Kolaeva notes

Hepatitis

1) Preicteric
a. Flu like
b. Dyspeptic
c. Asthenic
2) Protein enzyme dissociation
a. Hepatitis (must know)
3) Criteria of severity (laboratory criteria)
a. Main prothrombin index
i. <50 hemorrhagic syndrome
ii. NORMAL= 80-100
b. AST/ALT (Beritsane test)
i. >1 severe
ii. <1 moderate/ mild
1. GOLGI APPARATUS (mitochondria organelles) AST
2. ALT cell membrane
c. Bilirubin enzyme dissociation
i. Bilirubin increase
ii. Enzyme decrease ( due to enzyme that is used to dissociate bilirubin)
d. Sedimentation test
i. Albumin: globulin decrease (progress to cirrhosis)
1. Protein acute phase
2. Severe case of parenteral hepatitis 1.6-2.4
e. Solimovine test

4) Criteria of severity by clinical manifestation

a. Hemorrhagic syndrome
b. Anorexia
c. Dyspeptic syndrome
d. Repeated vomiting
e. Aseptic fever
f. Hiccups
g. Bradycardia and tachycardia

Cholera

- Stool characteristics
o Cloudy, white fluid that is odourless, rice water like
 HYPERSECRETORY mechanism
 No inflammation
- Vomiting
o Vomiting (WITHOUT nausea due to regurgitation)
 Destruction of epithelial cells
- Absence of INTOXICATION syndrome
 o No invasion (LPS not destroyed_
o No presence of constipation and no temperature
- What is algit
o Cold cholera (happened after fever)
- What are the drugs for ORS (I and II severity)
o ORS
o Rehydrone
o Oralit
o Citroglucosalane
- Crystalloid (III and IV)
o Disalt
o Threesalt
o Quartersalt
o Chosalt
o Acesalt
- What is the difference between crystalloid and ORS?
o Crystalloids have no glucose
o ORS is only for patient without vomiting
- Criteria of adequate rehydration therapy
o 7 steps
 Hemodynamics stabilisation
 Restoration of peripheral pulse and BP normalisation
 Restoration of normal body temperature after hypothermia
 Restoration of active diuresis
 30-40 min after beginning of rehydration therapy
 Cessation of volume
 Disappearance of muscle cramps
 Restoration of natural skin colour and turgidity
- What vaccines are present for cholera
o Killed
 Dukoral
o Live
 Orachal and mutachol
- Contraindication drugs
o Colloids
 It will absorb ion in patients with diarrhea will worsen
 Rheopolyglucin
 Hemodezerin (hemodez)

o Epinephrine
 Blood clotting
o Codeine/ caffeine
 Spasm
 Acute renal failure may develop
o Hydrochloride
 Give antibiotic 3-5 days to stop enterotoxin and stop diarrhea
 - Enterosorbents
o Bismuth salts
o Enterogel
o Active urogel

Rehydration therapy

- 2 phases
o Rehydrate
 Must do before 4 hours
o Maintenance
 Until diarrhoea stops
- There will the special poses done by the patient (gladiator pose )

Botulism

What are the 1st clinical manifestations?

A) Prodromal symptoms
a. Gastroenteritic variant
i. Nausea/ vomiting/ diarrhoea
1. Leads to constipation and dry mouth
b. Ocular variant
i. Blurred vision (in a fog_
1. Acute farsightedness
c. Acute respiratory failure
i. Air shortage and pain in thorax
B) General intoxication symptoms
a. Headaches
b. Dizziness
c. Muscular weakness
d. Insomnia
C) Paralytic period
a. Symmetrical impairment (descending)

Treatment

1) Hospitalisation
2) Induce vomiting and gastric lavage
a. Others need to refer to notes
i. Specifics
1. Serotherapy
2. Serum trivalent botulism antitoxin
a. Type A: 10000:4
b. Type B: 5000:4
c. Type E: 10000: 4
 i. Give 3-4 days
d. Must give fraction ( leptospirosis)

Food poisoning

Salmonellosis

INVASION with INTOXICATION syndrome

Classification

1) GI form
a. Gastritis
b. Gastro
c. Gastroenterocolitis
2) General typhoid like and septic form
3) Intestinal
a. Carrier state
i. Acute
ii. Chronic
iii. Transient

What is an exanthema?

- Rash on skin

What is an enanthema

- Rash on mucosa

Serological examination

1) Check for AB 5-7 days after disease onset

a. Indirect hemmaglutination
i. 1: 200
b. Complement fixation test
i. 1: 160
1. In dynamics there is an increase in titre (10-12 days)
2) Detect antigens in first day of disease
a. Co agglutination reaction
i. Only take around 20 mins
b. Latex agglutination reaction

Brucellosis

1) Diagnostics
 a. Skin test (allergen)
i. Brucellin
2) Why is there polymorphism? Why is it called the monkey of diseases?
a. It has antigen mimicry and mimics human tissue ( for brucellosis and yersinosis)

Shigellosis

1) Clinical variants
a. Colitis
b. Gastroenterocolitis
c. Gastroenteritis
2) Diagnostics
a. Colonoscopy (DDX other diseases only)
i. Can cause further complication
3) Colitic variant
a. Large amount of stool
b. Increase in number of defecation
c. Decrease volume of stool (mucus, blood, pus)
d. Pain in lower abdomen (LLQ)
i. Spasm of sigmoid colon
e. False needs
f. Tenesmus
i. Pain during defecation around anus
4) Components of shiga toxin
a. Cytotoxin
b. Neurotoxin
c. Enterotoxin
d. Hemolysin
5) What plexi are present at the small intestine
a. Auerbach
b. Meissner
i. (gastroenterocolitic dehydration due to neurotoxin)
1. Causes distal spastic tenesmus
6) Colitic variant does not have dehydration

7) What is reiter’s syndrome?

a. Urethritis
b. Conjunctivitis
c. Arthritis
i. Where else can u see reiters?
1. Salmonellosis
2. Yersiniosis (secondary focal form)
3. Post shigellosis
4. Chlamydia
Probiotics

- Treat dysbiosis
o Coribacterin
o Lectobacterin
o Bificol
o Linex

Typhoid fever

Where can we see L forms?

- In macrophages of skin
- Regional lymph nodes
- Bone marrow

In what other diseases can we see L forms?

- Erysipelas
o Treat relapse with lincomycin
 0.6> 3 times/d for 7 days
- Typhoid fever
- Yersiniosis

What are the kinds of lymphoid tissue present in intestine?

- Mesentarial lymph nodes

- M cells
- Peyer’s patches
- Solitary follicles

Drainage of lymphoid tissue edematous

Why does the patient look pale with high fever?

- Plethora abdominalis
o All the blood enters the abdomen
o When there is internal haemorrhage ( cold patch)
 Do not press
 Can cause perforation (need surgery)

Many symptoms of bleeding

1) Constipation  peristalsis
 2) Initial maybe diarrhea
3) Severe melena

Stages of morphological changes of lymphatic apparatus of small intestine

- Week 1: cerebriform swelling of Peyer’s patches and solitary follicles

- Week 2: necrosis
- Week 3: necrotic mass rejection (dirty ulcer)
- Week 4: clear ulcer
- Weeks 5-6: healing ulcer

Remember clinical classification

Clinical picture

a) Incubation period
a. 5-7 days
b. Subfebrile temperature
c. Increase in intoxication syndrome
d. Relative bradycardia
i. Pulse does not correlate to temperature ( temperature is 40 degrees bu
pulse is normal)
ii. If it is absolute
1. Increase in temperature will increase in pulse
e. Typhoid tongue
i. Back of tongue is brown
ii. Dry
iii. Teeth sign on tongue
iv. Incomplete closure of teeth
v. Edematous
vi. Thick
b) Padalka symptom
a. Percussion of RIF (painful)
i. Mesenteric lymphadenitis sign
ii. Can be seen in salmonella generalised form (typhoid fever like), yersiniosis,
tularemia
c) Rovsing sign
a. Palpate L iliac fossa, pain is seen on the R iliac fossa
d) Sternberg sign
e) Mark federna sign
a. From umbilicus go 90 degree 2-4 cm downwards
b. Palpation indicates pain

What is the triad of typhoid

 - Sleeplessness
- Headache
- Hyperpyrexia

Important complications of typhoid fever (5)

1) GT perforation
2) GI haemorrhage
3) Infection, intoxication shock (1st)
4) Myocarditis
5) Psychotic states

Treatment

- Remember antibiotics name and dosage

o Must not first line of treatment

Yersiniosis

Clinical classes

Local GI form:

- Acute appendicitis
- Gastroenterocolitis
- Terminal ileitis
- Mesenteric lymphadenitis

What is the strawberry tongue?

- Hyperplasia of epithelium

What is scarlet fever like form?

1) Red rash
2) Catarrhal angina (tonsillitis and can cause sore throat)
3) Desquamation of skin of extremities
4) Intoxication syndrome
5) Diarrhoea
6) Abdominal pain
7) Ileitis
8) Appendicitis

Why is there polymorphism?

 - Monkey of diseases

If it is caused by virus:

- Leukopenia
- Lymphomonocytosis
- Neutropenia ( shift to left)
- Eosinophilia

Intoxication stimulates endotoxin syndrome

SEM 2

ERYSIPELAS
What are the chronic streptococci foci?

- Tonsillitis
- Nephritis
- Arthritis
- Paroxysm

Acute strep infex if relapses becomes chronic

- Serous and hemorrhagic complex of necrosis ( not pus occurs)

Differentiate disseminated and metastatic

What is erythematous

- Erythema with edema

- Erythematous bullous
- Erythema bullous (edema or maybe 2)
- Bullous hemorrhagic
o May be bullous and serous with petechiae, erythema and edema

What are the consequences?

- Lymphostasis
o Lymphatic edema
- Fibredema
o Secondary elephantiasis

- Lymphatic edema - Fibroedema

 - Soft - Hard
- Warm - Cold
- On pressing, dents are seen - Hyperkeratosis
- Fold - Cannot fold
- Firm

Frequency of course

1) Primary
2) Repeated
a. Arise in 2 years other localisation of process
3) Relapsing
a. Due to L forms
b. Present not less than 3 relapses a year

L forms ( where can u see it?)

- Typhoid fever
- Erysipelas
o Relapse treat with lincomycin
 0.6g> 3 times a day for 7 days
- Yersiniosis
- Meningococcal disease

Location of L forms

1) Macrophage of skin
2) Regional lymph nodes
3) Bone marrow

Convalescence

- Will cause recurrence of symptoms

o Subfebrile temperature
o Increase in infiltration of skin
o Regional lymphadenopathy

Desensitizing antihistamine therapy

- Suprastin

Physiotherapy

- Laser and UV for acute periods

 - Magnet therapy after convalescence
- Radenavarim
o Prophylaxis of elephantiasis

What are the names for bicillin and prolonged penicillin?

- Bicillin 5
- Extensilin
- Rhertarpin

Erysipelas season

- In july, august, September, October

What is the severity of erysipelas?

- Hyperpyrexia
- Dyspepsia
- Nausea without vomiting

Influenza

- What are the 2 pathogenic factors?

o Neuraminidase
o Hemaglutinin
- Drift vs shift
o Drift
 Endemic
 Mutation of neuraminidase and hemagglutinin
o Shift
 Changes in structure of neuraminidase and hemagglutinin
- Is nose bleeding present
o No
- Processes occurring in nose
o Nose pharynx ( lymphoid, milky maybe adenovirus)  larynx (laryngitis, cough,
aphonia due to action of parainfluenza) trachea ( chest signs) bronchus
bronchiole alveoli
- Criteria of severe course of disease
o Hemorrhages
 Nasal bleeding
o Differences of exanthema and enanthema
 Exanthema is rash on skin
 Enathema is rash on mucosa
- Hepatolienal syndrome
o Adenoviral symptoms
 - Reyes syndrome
o After use of aspirin
o Influenza disease
 Contraindication of asthmatic symptoms in patient
 Can see bronchospasm
 Aspirin causing bronchospasm
 Is RR >40 /min can consider pneumonia
o Conjunctival signs: adenovirus
o Immunodiagnostics
 Immunofluorescence
 Increase titer of antibodies by 4 times
- Treatment
o Theraflu-paracetamol
o Tamiflu-oseltamivir

Meningococcal infection

1) Meningococcemia
a. From blood
2) Granuloma tularemia and rickettsia
3) All neurologic symptoms (like dysphagia, dysarthria, strabismus)
a. All are under botulism
4) Glucocorticoid
a. For severe infectious toxic shock
b. Stabilise hemodynamics
c. Membrane stabilisation
5) Prophylaxis of brain edema
a. Diuretics
i. Furosemide
b. Lasix
6) Why is meningococcal infection causing a decrease in glucose level?
a. Meningococcal bacteria loves glucose
7) Why do we administer higher dose of antibiotics (penicillin in meningitis)
a. As compared to erysipelas
i. Need of the drug to penetrate BBB
8) What other diseases can we use penicillin
a. Erysipelas
b. Meningococcal infection
9) What are the complications of the disease?
a. Brain edema
b. Meningeal liquor ( from CSF)?
c. Infectious toxic shock
10) If meningitis start what is the drug of immediate use?
a. Ceftriaxone regardless of aetiology
11) If there are hemorrhages what do u use?
a. Chloramphenicol (bacteriostatic)
12) If there are no symptoms
 a. Use penicillin with ceftriaxone and detoxification
i. Prevention of ITS
b. Pneumococcal meningitis resistance to penicillin is up to 20
13) What is meningitis
a. There are signs of headache/ vomiting without nausea and meningeal syndromes
with liquor changes
i. Liquor changes ( milky white)
14) What is the difference between meningism(pre meningitis) and meningitis

Meningism Meningitis
a. Increase in ICP b. Meningeal syndromes
c. No meningeal syndromes d. Change in liquor colour

15) Meningeal syndromes ( 4 groups)

i. Hyperesthesia
1. photophobia/ hyperacousia/ increase tactile sensation
ii. Hypertonus
1. Brudzinski sign
a. Upper
i. flexion of neck with involuntary flexion of leg
b. Middle
i. Flexion of hip with involutionary flexion of leg
c. Lower
i. Flexion of leg with involuntary flexion of other leg
2. Meningeal pose
a. Lie on one side with head thrown backwards and tighten
stomach area
b. Due to rigidity of longitudinal spine
iii. Reactive pain symptoms
1. Puladova symptom
a. Pain during skill percussion
2. Mendele symptom
a. Pain when ears are closed
3. Bextereba sign
a. Pain on percussion of cheek bone
4. Kerera sign
a. Pain on palpation of occipital fossa
5. Retroorbital pain
iv. Changes to Achilles tendon
1. In meningococcal disease, increase then decrease reflex
- Diagnostics
o Nonne applet test
 Presence of globulin in CSF
o Pandy test
 Detect proteins (globulin in CSF)
 Cell protein dissociation
Leptospirosis

Meningitis is purulent Meningococcal disease

- Meningitis is leptospirosis is serous

RHABDOMYOLYSIS

skin allergy test

- Tularin for tularemia

o Lesion >5 mm in diameter is positive

Which other tests have similar diagnostics?

- Brucellosis Brucellin test

- Mantoux test

Therapy

- Desredka
o Give fractionally
o Same as in botulism antitoxin

Malaria

Bradysporozoites

- In liver tissue

Malaria malariae

- Small dose

Paroxysm

- Chills fever and sweats

Why is falciparum severe?

- Increase parasitemia floor in blood

o Affects young and old RBC
- Affects microcirculation and vessels
o Small vessels in organs, brain. Intestine( diarrhoea) (only falciparum species got
diarrhoea)

HIV
 1) HIV is more dangerous or Hep?
a. HEP ( only need a small infectious dose)
2) Damage of HIV is to?
a. Neuroglia
b. Myocytes
c. CD4+ and T lymphocytes
i. Normal CD4 + is 500-1800/1900)
3) Kaposi’s sarcoma
a. For young <60 yo
4) 2 methods of diagnosis
a. ELISA
i. Screening
b. Immunoblots
i. For antibody detection and confirmation
ii. Elisa can be wrong
1. Esp in pregnant women
5) Remember 3 groups of treatment
6) Infectious mononucleosis
a. Fever
b. Lymphadenopathy
c. Pharyngitis
d. Rash
e. Lymphomonocytosis (viral infection)
f. Stomatitis
g. Temperature is febrile
h. Angina
i. Polylymphadenopathy
j. Hepatolienal syndrome
i. More common in EBV than CMV ( infectious mononucleosis)

Plague

Y. pt 8 serovars

Y enterocolitica >50 types

- More severe forms is primary pneumonic type

o Erythema nodosum yersiniosis
- Socks like, gloves like is caused by
o Y. PT

Incubation 5d

- Chalk like tongue is typical

Inx
 - Biological mice
- Hemogram
o Leucocytosis
o Neutrophils shift to left

Tularemia

Only have to know skin test

Abdominal form

- Mesenteric lymphadenitis
o Padalka sign
o Mark fedena sign
o Sternberg sign
- Pathogenesis is not asked but need to remember doses

DDX of mesenteric lymphadenitis sign

- Salmonellosis generalised form (typhoid fever like)

- Yersiniosis

INX

- Hemogram
o Leukopenia
o Lymphomonocytosis

Plague Tularemia
More sputum bloody and frothy Less sputum (interstitial pneumonia dry cough)
Neurotoxicosis No neurotoxicosis
Periadenitis and adenitis Only adenitis
BP with collapse Low BP no collapse
Embryocardia Relative bradycardia