be cured by a shot of Ceftrixone . </div> <div> <B>Uncomplicated Gonococcal Infections of the Cervix, Urethra, </B></div> <div> <B>and Rectum</B> </div> <div> <U>Recommended Regimens</U> </div> <div> Cefixme 400 mg orally in a single dose, </div> <div> OR </div> <div> Ceftriaxone 125 mg IM in a single dose, </div> <div> OR </div> <div> Ciprofloxacin 500 mg orally in a single dose, </div> <div> OR </div> <div> Ofloxacin 400 mg orally in a single dose, </div> <div> OR </div> <div> Azithromycin 1 g orally in single dose, </div> <div> OR </div> <div> Doxycyline 100 mg orally twice a day for 7 days.</div> <div> <IMG SRC="06cbc820.png" border=0 width="188" height="130" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Common treatments use drugs such as ciprofloxacin, ofloxacin, cefixime, ceftriaxone and most recently - azithromycin .</div> <div>  Azithrymycin is a convenient single-dose oral medication.</div> <div>  The most common side effects with 2-gram azithromycin include </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nausea (18%), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diarrhea/loose stools (14%), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vomiting (7%),</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> abdominal pain (7%),</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vaginitis (2%), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dyspepsia (1%), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and dizziness (1%). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ineffective or incomplete treatment can result in serious problems later, such as chronic lower abdominal pain, sterility, tubal pregnancy, and painful joints. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In order to avoid reinfection and potential transmission of infection to others, you should stop having sex until both you and your partner are cured. </div> <bR> <div> <B><U>Treatment for Complicated Gonorrhea</U></B> </div> <bR> <div> For <B>epididymitis and prostatitis</B> caused by gonorrhoea, patient should first treated with a prolonged course of antibiotic instead of the usual single dose in uncomplicated case. </div> <bR> <bR> <div> 1) Spectinomycin 2 gm IMI for three days + tetracyclines 500 mg x 1-2 weeks </div> <div> 2) Ceftriaxone 250 mg IMI (single) + doxycyline 100 mg bd x 10 days</div> <bR> <div> <B>Acute Bartholinitis with abscess formation</B> should be aspirated. If lesion recurs or persists, patient should be referred to gynaecologists for marsupialisation. Antibiotic in a dosage similar to that suggested for epididymitis should be employed for at least 4 days. </div> <div> Patients with pelvic inflammatory disease (PID) and disseminated gonococcal infection warrant admission to hospital, both for parenteral antibiotics treatment and to look for other causes of abdominal pain and septicaemia. </div> <bR> <bR> <div> <B> </B><B><U>Gonococcal PID</U></B> </div> <div> 1) Spectinomycin 2 gm IMI x 3 days or </div> <div> Cefuroxime 1.5 gm IMI x 3 days </div> <div> plus </div> <div> Co-trimoxazole tab 2 bd x 10-14 days or </div> <div> Erythromycin 500 mg Q6H x 10-14 days (pregnancy) or </div> <div> Tetracycline 500 mg Q6H x 10-14 days</div> <div> 2) Cefoxitin (Mefoxin) 2 gm IMI (single) or </div> <div> Ceftriaxone 250 mg IMI (single) </div> <div> plus </div> <div> Doxycycline 100 mg bd x 10-14 days</div> <div> 3) During hospitalization: </div> <div> Cefoxitin 2 gm IVI Q6H (max 12 g daily by also IV infusion in severe infection) </div> <div> plus </div> <div> Doxycycline 100 mg Q12H (PO or IVI)</div> <div> After discharge: </div> <div> Doxycycline 100 mg bd to complete 10-14 days total course </div> <div> 4) During hospitalization: </div> <div> Clindamycin 900 mg IVI Q8H plus </div> <div> Gentamicin 2 mg/kg load, followed by 1.5 mg/kg IVI Q8H </div> <div> After discharge: </div> <div> Doxycycline 100 mg bd to complete 10-14 days total course </div> <bR> <bR> <div> <B> </B><B><U>Disseminated Gonocococcal Infection</U></B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ceftriaxone 1 gm IVI per day x 7-10 days </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cefotaxime 500 mg IVI Q6H x 7-10 days </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cefoxitin 1 gm IVI Q6H x 7-10 days </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tetracycline or erythromycin 500 mg orally qid x 7-10 days</div> <bR> <bR> <div> <B>. </B><B><U>Gonococcal Ophthalmia</U></B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Admit into hospital and consult ophthalmologist </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sterile saline irrigation and chloramphenicol eye ointment Q6H plus </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neonate: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cefuroxime 100 mg/kg/day IMI/IVI in 2-3 divided doses x 1 week </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adult: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cefotaxime 500 mg IVI Q6H x 1 week </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infants born to mothers with gonococcal infection: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prophylactic single-dose therapy with cephalosporin should be given in neonatal dosage. The infant's eyes should be carefully cleaned immediately after birth. 1% silver nitrate solution or 1% tetracycline eye ointment is strongly recommended as a prophylactic measure.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Besides accurate diagnosis, effective treatment and careful follow up of patients, exclusion of other concomitant STD's and contact tracing are also important. Examination and treatment of all sexual partners in the preceding 2-4 weeks, regardless of whether there is clinical evidence of gonorrhoea has been advocated (epidemiologic treatment). Patient should also be advised to abstain from intercourse two weeks after treatment to ensure an non-infectious status before they resume sexual activities. It is also advisable to avoid alcohol during the follow-up period, since strong unmetabolized alcohol may irritate the urethra and cause confusion of symptom. Health education to the public, e.g. use of condom should be taught. </div> <bR> <div> <B>Pelvic inflammatory disease[see my obgyn page]</B> may be gonococcal, may be chlamydial or may be mixed aerobic and anaerobic organisms.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> What seems to happen is that the initial infection is usually either gonococcal or chlamydial and then the recurrent infections tend to be caused by genital organisms that are found normally in the vagina, mixed aerobes and anaerobes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sometimes that first episode is barely symptomatic, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">so the first truly symptomatic episode that comes to the attention of the physician, seemingly the first episode, is actually caused by aerobic and anaerobic organisms.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> But the state is set by an initial gonococcal or chlamydial infection.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There are greater than one million cases per year in the United States. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One-third of these cases require admission to the hospital, which means that two-thirds of them can clearly be treated at home and ten percent go on to require a surgical procedure. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One in four women with pelvic inflammatory disease will develop one or more chronic sequelae.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Some of these sequelae are well known to you and they are all quite significant. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is a sevenfold increased risk of ectopic pregnancy because of the damage done to the fallopian tube. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is an eleven percent risk of infertility after only one episode.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pelvic Inflammatory Disease is a general term for an infection anywhere in the female pelvic organs, including the lower abdomen. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The condition starts as a cervical infection and spreads upward to the uterus, fallopian tubes, ovaries, and into the abdominal cavity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Two common sexually transmitted diseases</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">, Chlamydia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and <FONT SIZE="3" COLOR="#800000" FACE="Trebuchet MS" >Gonorrhea</FONT>  [see above]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cause a large share of PID among college aged women.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Minor symptoms may be a </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">slight fever </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and aching in the lower abdomen, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and more serious symptoms may be high fever and intense pelvic pain resembling appendicitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is important to see a health care provider immediately for two reasons: the infection and complications may be life-threatening; and PID is now the leading cause of infertility among young women due to scarring and blockage of the fallopian tubes.</div> <DIV ALIGN="LEFT"></DIV> <div> <IMG SRC="07606d40.jpg" border=0 width="518" height="212" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>PID/ Pelvic Inflammatory Disease</U></div> <div> Bacteria</div> <div> <I>Transmission</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">During vaginal, oral, anal sex with mixing with infected person's body fluids (blood, mucus, semen, and vaginal secretions).</div> <div> <I>Incubation Period</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2 to 10 days. Begins with a chlamydia or <FONT SIZE="3" COLOR="#800000" FACE="Arial" >gonorrhea</FONT> infection. Spread to tubes have can have no symptoms. PID symptoms develop due to secondary or polymicribial infection when many other bacteria become invovled.</div> <div> <I>Symptoms</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can be none, but can lead to moderate to severe lower abdominal pain and fever.</div> <div> <I>Test to see if you have it</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Examination, and a sonogram.</div> <div> <I>Potential Complications</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can lead to sterility, ectopic pregnancy, chronic pain and even death.</div> <div> <I>Chance of transmitting or hurting an unborn baby</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">None.</div> <div> <I>Treatment</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Certain antibiotics. If in a relationship, both partners must be treated at the same times or else they will re-infect each other.</div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prevention</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">New intact condoms (latex or polyurethane) are the best defense if you are sexually active. Even better, use a spermicidal gel within the vagina AT THE SAME TIME as using a new intact latex or polyurethane condom. Avoid contact with needles or other people's bodily fluids. Also birth control can help prevent recurrent attacks.</div> <bR> <div> <IMG SRC="07760c00.jpg" border=0 width="352" height="192" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><FONT SIZE="3" COLOR="#000000" FACE="Trebuchet MS" ><B>Trichomoniasis</B></FONT> A second form of vaginitis is Trichomoniasis, characteristically associated with a malodorous yellow-green discharge and often a burning sensation, itching, redness, and swelling. The majority of women with such vaginitis have severe symptoms at some time. The infection may be transmitted by either heterosexual or homosexual contact</div> <bR> <div> <U>Chlamydia</U></div> <div> bacteria</div> <div> <I>Transmission</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Contact of mucous membranes (cervix, urethra) with infected person's fluids (semen and mucus). Transmission most common through vaginal or anal sex.</div> <div> <I>Incubation Period</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 to 3 weeks or may never become symptomatic but still be a carrier who unknowingly transmits this bacteria to sexual partners.</div> <div> <I>Symptoms</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually none. If present, they may be:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women: pain or dull aching from cervix, heavy feeling in pelvic area, pain with urination or intercourse, heavier menstrual flow, breakthrough bleeding, heavy cervical discharge.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Men: urethral discharge, pain with urination, epididymitis (pain from cord leading up from a or both testicles).</div> <div> <I>Test to see if you have it</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">urine of males or females or swab from female's genitals.</div> <div> <I>Potential Complications</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women: serious complications can occur if spread to fallopian tubes. May result in tubal scarring, infertility, and risk of tubal pregnancy. Pelvic inflammatory disease (PID) with abscesses (puss in the fallopian tube involving adajecnt ovary) may also result (Note: see PID later down this chart).</div> <div> <I>Chance of transmitting or hurting an unborn baby</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bacteria can be transmitted at birth (reason for putting antibiotic drops in eyes of all newborns). With proper pre and post pregnancy care the damage to an unborn baby is extremely low.</div> <div> <I>Treatment</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Certain antibiotics. If in a relationship, both partners must be treated at the same times or else they will re-infect each other.</div> <div> <I>Prevention</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">New intact condoms (latex or polyurethane) are the best defense if you are sexually active. Even better, use a spermicidal gel within the vagina AT THE SAME TIME as using a new intact latex or polyurethane condom.</div> <div> ==================================================================================================================</div> <DIV ALIGN="LEFT"></DIV> <div> Pelvic Adhesions from Pelvic Inflammatory Disease</div> <div> Fitz-Hugh-Curtis<FONT SIZE="4" COLOR="#000000" FACE="Arial" > syndrome</FONT></div> <div> <IMG SRC="07940f00.jpg" border=0 width="320" height="240" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07807ce0.jpg" border=0 width="263" height="206" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Notice the many adhesion bands between the liver and</div> <div> the diaphragm. These are called "violin string" adhesions,</div> <div> and are also called <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Fitz-Hugh-Curtis</FONT> syndrome, after Dr. Fitz-Hugh</div> <div> and Dr.Curtis, who reported this condition. The adhesions are usually</div> <div> due to either chlamydia or gonorrhea infections. The bacteria travel</div> <div> up the right side of the abdomen, and collect in the fluid above the liver.</div> <div> Some patients report pain in the right, upper area of the abdomen, but</div> <div> this patient did not have any symptoms in this area. These were treated</div> <div> by cutting during laparoscopy.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fitzu-curtis adhesions occur between the surface of the right diaphram and the liver.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> They are usually caused by infection in the fallopian tubes and/or ovaries and cause no symptoms.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> They are often associated with adhesions in the pelvis, fallopian tubes, and ovaries. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Fitz-Hugh-Curtis</FONT> syndrome is associated with severe PID. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pus in the fallopian tubes leaks out and finds its way up under the diaphragm.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The patient is usually very ill with peritonitis and high fever. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When the infection is treated, the healing process may result in adhesions forming from the liver to the underside of the diaphragm.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These are usually painless and found coincidently.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Adhesions about the ovaries however frequently cause severe pelvic pain and tenderness</div> <bR> <bR> <bR> <div> <B><U>Classification of STDs</U></B><B><U> </U></B></div> <bR> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 41 WIDTH="410"><div> <B><U>Bacterial</U></B><B> </B></div> <bR> </tD> <tD VALIGN=CENTER WIDTH="210"><div> <B><U>Viral</U></B></div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 168 WIDTH="410"><div> Syphilis </div> <div> Gonorrhoea </div> <div> Non-gonococcal urethritis </div> <div> Non-specific genital infection </div> <div> Chancroid </div> <div> Lymphogranuloma venereum</div> <div> Donovanosis (Granuloma inguinale)</div> <bR> </tD> <tD VALIGN=CENTER WIDTH="210"><div> Genital wart </div> <div> Herpes genitalis</div> <div> HIV infection</div> <div> Hepatitis B </div> <div> Cytomegalovirus </div> <bR> <bR> <bR> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 41 WIDTH="410"><div> <B><U>Fungal </U></B></div> <bR> </tD> <tD VALIGN=CENTER WIDTH="210"><div> <B><U>Parasitic</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 75 WIDTH="410"><div> Candidiasis (Moniliasis) </div> <div> Trichomoniasis </div> <div> Scabies</div> <bR> </tD> <tD VALIGN=CENTER WIDTH="210"><div> Pediculosis pubis</div> </tD> </tR> </TABLE></div> <div> <B>Laboratory investigations in Social Hygiene Clinic</B> </div> <bR> <div> <B><U>Male:</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> - VDRL *, FTA, TPHA, HIV-Ab * </div> <div> - Urethral smear </div> <div> - microscopy (Gram stain for pus cell & organism) </div> <div> - culture x gonococci </div> <div> - wet film x trichomonas </div> <div> - direct IMF, ELISA, culture x chlamydia (Chlamydiazyme Test) </div> <div> - Dark ground examination x spirochaete </div> <div> - Swab from vesicle/sore x Herpes culture </div> <div> - Swab x Candida culture </div> <div> - Smear from sore x Haemophilus ducreyi </div> <div> (Homosexual and bisexual) </div> <div> - Pharyngeal & culture x gonococci </div> <div> - Rectal smear & culture x gonococci </div> <div> - Hepatitis virology </div> <div> <B><U>Female:</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> - VDRL *, FTA, TPHA, HIV-Ab * </div> <div> - Urethral & cervical smear </div> <div> - microscopy (Gram stain x pus cell, epithelial cell, candida, trichomonas) * </div> <div> - culture x gonococci * </div> <div> - direct IMF, ELISA, culture x chlamydia </div> <div> - High vaginal smear x C&ST </div> <div> - Dark ground examination x spirochaete </div> <div> - Papanicolaou smear </div> <div> - Endocervical/sore swab x herpes culture </div> <div> - Pharyngeal & culture x gonococci </div> <div> - Rectal smear & culture x gonococci </div> <div> (* Routine tests)</div> <bR> <bR> <div> <B>Management of the Patient with an Abnormal Smear</B> </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1043" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#EEEEEE > <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="30"><div> <B> </B></div> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Cytology Report</B></div> <bR> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Recommended Management</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="30"><div> <B>1.</B></div> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Negative</B></div> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Routine recall</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="30"><div> <B>2.</B></div> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Unsatisfactory</B></div> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Repeat smear as soon as possible</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 WIDTH="30"><div> <B>3.</B></div> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Satisfactory but limited by .....</B></div> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>A repeat smear not necessarily required. Ultimate determination rests with the attending doctor</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="30"><div> <B>4.</B></div> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Infection/Reactive changes</B></div> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Treat infection accordingly then routine recall</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 170 WIDTH="30"><div> <B>5.</B></div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Atypical cells of undetermined significance (squamous/glandular)</B></div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Repeat smear in 3-6 months' time </B></div> <div> <B>After 2-3 consecutive negative smears, go back to routine recall </B></div> <div> <B>After 2 persistent atypical reports, refer to specialists</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="30"><div> <B>6.</B></div> <bR> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Low Grade Squamous Intraepithelial Lesion (LSIL)</B></div> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Refer to specialists for colposcopy</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 WIDTH="30"><div> <B>7.</B></div> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>High Grade Squamous Intraepithelial Lesion (HSIL) Carcinoma</B></div> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Refer to specialists for colposcopy and </B></div> <div> <B>treatment</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 WIDTH="30"><div> <B>8.</B></div> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Endometrial cells, cytologically benign in a postmenopausal woman</B></div> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Refer to exclude endometrial pathology</B></div> <bR> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 95 WIDTH="30"><div> <B>9.</B></div> <bR> <bR> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="380"><div> <B>Endometrial cells found out of phase in premenopausal women</B></div> <bR> <bR> <bR> </tD> <tD VALIGN=CENTER WIDTH="613"><div> <B>Clinically exclude hormonal therapy, IUCD, DUB, scraping from lower segment etc. If presence of endometrial cells cannot be explained clinically, refer for investigation</B></div> </tD> </tR> </TABLE></div> <div>  </div> <bR> <bR> <bR> <div> ====================================================================================================</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the classic basophilic intranuclear inclusion of cytomegalovirus (CMV). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV pneumonitis is particularly common in organ transplantation patients, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">especially bone marrow allograft recipients (10%-15%) and those with acquired immune deficiency syndrome (AIDS).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> CMV hyperimmune globulin given to seronegative bone marrow recipients provides some protection from contracting the infection.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Ganciclovir is sometimes given to patients before transplantation as a preventive measure. It can also be used in treatment of CMV. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The mortality rate is 85%. </div> <bR> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pneumocystis carinii</I> is not visualized with standard hematoxylin-eosin stains. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Methenamine silver, Giemsa stains, and direct immunofluorescent stains are useful in identifying organisms in bronchial lavage specimens or biopsies of lung. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The organisms look like crushed Ping-Pong balls. </div> <div> <I><B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cryptococcus neoformans</B></I><B>  is the most common systemic fungal infection in the immunocompromised host</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In tissue, it is an encapsulated yeast with narrow-based buds. </div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blastomyces dermatitidis</I> is a systemic fungal infection, which, in tissue, is a yeast with broad-based buds. </div> <bR> <bR> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Candida albicans</I>  is a systemic fungal infection with yeast forms and pseudohyphae, the latter indicating the invasiveness of the organism. <I>Pneumocystis</I>, <I>Cryptococcus</I>, <I>Blastomyces</I>, and <I>Candida</I> do not produce intranuclear inclusions.</div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cytomegalovirus (CMV) is a common opportunistic pathogen in individuals infected with HIV, causing</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> retinitis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> colitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and encephalitis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cytomegalovirus disease occurs in 20-40% of patients with AIDS.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> HIV-infected persons withCD4<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+ </FONT>cell counts below 50/<FONT SIZE="1" COLOR="#000000" FACE="WP MathA" >F</FONT>L are at highest risk for CMV disease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Retinitis usually begins unilaterally, but, untreated, progression to bilateral involvement is common. </div> <bR> <bR> <div> <B>Clinical evaluation</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Retinitis is the most common manifestation of CMV infection, accounting for 75% to 85% of CMV disease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Typically, the disease appears as a yellow to white area of retinal necrosis and edema, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">which follows a vascular distribution and is sometimes hemorrhagic. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An ophthalmologist can establish the diagnosis with a dilated retinal examination.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Symptoms of CMV retinitis may include</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> light flashes, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">floaters, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">loss of central or peripheral visual field, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and blurred or distorted vision.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Asymptomatic retinitis can be detected by ophthalmologic screening of HIV-infected persons at high risk.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with CD4<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+ </FONT>cell counts below 50/<FONT SIZE="1" COLOR="#000000" FACE="WP MathA" >F</FONT>L should receive ophthalmologic screening every 3 to 6 months.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients with extraocular CMV disease should also be examined regularly.</div> <bR> <div> <B>Treatment of cytomegalovirus retinitis</B></div> <div> <B>Ganciclovir</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ganciclovir is a nucleoside analogue. Intravenous and oral ganciclovir are available for clinical use. It is administered by intravenous infusion over 1 hour in a dosage of 5 mg/kg two times daily during initial induction (14-21 days). Maintenance therapy consists of 5 mg/kg once daily. The dosage must be reduced with impaired renal function.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Initial response in retinitis occurs in 75% of patients. Maintenance therapy should be continued for life. Even with continued maintenance therapy, progression of CMV retinitis eventually occurs. Maintenance intravenous ganciclovir is given in a dose of 5-6 mg/kg, 5-7 days per week.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Oral treatment (4.5 and 6.0 grams/day) is inferior to intravenous treatment.</div> <bR> <div> <B>Intravitreal treatment.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Intravitreal delivery is effective and safe, although it does not treat systemic CMV disease that is frequently present in patients with retinitis. Sustained intravitreal release by a surgically implantable device must be accompanied by systemic therapy (eg, oral drug) to prevent contralateral eye and extraocular disease.</div> <bR> <div> <B>Clinical use of ganciclovir.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Intravenous ganciclovir is recommended for the initial treatment of acute CMV infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Oral ganciclovir may be considered for maintenance therapy (not induction) in patients who do not have immediate sight-threatening disease (ie, retinitis near the macula or the optic nerve) because it is not as effective as intravenous therapy.</div> <bR> <div> <B>Resistance.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> After 3 months of ganciclovir therapy, 10% of AIDS patients develop resistant CMV.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These strains remain sensitive to foscarnet, which may be used as alternate therapy.</div> <bR> <div> <B>Ganciclovir toxicity</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> frequently limits therapy with ganciclovir.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Sixteen percent of patients receiving ganciclovir develop <B>neutrophil counts of less than 500/</B><FONT SIZE="1" COLOR="#000000" FACE="WP MathA" ><B>F</B></FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>L.</B> </FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The dosage should be reduced when absolute neutrophil counts fall below 750-1000 </B><FONT SIZE="3" COLOR="#000000" FACE="WP MathA" ><B>F</B></FONT><B>L or discontinued when severe leukopenia occurs (absolute neutrophil counts less than 500/</B><FONT SIZE="3" COLOR="#000000" FACE="WP MathA" ><B>F</B></FONT><B>L). </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cytokines such as granulocyte colony-stimulating factor (G-CSF) are effective in reversing ganciclovir-induced neutropenia.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Thrombocytopenia occurs in 9%.</div> <bR> <bR> <div> <B>Foscarnet</B></div> <div> Foscarnet is a pyrophosphate that inhibits herpes DNA polymerase. Induction therapy is 60 mg/kg administered intravenously every 8 hours. Maintenance dosage is 120 mg/kg.</div> <bR> <div> <B>Adverse effects</B> include renal impairment, anemia, hypocalcemia, hypomagnesemia, and hypophosphatemia. Daily infusion of a 1 liter saline reduces nephrotoxicity.</div> <bR> <div> <B>Combination therapy with ganciclovir and foscarnet</B> is effective for relapsing retinitis in patients initially treated with either ganciclovir or foscarnet. When ganciclovir, 5 mg/kg/day was used together with foscarnet 90 mg/kg/day, the combination therapy controlled CMV retinitis more effectively than ganciclovir or foscarnet alone.</div> <bR> <div> <B>Cidofovir</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cidofovir is a nucleotide analog, which is active against the majority of ganciclovir-resistant CMV strains. The drug has an extremely long half-life, permitting intravenous administration every 2 weeks during maintenance treatment. Induction therapy consists of 5 mg/kg IV weekly for 2 weeks. Maintenance therapy is 5 mg/kg IV every 2 weeks.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cidofovir is nephrotoxic, but this can be diminished by prehydration and probenecid (2 g PO 3 hours prior to cidofovir, 1 g PO 2 hours after, and 1 g PO 8 hours after). Renal function and toxicity must be monitored carefully, and proteinuria or a rising creatinine are reasons for dosage reduction, interruption, or discontinuation. §</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cytomegalovirus is a member of the herpesvirus group, which includes the herpes simplex viruses 1 and 2, varicella-zoster virus, Epstein_Barr virus (EBV), human herpesvirus 6 (roseola), and human herpesvirus 7 (nonspecific febrile illness). These viruses are widely distributed in humans and have a propensity for latency and reactivation. </div> <bR> <bR> <div> <B>Congenital Transmission</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One percent of newborns have CMV in the urine at the time of birth, which makes CMV the most common congenital infection.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Maternal infection is transmitted to 30-50% of fetuses when the mother has no antibody prior to the pregnancy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Prior maternal infection that recurs during pregnancy is transmitted to the fetus in 1.5% of cases.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Transmission of a primary maternal CMV infection to the fetus results in disease in 20% of involved infants and is responsible for almost all of the mortality and morbidity associated with this congenital infection.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mortality in symptomatic newborns is 20-30%. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fetal infection in the first 6 months of pregnancy is much more likely to cause fetal damage</B>.</div> <bR> <bR> <div> <B>Postnatal Transmission</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV can be transmitted to the infant via </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the maternal cervicovaginal secretions, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">urine, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">saliva, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and breast milk.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Virus is also acquired during the preschool years, especially among children attending day care centers.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The prevalence of active CMV infection among such children is 22-78%.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The spread of virus in day care centers is caused by saliva-contaminated toys and poor hygiene.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Seronegative pregnant mothers are at risk of acquiring infection from an infected toddler attending a day care center.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <B>Twenty one percent of seronegative parents with children in day care centers become seropositive.</B></div> <bR> <bR> <div> <B>Transmission in Adolescents and Adults</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Transmission of CMV after puberty usually results from heterosexual and homosexual activity, and the transmission rate increases with the number of sexual partners.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is no evidence that health-care workers can acquire CMV from infected hospitalized patients.</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, an infected infant can transmit infection to other infants in the nursery.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV can also be transmitted through blood transfusion, bone marrow, and other organ transplants.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reactivation, reinfection, and primary infection all can occur in immunosuppressed patients, including those with AIDS.</div> <bR> <bR> <div> <B>Pathophysiology</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV disease may be acquired as a primary infection,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> as a reactivation of latent infection, or as a reinfection with an antigenically different strain of virus.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV infections acquired during or after birth require 2-4 weeks to become culture_positive, and these infections are usually asymptomatic. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When disease occurs, it usually is manifest by</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <B>lymphadenopathy, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hepatosplenomegaly, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">petechial rashes, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or pneumonitis. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Deafness, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mental retardation, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">microcephaly, </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and other CNS diseases have not been associated with infection acquired at birth or shortly thereafter.</div> <bR> <bR> <div> <B>Clinical Evaluation</B></div> <bR> <div> <B>Symptoms and Signs</B></div> <bR> <div> <B>Congenital Infections</B>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">About 40,000 infants are born in the US with congenital CMV infection each year.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Twenty percent develop clinical CMV disease; however, only 35% of these infants will have clinically recognized infection in the newborn period.</div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="544" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#008000 HEIGHT= 20 ><NOBR><div> <B>Signs of Cytomegalovirus Disease in the Newborn</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 150 WIDTH="534"><div> Chorioretinitis</div> <div> Hepatosplenomegaly</div> <div> Hyperbilirubinemia</div> <div> Intrauterine growth retardation</div> <div> Microcephaly</div> <div> Periventricular calcifications</div> <div> Petechiae/purpura</div> <div> Psychomotor retardation</div> </tD> </tR> </TABLE></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most common irreversible effects of fetal infection are those associated with damage to </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the brain, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">eyes, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and inner ear. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Almost all newborns who have symptoms of congenital disease are damaged neurologically or have sensorineural hearing loss.</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some signs or symptoms of congenital infection, notably microcephaly, deafness, mental retardation, and motor disabilities, may not manifest until well into the first year of life.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV disease may present only as a fleeting petechial rash in the first 24 hours of life or by jaundice with an unexplained elevation of </B><B><U>direct bilirubin. </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other findings may include</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> lethargy,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> respiratory distress, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">seizures, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">a high_pitched cry, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">increased or decreased muscle tone, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or a small anterior fontanelle.</div> <bR> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="898" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=2 BGCOLOR=#008000 HEIGHT= 20 WIDTH="886"><div> <B>CNS and Ocular Abnormalities Associated with Congenital CMV Disease</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="357"><div> <B>Common</B></div> </tD> <tD VALIGN=CENTER WIDTH="526"><div> <B>Rare</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 168 ><NOBR><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anomaly of optic disc, optic atrophy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chorioretinitis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Microcephaly</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Periventricular calcifications</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sensorineural hearing loss</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="526"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anterior chamber malformation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cerebellar aplasia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cerebral cyst formation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Encephalomalacia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Microgyria</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Microphthalmia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Spongiosis of brain</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Strabismus</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ventriculomegaly with hydrocephalus</div> </tD> </tR> </TABLE></div> <div> <B><IMG SRC="07bc80e0.jpg" border=0 width="200" height="270" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07c91960.jpg" border=0 width="145" height="150" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07dbaf20.jpg" border=0 width="186" height="242" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><A HREF="http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\oph\images\Large\455cmv6.jpg&template=izoom2" TARGET="_top" TITLE="http://www.emedicine.com/cgi-bin/foxweb."><U><B><IMG SRC="07ec8a60.jpg" border=0 width="200" height="166" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B><IMG SRC="07fc8a70.jpg" border=0 width="200" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><A HREF="http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\oph\images\Large\455cmv6.jpg&template=izoom2" TARGET="_top" TITLE="http://www.emedicine.com/cgi-bin/foxweb."><U><B><IMG SRC="080c8a70.jpg" border=0 width="200" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B><IMG SRC="081c8a70.jpg" border=0 width="200" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><A HREF="http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\oph\images\Large\455cmv6.jpg&template=izoom2" TARGET="_top" TITLE="http://www.emedicine.com/cgi-bin/foxweb."><U><B><IMG SRC="082c8a80.jpg" border=0 width="200" height="168" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B><IMG SRC="083c8a00.jpg" border=0 width="200" height="160" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><A HREF="http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\oph\images\Large\455cmv6.jpg&template=izoom2" TARGET="_top" TITLE="http://www.emedicine.com/cgi-bin/foxweb."><U><B><IMG SRC="084c8ae0.jpg" border=0 width="200" height="174" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B><IMG SRC="085c8a70.jpg" border=0 width="200" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><A HREF="http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\oph\images\Large\455cmv6.jpg&template=izoom2" TARGET="_top" TITLE="http://www.emedicine.com/cgi-bin/foxweb."><U><B><IMG SRC="086c8a70.jpg" border=0 width="200" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B><IMG SRC="0884adb0.jpg" border=0 width="330" height="219" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08ae04a0.jpg" border=0 width="480" height="330" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><A HREF="http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\oph\images\Large\455cmv6.jpg&template=izoom2" TARGET="_top" TITLE="http://www.emedicine.com/cgi-bin/foxweb."><U><B><IMG SRC="08be0520.jpg" border=0 width="480" height="338" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08c00000.png" border=0 width="256" height="256" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08de0400.jpg" border=0 width="480" height="320" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08e90450.jpg" border=0 width="400" height="325" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <B>CMV Mononucleosis and Other Acquired CMV Infections</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV mononucleosis is characterized by persistent fever, malaise lasting 1 to 4 weeks, and atypical lymphocytosis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unlike EBV mononucleosis, CMV disease does not produce a positive heterophile antibody test.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pharyngitis, tonsillitis, and lymphadenopathy may occur in CMV mononucleosis.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In immunocompromised patients, CMV may cause</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> fever, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lymphadenopathy, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hepatitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pneumonia, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">gastritis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">colitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">arthralgia/arthritis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">retinitis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> leukopenia,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and encephalitis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with preexisting CMV antibody can become ill because of reactivation of previous infection.</div> <bR> <div> <B>Laboratory Diagnosis</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Congenital CMV infection may be diagnosed by isolating virus from the urine or upper respiratory tract in the f<B>irst 2 weeks of life.</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute and convalescent antibody titers are not useful to detect infection acquired weeks before birth; however, serial titers help determine if antibody is acquired either passively or actively by the infant.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The presence of CMV IgM antibody in the newborn suggests congenital infection, but this test must be confirmed by isolating the virus.</div> <bR> <div> <B>Treatment</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe CMV infections are treated with ganciclovir, a nucleoside analog which is structurally similar to acyclovir. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ganciclovir is virostatic, only suppressing viral replication. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ganciclovir is indicated for CMV retinitis, colitis, meningoencephalitis, esophagitis, hepatitis, and pneumonitis.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Foscarnet inhibits CMV DNA polymerase.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It has been useful in the treatment of adult CMV infections. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use in children is not recommended because it is deposited in bone, teeth, and cartilage, and it can impair renal function. </B></div> <div> ==================================================================================================================</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cabbage, brussel sprouts, broccoli, spinach, soya protein, and green, leafy vegetables are rich in vitamin K, thus decreasing the efficacy of warfarin.</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tubers, seeds, and fruit [e.g., mango  contain far less vitamin K than do green leaves. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intestinal bacteria also produce vitamin K, which is the most important source for it in human beings.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Thus, there is no specific need for supplements except under special circumstances (e.g., liver disease, malabsorption syndrome)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. While carrots, milk, and eggs  have a very small amount of vitamin K, they do not affect the overall efficacy of warfarin.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Liver and pork are very rich in vitamin K. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Among all sources of vitamin K, spinach contains the highest quantity.</div> <div> ====================================================================================================</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urinary casts are a mold of the renal tubules.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> They consist of a mixture of protein, with or without cells or cellular debris that is present in the renal tubules as a result of a normal process or disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Their presence in the urine indicates pathological processes that are occurring in the kidneys rather than in the lower urinary tract.</div> <bR> <div> <B>1: </B>Children who present with </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">generalized edema (anasarca) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">associated with a 24-hour urine protein greater than 3.5 g</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> have the nephrotic syndrome. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Minimal change disease (nil disease, lipoid nephrosis) is the most common cause of the nephrotic syndrome in children. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The syndrome results from the loss of polyanions (negative charge) in the glomerular basement membrane, with massive loss of albumin in the urine. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypoalbuminemia reduces the plasma oncotic pressure, resulting in generalized, pitting edema.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In addition, the hypoalbuminemia stimulates liver production of excess cholesterol, resulting in hypercholesterolemia. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some of the cholesterol is lost in the urine where it produces lipiduria, fatty casts, and oval fat bodies (renal tubular cells or macrophages with cholesterol). </div> <bR> <bR> <div> <B> 2: The white blood cell (WBC) cast distinguishes acute pyelonephritis from acute cystitis.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Acute pyelonephritis is an acute tubulointerstitial disease most commonly secondary to ascending infection (usually <I>Escherichia coli</I>) from the bladder. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute inflammation results in the presence of neutrophils that form microabscesses in the kidney and in the renal tubules.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Lower urinary tract infections like acute cystitis have neutrophils in the urine (pyuria), but do not have casts, which are formed only in the kidney. </div> <bR> <div> <B> 3: </B>Waxy casts are acellular casts that represent the progressive degeneration of a cellular cast. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The progression is thought to occur as follows: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cellular cast [leukocytes, red blood cells (RBCs), renal tubular cells] <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >®</FONT> coarsely granular cast <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >®</FONT> finely granular cast <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >®</FONT> waxy cast. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They are highly refractile and have sharp borders,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> unlike a hyaline cast, which has soft features and round borders. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Waxy casts are a marker for end-stage chronic renal disease. </div> <bR> <bR> <div> <B> 4: </B>RBC casts are a marker for glomerulonephritis, which is divided into the nephritic and nephrotic types (discussed previously). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The nephritic type is commonly seen in poststreptococcal glomerulonephritis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">as in this patient recovering from scarlet fever, and in renal involvement in systemic lupus erythematosus (SLE),</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> to name two. RBC casts, hematuria (smoky urine), and mild-to-moderate proteinuria are the hallmarks of the nephritic syndrome. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Renal tubular casts  are associated with acute tubular necrosis secondary to ischemic or nephrotoxic damage. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They are partially responsible for the oliguria associated with acute tubular necrosis.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hyaline casts  are the most common overall cast. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When present in small numbers, they have the least clinical significance of all casts. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Formed from the protein gel in the renal tubule, these casts are called<B> Tamm-Horsfall mucoprotein</B>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One hyaline cast per low-power field is commonly seen in normal urine. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, increased numbers are associated with any condition accompanied by proteinuria (e.g., fever, exercise, renal disease).</div> <div> ====================================================================================================</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ototoxicity is a complication that follows administration of furosemide</B>,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> especially when given intravenously at a rapid rate.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There may be a feeling of fullness, tinnitus, hearing impairment, and deafness.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Vertigo can also occur. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complications include</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <B>hyperuricemia</B> (rarely causes gout),</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> hyperglycemia (rarely precipitates diabetes mellitus), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">elevation of low-density lipoprotein (LDL)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> cholesterol and triglycerides, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and lowering of high-density lipoprotein (HDL) cholesterol. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other complications include </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">skin rashes,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> photosensitivity, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bone marrow depression,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and gastrointestinal problems.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Furosemide <B>does not affect</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acuity of vision, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">visual fields ,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> pupillary size in response to light </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">, or sense of smell </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. It would be judicious to ascertain that there is no hearing loss before administering a rapid intravenous dose of furosemide to avoid being accused of inducing it if there was evidence for it in the first place.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">furosemide<FONT SIZE="3" COLOR="#000000" FACE="Arial" > increases prostaglandin production, it could potentially help prevent indomethacin-related toxicity but also decrease ductal response to indomethacin. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lasix® can cause kidney stones, hearing problems, and low calcium levels, which can lead to softening of the bones (or <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B><U>rickets</U></B></FONT>)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. For these reasons try to use Lasix® for as short a time as possible. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When a baby has been on Lasix® for a long period of time, often order an ultrasound of the kidneys and a hearing test. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> also look for signs of rickets. </div> <bR> <div> Furosemide</div> <div> <B>Mechanism of Action</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Furosemide<FONT SIZE="3" COLOR="#000000" FACE="Arial" > is a potent, rapidly acting diuretic that inhibits reabsorption of sodium and chloride in the ascending loop of Henle. In patients with pulmonary edema, IV </FONT>furosemide<FONT SIZE="3" COLOR="#000000" FACE="Arial" > exerts direct venodilating effects that reduce venous return and thus central venous pressures. This effect is seen before the onset of diuresis. Diuresis begins roughly 10 minutes after treatment, reaches peak effect in about 30 minutes, and lasts for about 6 hours. These reductions in intravascular volume are generally associated with a decline in cardiac output, especially in patients with acute myocardial infarction.</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In patients with chronic heart failure and excess extravascular fluid, diuresis may be induced in part by changes in osmolarity. When this occurs, the egress of extravascular fluid into the intravascular space results in no net change in intravascular volume. In addition, a generalized pressor response has been described when large doses of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT> are administered IV to patients with chronic heart failure.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In patients with acute myocardial infarction and other disease states associated with abnormal left ventricular compliance, diuretics must be used cautiously since small changes in volume may induce large changes in left ventricular pressure. This may reduce cardiac output or induce hypotension, which can reduce coronary pressure. Because the effects of diuretics on preload are synergistic with those of morphine and nitrates, combination therapy should be used with caution.</div> <bR> <div> <B>Indications</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In emergency cardiac care, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT> is indicated for the emergency treatment of pulmonary congestion associated with left ventricular dysfunction.</div> <bR> <div> <B>Dosage</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The initial dose of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT> is 20 to 40 mg IV (or 0.5 to 1.0 mg/kg as an initial dose and up to 2 mg/kg in toto). It should be injected slowly over at least 1 to 2 minutes. Patients who fail to respond to bolus administration of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT> may respond to continuous infusions per hour. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Furosemide</FONT> infusions at rates of 0.25 to 0.75 mg/kg per hour may produce adequate diuresis even in patients with renal dysfunction. A prospective, randomized, crossover study in patients with severe congestive heart failure showed that <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT> infusions (2.5 to 3.3 mg/h for 48 hours preceded by a loading dose of 30 to 40 mg) produced significantly greater diuresis and natriuresis than an intermittent administration regimen (30 to 40 mg every 8 hours for 48 hours). Total urine output increased by 12% to 26% and total sodium excretion increased by 11% to 33% (<I>P</I> <.01) without any difference in side effects.</div> <bR> <div> <B>Precautions</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dehydration and hypotension can result from overzealous diuresis. Sodium, potassium, calcium, and magnesium depletion are common and may pose a serious threat to patients with coronary heart disease as well as those receiving digitalis or antiarrhythmic agents. Hyperosmolality and metabolic all can occur. Since <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT> is a sulfonamide derivative, it may induce allergic reactions in patients with sensitivity to sulfonamides.</div> <bR> <bR> <bR> <bR> <div> ====================================================================================================================</div> <div> <B>Recommended childhood immunization schedule*--United States, January-December 1998.</B> From American Academy of Pediatrics, Committee on Infectious Diseases: "Recommended Childhood Immunization Schedule--United States, January-December, 1998." <I>Pediatrics</I> 101:155-156, 1998.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><IMG SRC="08f4e580.png" border=0 width="590" height="344" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><B>Infants born to hepatitis B surface antigen (HBsAg)-negative mothers</B> should receive 2.5 µg of Merck vaccine (Recombivax HB®) or 10 µg of SmithKline Beecham (SB) vaccine (Engerix-B®). The second dose should be administered at least 1 mo after the first dose. The third dose should be administered at least 2 mo after the second but not before 6 mo of age. <B>Infants born to HBsAg-positive mothers</B> should receive 0.5 mL hepatitis B immune globulin (HBIG) within 12 h of birth, and either 5 µg of Merck vaccine (Recombivax HB®) or 10 µg of SB vaccine (Engerix-B®) at a separate site. The second dose is recommended at age 1-2 mo and the third dose at age 6 mo. <B>Infants born to mothers whose HBsAg status is unknown</B> should receive either 5 µg of Merck vaccine (Recombivax HB®) or 10 µg of SB vaccine (Engerix-B®) within 12 h of birth. The second dose of vaccine is recommended at age 1 mo and the third dose at age 6 mo. Blood should be drawn at the time of delivery to determine the mother's HBsAg status; if it is positive, the infant should receive HBIG as soon as possible (no later than age 1 wk). The dosage and timing of subsequent vaccine doses should be based on the mother's HBsAg status.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">§ Children and adolescents who have not been vaccinated against hepatitis B in infancy may begin the series during any visit. Those who have not previously received three doses of hepatitis B vaccine should initiate or complete the series during the routine visit to a health care provider at age 11-12 yr, and unvaccinated older adolescents should be vaccinated whenever possible. The second dose should be administered at least 1 mo after the first dose, and the third dose should be administered at least 4 mo after the first dose and at least 2 mo after the second dose.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">¶ Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) is the preferred vaccine for all doses in the vaccination series, including completion of the series in children who have received one or more doses of whole-cell diphtheria and tetanus toxoids and pertussis vaccine (DTP). Whole-cell DTP is an acceptable alternative to DTaP. The fourth dose (DTP or DTaP) may be administered as early as age 12 mo, provided 6 mo have elapsed since the third dose and if the child is unlikely to return at age 15-18 mo. Tetanus and diphtheria toxoids, adsorbed, for adult use (Td), is recommended at age 11-12 yr if at least 5 yr have elapsed since the last dose of DTP, DTaP, or diphtheria and tetanus toxoids, adsorbed, for pediatric use (DT). Subsequent routine Td boosters are recommended every 10 yr.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Three H. <I>influenzae</I> type b (Hib) conjugate vaccines are licensed for infant use. If <I>Haemophilus</I> b conjugate vaccine (meningococcal protein conjugate) (PRP-OMP) (PedvaxHIB® [Merck]) is administered at ages 2 and 4 mo, a dose at age 6 mo is not required.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Two poliovirus vaccines are currently licensed and distributed in the United States: inactivated poliovirus vaccine (IPV) and oral poliovirus vaccine (OPV). The following schedules are all acceptable to the ACIP, AAP, and AAFP. Parents and providers may choose among these options: (1) two doses of IPV followed by two doses of OPV; (2) four doses of IPV; or (3) four doses of OPV. ACIP recommends two doses of IPV at ages 2 and 4 mo followed by a dose of OPV at age 12-18 mo and at age 4-6 yr. IPV is the only poliovirus vaccine recommended for immunocompromised persons and their household contacts.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">§§ The second dose of measles-mumps-rubella vaccine (MMR) is recommended routinely at age 4-6 yr but may be administered during any visit provided at least 1 mo has elapsed since receipt of the first dose and that both doses are administered beginning at or after age 12 mo. Those who have not previously received the second dose should complete the schedule no later than the routine visit to a health care provider at age 11-12 yr.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">¶¶ Susceptible children may receive varicella vaccine (Var) at any visit after the first birthday, and those who lack a reliable history of chickenpox should be vaccinated during the routine visit to a health care provider at age 11-12 yr. Susceptible children aged >= 13 yr should receive two doses at least 1 mo apart.</div> <bR> <div> ====================================================================================================</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> otosclerosis, which refers to sclerosis and fixation of the middle ear ossicles associated with a conductive type of hearing loss and possible deafness.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It may be bilateral and has a strong autosomal dominant inheritance pattern. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is the most common cause of conductive hearing loss in adults.</B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Presbycusis  </B>is the<B> most common cause of nerve deafness in adult</B>s. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is associated with </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">a progressive, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">predominantly symmetric,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> high-frequency hearing loss</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">, and there is a loss of speech discrimination, particularly in noisy places. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is a genetic predisposition.</div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic otitis media can be associated with the ingrowth of keratinizing squamous epithelium, which is called a cholesteatoma </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ear wax decreases hearing but is not associated with a conductive hearing loss.</div> <bR> <div> =====================================================================================================================</div> <div> <B>Hyperkalemia</B></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" > (K</FONT>+ <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >³</FONT> 5.5 mEq/L) and infection are the most life-threatening <FONT SIZE="1" COLOR="#800000" FACE="Arial" >complication</FONT>s associated with ARF. Acute hyperkalemia is poorly tolerated, especially when ARF is associated with extensive tissue damage (crush injuries, tumor lysis, and rhabdomyolysis). The clinical symptoms correlate with the serum K<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+ </FONT>level and range from harmless peaking of the T wave of the ECG to ventricular fibrillation and cardiac arrest. Consequently, this <FONT SIZE="1" COLOR="#800000" FACE="Arial" >complication</FONT> must be addressed on emergent basis. The pharmacologic interventions  are aimed at preventing or reversing the cardiac manifestations of hyperkalemia by reducing the serum K<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+ </FONT>level. This is accomplished by promoting the elimination of K<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+ </FONT>from the body and, if necessary, by causing it to move from the extracellular into the intracellular space. The administration of Ca gluconate has a membrane-stabilizing effect on cardiac cells and serves to counteract the depolarizing effect of elevated extracellular K concentration. </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="959" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=5 BGCOLOR=#FFFFFF HEIGHT= 30 WIDTH="941"><bR> <div> <B>Treatment of Hyperkalemia</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 15 WIDTH="103"><div> <B>Treatment</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="145"><div> <B>Adult dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> <B>Onset</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> <B>Duration</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="465"><div> <B>Comments</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 59 ><NOBR><div> <B>Ca</B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>++</B></FONT><B> Gluconate</B></div> <div> <B>(10 mL of 10%) </B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="145"><div> Up to 9.4 mEqs of Ca<FONT SIZE="1" COLOR="#000000" FACE="Arial" >++</FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" > (20 mL) iv over 3 min.</FONT></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> Immediate</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> 5 - 20 min</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="465"><div> Contraindicated in pts receiving digoxin.</div> <div> <FONT SIZE="1" COLOR="#000000" FACE="Arial" >Don't mix with HCO </FONT>3-</div> <div> May use an equivalent amount of CaCl<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 45 ><NOBR><div> <B>Insulin + glucose</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="145"><div> 5 U + 50 mL D50W</div> <div> or multiple thereof (ratio is 1 unit per 5 g)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> 30 - 60 min</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> 3 - 4 hrs</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> Monitor glucose level</div> <div> This treatment should be preceded by the administration of Ca salt </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 30 WIDTH="103"><div> <B>NaHCO</B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>3</B></FONT></div> <div> <B>(1 mEq/mL)</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> 50 mEqs over 2 - 5 min</div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> 30 - 60 min</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> 0.5 - 3 hrs</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="465"><div> large Na load</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 30 WIDTH="103"><div> <B>Albuterol</B></div> <div> (ß-agonist)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> 0.5 mg iv over 15 min</div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> <30 min</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> 2 -6 hrs</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> May use nebs in place of iv ; watch for tachycardia and tremor</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 45 WIDTH="103"><div> <B>Na polystyrene solfonate (Kayexalate</B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>®</B></FONT>)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> Up to 60 g PO or Rectally</div> <div> May repeat after 3 hrs.</div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> 2 - 3 hrs</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> ---</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="465"><div> Each gram of resin removes 1 mEq of K and adds 2 mEq of Na. Preparation contains sorbitol to prevent constipation</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 15 WIDTH="103"><div> <B>Dialysis</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="145"><div> ---</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="105"><div> Hours</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="111"><div> Variable</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="465"><div> ---</div> </tD> </tR> </TABLE></div> <bR> <div> <B><IMG SRC="0902cef0.png" border=0 width="300" height="239" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="09168d30.png" border=0 width="360" height="211" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="092a6330.png" border=0 width="422" height="307" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="950" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="940"><div> <B>Summary of the Pharmacotherapeutic Management of Chronic Renal Failure</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 95 WIDTH="940"><div> <B>Hyperphosphatemia</B>: </div> <div> Phosphate binders: CaCO3; Ca-acetate; Mg (OH)2; Al(OH)3.</div> <div> For patients who must avoid Al, Ca, and Mg, there is sevelamer (<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U> Renagel</U></FONT>), which decreases the incidence of hypercalcemic episodes in hemodialysis patients relative to patients on calcium acetate treatment. Each Renagel® capsule contains 403 mg of sevelamer. The recommended starting dose is 2 to 4 capsules with each meal depending on the severity of hyperphosphatemia. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 56 WIDTH="940"><div> <B>Secondary Hyperthyroidism & Renal Osteodystrophy</B>:</div> <div> Calcitriol [e.g., 0.25 µg qday]</div> <div> Paricilcitol (Zemplar) [0.04 - 0.1 µg/kg IV 3 times / week] </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 43 WIDTH="940"><div> <B>Metabolic Acidosis</B>:</div> <div> Moderately low protein diet + Alkali (NaHCO3, vegetables)</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 94 WIDTH="940"><div> <B>Anemia</B>:</div> <div> Make sure the patient has an adequate iron level with a transferrin saturation <FONT SIZE="3" COLOR="#000000" FACE="Symbol" >³</FONT> 20%. Oral iron supplementation may be sufficient. However, if necessary use iron dextran or other intravenous iron forms (e.g., Ferrlecit]</div> <div> Vitamin supplements (particularly B12 and folate)</div> <div> Epoetin [starting dose 50 - 100 units/kg SQ 3 times/wk] </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 94 WIDTH="940"><div> <B>Hyperlipidemia</B>:</div> <div> Hypertriglyceridemia: niacin, clofibrate, atorvastatin etc.</div> <div> Hypercholesterolemia (an HMG-CoA-RI like ~webtent/lipitor.html"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>atorvastatin</U></FONT>)</div> <div> To learn more about dyslipidemias click ~webtent/hyperlipidemia.html"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>here</U></FONT></div> <div> Also, here is a summary table of ~webtent/lipidloweringdrugs.html"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Lipid-Lowering Drugs</U></FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 131 ><NOBR><div> <B>Hypertension</B>:</div> <div> Target Blood Pressure: <130/85;</div> <div> Prevent fluid overload, but protect RBF and avoid hyperkalemia</div> <div> Diuretics: avoid K-sparing (specially triamterene);</div> <div> ACE inhibitors: fosinopril is best for renal pts (no dose adjustment required)</div> <div> ß-blockers: labetolol may be the best choice; it does not reduce RBF and does not require renal dose adjustment)</div> <bR> </NOBR></tD> </tR> </TABLE></div> <div>  </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="601" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 39 WIDTH="591"><bR> <div> <B>Drugs excreted mostly unchanged by the kidney</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 76 WIDTH="591"><div> Acyclovir, amantadine, aminoglycosides, amphetamine, ampicillin, atenolol, PCN G, carbapenems carbenicillin, chlorothiazide, cimetidine, clonidine, digoxin, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >furosemide</FONT>, gabapentin, methotrexate, neostigmine, oxytetracycline, propantheline, pyridostigmine, and vancomycin, vit B12. </div> </tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="601" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 39 ><NOBR><bR> <div> <B>Drugs whose active metabolites are excreted mainly by the kidney</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 114 WIDTH="591"><div> Adriamycin, acebutolol, azathioprine, captopril, ceftazidime, chlordiazepoxide, chloroquine, ciprofloxacin, cyclophosphamide, cytarabine, diazepam, digitoxin, disopyramide, enalapril, flecainide, meperidine metoprolol, methyldopa, nitrofurantoin, nitroprusside, primidone, procainamide, propoxyphene, sulfamethoxazole, valproate, and vidarabine.</div> <bR> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="601" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 39 ><NOBR><bR> <div> <B>Drugs Secreted by the Organic Acid Transport System</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 75 WIDTH="591"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">NSAIDs like salicylates and ketorulac.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Penicillins and cephalosporins</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Loop diuretics and thiazide diuretics</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acetazolamide, enalaprilat, methotrexate, etc. </div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="601" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 39 ><NOBR><bR> <div> <B>Drugs Secreted by the Organic Base Transport System</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFF00 HEIGHT= 57 WIDTH="591"><div> Amiloride, atropine, choline, dopamine, ephedrine, epinephrine, ethamutol, H2-blockers, morphine, neostigmine, procainamide (& NAPA), pseudoephedrine, quinidine, quinine, trimethoprim, etc.. </div> </tD> </tR> </TABLE></div> <bR> <bR> </td> </tr></table></body>