CASE STUDIES OF COMMUNICABLE DISEASES HANDLED

A. TYPHOID FEVER
Typhoid fever, otherwise known as enteric fever, is an acute illness associated with fever caused by the Salmonella typhi bacteria. S. typhosa is a short, plump, gram negative rod that is flagellated and actively motile. Contaminated food or water is the common medium of contagion. Stages of Disease: The disease follows four stages. The first stage is known as incubation period, usually 1014 days in occurrence. In this stage generalization of the infection occurs. In the second stage, aggregation of the macrophage and edema in focal areas indicates bacterial localization (embolization) and resultant toxic injury which disappear after few days. The third stage of disease is dominated by effects of local bacterial injury especially in the intestinal tract, mesenteric lymph nodes, spleen, and liver. The fourth stage, or the stage of lysis, is the stage wherein the infectious process is gradually overcome. Pathophysiology Risk factors for acquiring typhoid fever likely include improper food handling, eating food from outside sources like carinderia, drinking contaminated water, poor sanitation and even poor hygiene practices. Both genders do have equal chances on acquiring such disease. Asian, African and Americans are at greatest risks of acquiring the disease since geographical locations play a part. After ingestion in food or water, typhoid organisms pass through the pylorus and reach the small intestine. They rapidly penetrate the mucosal epithelium via either microfold cells or enterocytes and arrive in the lamina propria, where they rapidly elicit an influx of macrophages (Mp) that ingest the bacilli but do not generally kill them. Some bacilli remain within Mp of the small intestinal lymphoid tissue. Other typhoid bacilli are drained into mesenteric lymph nodes where there is further multiplication and ingestion by Mp. It is believed that typhoid bacilli reach the bloodstream principally by lymph drainage from mesenteric nodes, after which they enter the thoracic duct and then the general circulation. As a result of this silent primary bacteremia the pathogen reaches an intracellular haven within 24 hours after ingestion throughout the organs of the reticuloendothelial system (spleen, liver, bone marrow, etc.), where it resides during the incubation period, usually of 8 to 14 days. Symptoms Symptoms slowly disappear and the temperature gradually returns to normal. The symptoms of typhoid fever include high fever, chills, cough, muscle pain, weakness, stomach pain, headache and a rash made up of flat, rose-colored spots. Diarrhea is a less common symptom of a typhoid fever, although it is a gastrointestinal disease. Sometimes

there are mental changes, known as typhoid psychosis. A characteristic feature of typhoid psychosis is plucking at the bed linens if patient is confined to bed. Complications Complications of typhoid fever are secondary conditions, symptoms, or other disorders that are caused by typhoid fever. Complications include overwhelming infection, peritonitis, intestinal bleeding, and intestinal perforation which may eventually lead to death. Diagnostic Tests Typhoid fever is one of the most protean of all bacterial diseases thus laboratory procedures are usually depended on to confirm or disprove suspicion of such disease. The place of blood culture, serologic studies and bacteriologic examination feces and urine are useful in establishing the diagnosis. Agglutination (Widal) for typhoid fever and Typhidot test are done to determine antibody response against different antigenic fractions of organisms. Treatment Modalities Typhoid fever is treated with antibiotics which kill the Salmonella bacteria. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. General management Supportive measures are important in the management of typhoid fever, such as oral or intravenous hydration, the use of antipyretics, and appropriate nutrition and blood transfusions if indicated. Antimicrobial therapy Efficacy, availability and cost are important criteria for the selection of first-line antibiotics to be used in developing countries. Drug of choice The fluoroquinolones are widely regarded as optimal for the treatment of typhoid fever in adults. The available fluoroquinolones (ofloxacin, ciprofloxacin, fleroxacin, perfloxacin) are highly active and equivalent in efficacy (with the exception of norfloxacin which has inadequate oral bioavailability and should not be used in typhoid fever). The conventional therapy for uncomplicated cases of typhoid fever is as follows: Chlorampenicol 3-4 gm per day PO in 4 divided doses for 14 days or Co-Trimoxazole forte or double -strength tab twice a day PO for 14 days or Amoxyxillin 4-6 gm per day PO in 3 divided doses for 14 days Management of complications In severe typhoid the fluoroquinolones are given for a minimum of 10 days. Typhoid fever patients with changes in mental status, characterized by delirium, obtundation and stupor, should be immediately evaluated for meningitis by examination of the cerebrospinal fluid. If the findings are normal and typhoid meningitis is suspected, adults and children should immediately be treated with high-dose intravenous dexamethasone in addition to antimicrobials.

Nursing Management Health Teaching Teach members of the family how to report all symptoms to the attending physician especially when patient is being cared for at home Teach, guide and supervise members of the family on nursing techniques which will contribute to the patients recovery Interpret to family nature of disease and need for practicing preventive and control measures. Management Demonstrate to family how to give bedside care such as tepid sponge, feeding changing of bedlinen, use of bedpan and mouth care Any bleeding from the rectum, blood in stools sudden acute abdominal pain restlessness, falling of temperature should be reported at once to the physician or the patient should be brought at once to the hospital. Take vital signs and teach patient family member how to take and record same. Prevention Vaccination: VI vaccine this is thought to be 75% effective against typhoid fever in the first year after vaccination. VI vaccine is more effective than Ty21a and is given by injection. The protective effect of the VI vaccine will last for around three years, after which a follow-up booster vaccination will be required. Ty21a vaccine this is thought to be 5060% effective against typhoid fever in the first year after vaccination. Some people prefer to have the Ty21a vaccine because it is available as a tablet. However, as the Ty21a vaccine contains a live sample of Salmonella typhi bacteria, it is not suitable for people who have a weakened immune, such as people with HIV. The Ty21a vaccine will last for around one year before a booster shot is required. Avoiding Risky Foods and Drinks: For drinking water, buy it bottled or bring it to a rolling boil for one minute before you drink it. Bottled carbonated water is safer than noncarbonated water. Ask for drinks without ice, unless the ice is made from bottled or boiled water. Avoid Popsicles and flavored ices that may have been made with contaminated water. Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors. Eat foods that have been thoroughly cooked and that are still hot and steaming. Avoid raw vegetables and fruits that cannot be peeled.

B. DENGUE FEVER
Dengue fever is a mosquito borne disease. Dengue fever occurs in a wet and warm climate of the monsoon season and declines in the winter when mosquitoes are rendered inactive. It is caused by the bite of an infected mosquito Aedes Aegypti. These mosquitoes then transmit the virus to human. The virus that causes dengue fever is called an ARBO Virus Arthropod Born Virus. Dengue Virus: Dengue fever DF and Dengue Hemorrhagic fever DHF are caused by one of four closely related but antigenicaly distinct virus serotypes DEN 1, DEN 2, DEN 3, DEN 4 of the genus Flavi-virus. Transmission There are two factors which play important role to spread the dengue virus Vector and Host. An animal including human that can be infected with a particular disease is called Host. An organism that can carry a particular disease causing agent (virus) without developing the disease is called Vector. Dengue viruses require an intermediate vector. Here the mosquito which is infected by biting an infected patient, works as an intermediate vector. Within seven to ten days of the bite, the mosquito becomes infected and remains infected for the rest of its life. However the virus is not transmitted to the progeny of the insect. This infected mosquito bites a normal person and passes the virus into his body. After the virus has been transmitted to the human host, the virus travels to various glands where it multiplies. The viruses then enter into the blood stream. This process takes five to eight days and this period is called incubation period. Phases and Symptoms of Dengue Fever There are three phases of dengue. (1) Febrile Phase (2) Critical Phase and (3) Recovery Phase 1) Febrile phase: Patients typically develop high-grade fever suddenly. This acute febrile phase usually lasts 27 days and is often accompanied by Facial flushing Skin erythema (redness of the skin due to congestion of the tiny blood vessel) Generalized body ache Myalgia (Muscular pain) Arthralgia (pain in joints) Headache Some patients may have sore throat, infected pharynx, anorexia (decreased appetite), nausea and vomiting. 2) Critical phase: Around the time of remission of fever, when the temperature drops to 37.538C or less and remains below this level, usually on days 37 of illness, an increase in capillary (tiny blood vessels) permeability in parallel with increasing haematocrit (the percentage volume of red blood cells in the blood) levels may occur. This marks the beginning of the critical phase. The period of clinically significant plasma leakage usually lasts 2448 hours. Progressive leukopenia (decreased number of total white blood cells in the blood) followed by a rapid decrease in platelet count usually precedes plasma leakage. At this point patients without an increase in capillary permeability will improve, while those with

increased capillary permeability may become worse as a result of lost plasma volume. This condition is called Dengue Hemorrhagic Fever (DHF).DHF that deteriorate into shock is called Dengue Shock Syndrome (DSS). About one third of the patients with DHF will develop shock. It usually occurs around the time when the fever subsides. 3) Recovery phase If the patient survives the 2448 hour critical phase, a gradual re-absorption of extra vascular compartment fluid takes place in the following 48-72 hours. General well-being improves, appetite returns, gastrointestinal symptoms abate, hemodynamic status stabilizes and diuresis ensues. Some patients may have a rash of isles of white in the sea of red. Some may experience generalized pruritus. Bradycardia and electrocardiographic changes are common during this stage. White blood cell count usually starts to rise soon after remission of fever but the recovery of platelet count is typically later than that of white blood cell count. Alarming signs and symptoms: Alarming signs and symptoms are situations where extra caution is needed. In a dengue outbreak, the following can be alarming signs and symptoms: Abdominal Pain: Acute abdominal pain is a frequent complaint shortly before the onset of shock. When it occurs just around the time of the fever subsiding, suspicion must be raised. Bleeding : Bleeding phenomenon to watch out for and to monitor are epistaxis, bleeding gums, gastrointestinal bleeding, and menorrhagia. Presence of easy bruising, petechiae and a positive tourniquet test indicate the presence of hemorrhagic phenomenon. The patient may have developed DHF. Rapid fall in temperature: In DHF, the critical phase of illness often occurs at the end of the febrile period. Falling temperature may be accompanied by signs of circulatory failure of variable levels of distress. Diagnostic Tests Serological tests: IgM is the first immunoglobulin to appear and it is followed by the IgG in due course, in the acute phase in serum. These antibodies can only be detected after 4 to 6 days of the clinical signs and symptoms. However, dengue NSI antigen must be employed, as it is positive within first 24 hours of onset of the fever. For the prompt diagnosis, the dengue NSI Ag should be done as soon as the first clinical sign appear. NSI Ag test offers an early detection of the primary infection as compared to the conventional serology employed currently, as it saves time by at least 4 to 6 days. Daily total white cell count and platelet count: Leukopenia helps in the clinical diagnosis of dengue fever. Platelet count helps in the monitoring of patients for the development of complications. A platelet count of < 80,000 cells per cubic mm is a criterion for hospital referral and admission. Apart from absolute numbers, trends and clinical correlations should be taken into consideration. Treatment There is no established cure for dengue. The patient is to be treated symptomatically for secondary infection or ailments. At the most, Nimesulide and Paracetamol may be given to reduce muscle aches and fever. Nimesulide and Paracetamol are metabolized by the liver and are hepatotoxic in high doses.

Platelets replacement by platelet concentrate, fresh plasma or whole blood. Generally, the platelet count falls below 40-50,000/mm and hemorrhagic rash does not appear in all cases. However, if the platelets are reduced to a level of about 20,000/mm in a patient, platelet therapy becomes necessary, as the chance of bleeding become more. However, platelets are decrease in number of diseases other than dengue (e.g. malaria and other viral diseases) The patient has to be well hydrated.

Nursing Management Supportive management which could be symptomatic in nature may involve: Rapid replacement of fluids: clients are encouraged to increase their fluid intakes as much as possible if tolerated; In the community, ORS is given to halt moderate dehydration at 75ml/ kg in 4 -6 hours or up to 2- 3 liters in adults. Close observation and intensive monitoring of vital signs Early detection for signs of bleeding and immediate referral Use of Tourniquet test (Rumpel Leade test) to detect petechial haemorrhage Health education on the prevention of hemorrhage may include: Avoidance of dark colored foods and liquids Client is encouraged to prevent from using sharp- bristled toothbrushes, instead advised to gargle with saline solution Clients are educated not to use hot liquids for alleviation of chills etc. Avoidance of sharp objects like razors are emphasized on adults The use of ASPIRIN is strictly prohibited. In cases that hemorrhage sets in, nursing care may involve the following: Keep the client at bed rest and ensure safety to prevent from injury Client is usually placed in dorsal recumbent position. Hourly monitoring noting for narrowing pulse pressure, sudden drop in temperature, decreased blood pressure and pulse rate and other signs of deterioration. Monitoring client for signs of adverse reactions from blood products administered. Strict monitoring of fluid intake and output Immediate referral for any change in clients status and proper documentation of procedures given. Prevention The Four S drive implemented by the Department of Health corresponds to: Search and destroy the mosquito dengue carriers breeding (recently pinpointing buko shell or coconut shells, tires, and bromeliads). It may also involve frequent changing of water and scrubbing sides of vases and keeping water containers covered at all times, destroying of breeding places stated above by cleaning the surroundings (3Oclock habit) and proper disposal of tires and containers. Self protection against mosquito (use of loose clothing with long sleeves and long socks, use of mosquito nets, tested mosquito repellants and the like) Seek early consultation (Early detection of condition means treatment could be administered readily to prevent fatal complications of dengue). Say NO to indiscriminate fogging (Fogging is not advised nowadays because it does not really eliminate mosquitoes but it only scares them away. It is also not recommended because of its respiratory consequences).

C. PULMONARY TUBERCULOSIS
Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs. TB is caused by the bacteria Mycobacterium tuberculosis (M. tuberculosis). Pathophysiology When the patient inhales a droplet of tuberculosis or particle of dried sputum, the organisms are phagocytized (or "eaten") by the white blood cells of the immune system, but this does not kill them. Inside the white blood cells, the living microbes slowly multiple until the white blood cells burst. After bursting from the white blood cells, if the tuberculosis is in the lungs, an acute inflammatory response follows, causing pneumonia-like symptoms. The bacteria form lesions in the lungs, which solidify into nodules called tubercles. If the tubercles are near blood vessels, they can perforate the vessels and cause hemorrhage, resulting in blood-tinged spit. The following people are at higher risk for active TB: Elderly Infants People with weakened immune systems, for example due to AIDS, chemotherapy, diabetes, or certain medications The following factors may increase the rate of TB infection in a population: Frequent contact with people who have TB Poor nutrition Crowded or unsanitary living conditions Increase in HIV infections Increase in number of homeless people (poor environment and nutrition) The appearance of drug-resistant strains of TB Symptoms The primary stage of TB usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include: Cough (usually cough up mucus) Coughing up blood Excessive sweating, especially at night Fatigue Fever Unintentional weight loss Other symptoms that may occur with this disease: Breathing difficulty Chest pain Wheezing

Signs and Tests Physical examination shows: Clubbing of the fingers or toes (in people with advanced disease) Swollen or tender lymph nodes in the neck or other areas Fluid around a lung (pleural effusion) Unusual breath sounds (crackles) Tests may include: Biopsy of the affected tissue (rare) Bronchoscopy Chest CT scan Chest x-ray

Interferon-gamma blood test such as the QFT-Gold test to test for TB infection Sputum examination and cultures Thoracentesis Tuberculin skin test (also called a PPD test)

Treatment The goal of treatment is to cure the infection with drugs that fight the TB bacteria. Treatment of active pulmonary TB will always involve a combination of many drugs (usually four drugs). All of the drugs are continued until lab tests show which medicines work best. The most commonly used drugs include: Isoniazid Rifampin Pyrazinamide Ethambutol Other drugs that may be used to treat TB include: Amikacin Ethionamide Moxifloxacin Para-aminosalicylic acid Streptomycin When people do not take their TB medications as recommended, the infection may become much more difficult to treat. The TB bacteria may become resistant to treatment, and sometimes, the drugs no longer help treat the infection. When there is a concern that a patient may not take all the medication as directed, a health care provider may need to watch the person take the prescribed drugs. This is called directly observed therapy. In this case, drugs may be given 2 or 3 times per week, as prescribed by a doctor.

Nursing Management Help incubation emergency if necessary. Give medications: bronchodilators, corticosteroids as indicated as per order. Maintain a fluid intake. Clean secretions from the mouth and trachea, suction if necessary. Give the patient or the semi-Fowler position for effective coughing and breathing exercises. Encourage or provide good mouth care after coughing. Breath deeply and slowly when sitting as straight as possible. Teach the client about the proper method of controlling cough.

Expectations (prognosis) Symptoms often improve in 2 - 3 weeks. A chest x-ray will not show this improvement until weeks or months later. The outlook is excellent if pulmonary TB is diagnosed early and treatment is begun quickly. Complications Pulmonary TB can cause permanent lung damage if not treated early. Prevention Vaccination: Bacille Calmette Guerin (BCG) is the current vaccine for tuberculosis. It was first used in 1921. BCG is the only vaccine available today for protection against tuberculosis. It is most effective in protecting children from the disease. Avoid getting an active TB infection: Do not spend long periods of time in stuffy, enclosed rooms with anyone who has active TB until that person has been treated for at least 2 weeks. Use protective measures, such as face masks, if you work in a facility that cares for people who have untreated TB. If you live with someone who has active TB, help and encourage the person to follow treatment instructions.

D. TETANUS
Tetanus is infection of the nervous system with the potentially deadly bacteria Clostridium tetani (C. tetani). Pathophysiology Spores of the bacteria C. tetani live in the soil and are found around the world. In the spore form, C. tetani may remain inactive in the soil, but it can remain infectious for more than 40 years. Infection begins when the spores enter the body through an injury or wound. The spores release bacteria that spread and make a poison called tetanospasmin. This poison blocks nerve signals from the spinal cord to the muscles, causing severe muscle spasms. The spasms can be so powerful that they tear the muscles or cause fractures of the spine. The time between infection and the first sign of symptoms is typically 7 to 21 days. Symptoms Tetanus often begins with mild spasms in the jaw muscles (lockjaw). The spasms can also affect the chest, neck, back, and abdominal muscles. Back muscle spasms often cause arching, called opisthotonos. Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems. Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups. This is called tetany. These episodes can cause fractures and muscle tears. Other symptoms include: Drooling Excessive sweating Fever Hand or foot spasms Irritability Swallowing difficulty Uncontrolled urination or defecation Tests Your doctor will perform a physical exam and ask questions about your medical history. No specific lab test is available to determine the diagnosis of tetanus. Other tests may be used to rule out meningitis, rabies, strychnine poisoning, and other diseases with similar symptoms. Treatment Antibiotics, including penicillin, clindamycin, erythromycin, or Metronidazole (Metronidazole has been most successful) Bedrest with a nonstimulating environment (dim light, reduced noise, and stable temperature) Medicine to reverse the poison (tetanus immune globulin) Muscle relaxers such as diazepam Sedatives Surgery to clean the wound and remove the source of the poison (debridement) Breathing support with oxygen, a breathing tube, and a breathing machine may be necessary.

Nursing Considerations While a very dangerous disease, it's not (easily) communicable. Lots of IV's in a convulsive patient spell trouble with sharps; be very alert. Restraints are problematic in that the patient is not in control of the spasms, and so you cannot assume that pain will act to slow the patient down; be prepared for potential damage from restraints, if used. Cardiac and respiratory problems abound, so constant observation in severe cases is called for, even more than is usual in ICU's. Note that neonatal tetanus does in fact exist and should be a consideration in administering childbirths. Expectations (prognosis) Without treatment, one out of four infected people die. The death rate for newborns with untreated tetanus is even higher. With proper treatment, less than 10% of infected patients die. Wounds on the head or face seem to be more dangerous than those on other parts of the body. If the person survives the acute illness, recovery is generally complete. Uncorrected episodes of hypoxia (lack of oxygen) caused by muscle spasms in the throat may lead to irreversible brain damage. Complications Airway obstruction Respiratory arrest Heart failure Pneumonia Fractures Brain damage due to lack of oxygen during spasms Prevention Immunization: Tetanus is completely preventable by active tetanus immunization. Immunizations begin in infancy with the DTaP series of shots. The DTaP vaccine is a "3-in-1" vaccine that protects against diphtheria, pertussis, and tetanus. It is a safer version of an older vaccine known as DTP. Td vaccine or Tdap vaccine is used to maintain immunity in those ages 11 and older. Td boosters are recommended every 10 years starting at age 19. Thorough cleaning of all injuries and wounds and the removal of dead or severely injured tissue (debridement), when appropriate, may reduce the risk of developing tetanus. If you have been injured outside or in any way that makes contact with soil likely, contact your health care provider regarding the possible risk for tetanus.

E. HIV INFECTION / AIDS

HIV infection is a communicable disease caused by the human immunodeficiency virus (HIV) which damages the body's immune system, the system that fights infections. Over time and without the immune system's protection, the body is defenseless against serious and potentially life-threatening diseases which can lead to the development of Acquired Immune Deficiency Syndrome (AIDS), the later stage of HIV infection. Pathophysiology A retrovirus, the Human Immunodeficiency Virus (HIV) was identified in 1983 as the pathogen responsible for the Acquired Immunodeficiency Syndrome (AIDS). AIDS is characterized by changes in the population of T-cell lymphocytes that play a key role in the immune defense system. In the infected individual, the virus causes a depletion of T-cells, called T-helper cells, which leaves these patients susceptible to opportunistic infections, and certain malignancies. Transmission HIV is found in all the body fluids including saliva, nervous system tissue and spinal fluid, blood, semen, pre-seminal fluid, which is the liquid that comes out before ejaculation, vaginal secretions, tears and breast milk. Only blood, semen, and breast milk have been shown to transmit infection to others. The virus is transmitted by sexual contact including unprotected oral, vaginal, and anal sex and via transfusion of contaminated blood that contains HIV. Another mode of transmission is sharing needles or injections with HIV infected individuals. A pregnant woman can transmit the virus to her unborn baby through their shared blood circulation, or a nursing mother can transmit it to her baby in her breast milk.

Symptoms of HIV/AIDS HIV infection may cause no symptoms for a decade or longer. At this stage carriers may transmit the infection to others unknowingly. If the infection is not detected and treated, the immune system gradually weakens and AIDS develops. Disease Progression With advancing HIV infection the blood shows higher viral load and CD4 T-cell count drops below 200 cells/mm3. CD4 cells are a type of T cell. T cells are cells of the immune system. They are also called "helper cells." Opportunistic infections These are infections that normally do not affect an individual with a healthy immune system but AIDS patients are susceptible to these infections. These include viral infections like: herpes simplex virus herpes zoster infection cancers like Kaposi sarcoma, non-Hodgkins lymphoma fungal infections like candidiasis bacterial infections like tuberculosis

Other infections include Bacillary angiomatosis, Candida esophagitis, Pneumocystic jiroveci pneumonia, AIDS dementia, Cryptosporidium diarrhea, cryptococcal meningigits and Toxoplasma encephalitis. Treatment of AIDS There is no cure for AIDS once it develops. There are agents available that can help keep symptoms at bay and improve the quality and length of life for those who have already developed symptoms. Drugs against HIV include antiretroviral therapy. These prevent the replication of the HIV virus in the body. A combination of several antiretroviral drugs, called highly active antiretroviral therapy (HAART), has been very effective in reducing the number of HIV particles in the bloodstream. Preventing the virus from replicating can improve T-cell counts or CD4 cell counts and help the immune system recover from the HIV infection. Medicines are also prescribed to prevent opportunistic infections if the CD4 counts are low. Nursing Goals of Management Monitoring of disease progression -Baseline assessment -Patient education -Psychosocial aspects Prevent opportunistic infections Monitoring antiretroviral treatment Management of signs and symptoms Prevent complications of treatment Outcome of HIV AIDS is almost always fatal without treatment. HAART however has dramatically increased the amount of time people with HIV remain alive. Prevention of HIV Safe sex measures (e.g. use of condoms, practice abstinence or monogamy) Shunning use of illicit drugs or shared needles or syringes Avoidance of contact with blood and fluids by wearing protective clothing, masks, and goggles etc. helps prevent transmission HIV-positive women who wish to become pregnant may need therapy while they are pregnant to prevent transmission to their babies. Avoid breastfeeding to prevent transmitting HIV to their infants through breast milk.