SECTION 11 WOMEN’S HEALTH Benefits of Oral Contraceptives

45 CONTRACEPTION
Acne
• The term “contraception” is defined as the intentional
prevention of pregnancy. • Depending on the woman, COC use may cause acne
to appear, disappear, or significantly improve.
• Contraception (birth control) prevents pregnancy by
interfering with the normal process of ovulation, • Most women will have improvement in acne with any
fertilization, and implantation. COC used, only a few formulations are FDA
approved for this indication.
• Contraception choices have medical, personal and
public health considerations. Benign Breast Disease

• The personal aspects include issues related to • A 50% to 75% reduction in the risk of
sexuality, religious, or cultural beliefs. fibroadenomas, chronic cystic breast disease, and
breast biopsies appears to exist in COC users.
• Medical conditions that affect contraceptive selection
or the risks associated with pregnancy also must be • The progestin component may be primarily
considered. responsible for this protection, progestin-dominant
COCs that contain a less estrogenic progestin such as
• are therefore pharmaceuticals or devices that prevent levonorgestrel, are preferred.
pregnancy.
Dysmenorrhea and Premenstrual Syndrome
GOAL
• Premenstrual tension has been reported to be reduced
- The goal of contraception “therapy” is to prevent 29% in COC users, and other premenstrual symptoms
unintended pregnancy without causing adverse seem to be relieved as well.
effects and to preserve fertility, when desired.
Endometrial Cancer
COMPARISON OF CONTRACEPTIVE METHOD
EFFECTIVENESS • Clinical data suggest that cyclic COCs contain
sufficient progestin to prevent endometrial
The effectiveness of any contraceptive method depends on its hyperplasia and to reduce the risk of endometrial
mechanism of action, availability (e.g., if a prescription is cancer by about 50% to 70%.
required, cost), adherence, and acceptability (e.g., side
effects, ease of use, religious and social beliefs). • The protection is directly related to duration of use
and may persist for many years after discontinuation.
Manipulating the normal physiologic feedback mechanisms of
the menstrual cycle using estrogen and progestin has proved • A meta-analysis of 11 studies showed a 56%, 67%,
to be an effective method of contraception. and 72% reduction in endometrial cancer risk after 4,
8, and 12 years of COC use, respectively.
Estrogens are hormones that are important for sexual and
reproductive development, mainly in women. Menorrhagia (Heavy Menstrual Bleeding)

Progestin is a natural or synthetic steroid hormone, such as • The total amount of menstrual flow in established
progesterone, that maintains pregnancy and prevents further COC users is decreased by up to 40%, which may
ovulation during pregnancy. caused by the progressive thinning of the
endometrium induced by use or a lack of irregular
The most commonly used reversible method of contraception bleeding.
containing estrogen and a progestin, and are very effective in
preventing pregnancy is the COMBINATION ORAL • Bleeding may be decreased the most by COCs that
CONTRACEPTIVE PILLS (COC) have a high ratio of progestin to estrogen, because
endometrial thinning is maximized.
Oral Contraceptive Risks and Adverse Effects
Ovarian Cancer and Functional Ovarian Cysts
Some women may not be candidates for a COC because of the
risks and adverse effects associated with use. • The risk of developing functional ovarian cysts is
decreased, pre-existing cysts are more rapidly
Other women may experience minor side effects with COC resolved, and surgery rates for ovarian masses are
that may be managed by changing to a formulation with a reduced in women taking COCs.
different type or dose of estrogen or progestin.
• This is likely owing to reducing ovulation,
suppressing androgen production, or increasing
progesterone levels.
 Pelvic Inflammatory Disease and Ectopic Pregnancy • Pregnancy is typically divided into three trimesters,
approximately 13 to 14 weeks each.
• Many clinicians prefer to prescribe COCs with
condoms for STD protection to young women with Delivery
multiple sexual partners because PID has been found
to be less prevalent with this combination of • Depending on the gestational age at the time of
contraceptive methods. delivery, the result can be an abortion, preterm,
term, or post-term birth.
• The risk of ectopic pregnancy is greater for women
who already have had PID, and COC use has been • Abortion (Spontaneous or Terminal)
shown to prevent hospitalizations and deaths • is a delivery before 20 weeks’ gestation.
stemming from ectopic pregnancies.
• A term infant is a fetus delivered between 37 and 42
Other Issues with Oral Contraceptives weeks gestation.
• Breast Cancer Preterm Birth
• Depression – is one occurring between
• Diabetes 20 and 37 weeks’
gestation.
• Gallbladder Disease
Post-term Birth (Postmaturity)
• Use During Pregnancy and Breastfeeding
– birth occurs after the
46 OBSTETRIC DRUG THERAPY beginning of 43 weeks’
gestation.
Prenatal Care
– Parturition refers to labor,
• The goal of prenatal care is to promote a safe and and the Puerperium is the
successful pregnancy and the delivery of a healthy 6 to 8 weeks after
infant, can be achieved through education and by delivery.
monitoring the health of the mother and fetus.
VITAMINS AND MINERALS
Conception begins with the fertilization of an ovum.
• Iron Requirements
• Conceptional or Developmental Age
– Iron requirements increase during pregnancy
– Is the time after conception. because of maternal blood volume
• Gestational age or Menstrual Age expansion, fetal needs, placenta and cord
needs, and blood loss at time of delivery.
– is the time from the start of the last
menstrual period (LMP) and generally • Folate Requirements
exceeds the developmental age by 2 weeks. – Folic acid is essential in the synthesis of
Definitions DNA and RNA. Pregnant women who take
0.4 to 0.8 mg of folic acid daily during the
• Parity and Gravida first trimester of pregnancy are significantly
less likely to have a child with neural tube
– Parity and Gravida are terms used to
defects (NTD).
describe a pregnant woman.
• Calcium Requirements
Parity - is the number of deliveries after 20 weeks’
gestation. – Calcium is needed during pregnancy for
adequate mineralization of the fetal skeleton
Gravida - refers to the number of pregnancies a
and teeth, especially during the third
woman has had regardless of the outcome.
trimester when teeth are formed and skeletal
Trimesters of Pregnancy growth is greatest.

• The average pregnancy is approximately 280 days or DIABETES MELLITUS

40 weeks when calculated from the first day of the
• Diabetes mellitus is the most common maternal
LMP (Last Menstrual Period).
medical complication during pregnancy.
 Diabetes during pregnancy can be detected before or ALTERNATIVE ANTIHYPERTENSIVE DRUGS
during pregnancy and can be separated in two groups:
• Labetalol
(a) Pregestational Diabetes, which includes women who have
been diagnosed before pregnancy with either insulin – Labetalol (Trandate) is the second most
dependent or insulin-independent diabetes mellitus. commonly used drug to treat severe
hypertension during pregnancy.
(b) Gestational Diabetes Mellitus (GDM) defined as
carbohydrate intolerance first detected during pregnancy. – It should be administered IV in increasing
doses of 20, 40, and 80 mg every 10 minutes
INSULIN THERAPY to a cumulative dose of 300 mg or until the
diastolic pressure is <100 mm Hg.
• Insulin is the hypoglycemic of choice during
pregnancy because it does not cross the placenta and ALTERNATIVE ANTIHYPERTENSIVE DRUGS
has an established safety record for both mother and
fetus. • Nifedipine

• The goal with insulin therapy is to imitate the – Nifedipine (Procardia, Adalat) has been used
glucose levels of a healthy pregnant woman. in doses of 10 mg for acute treatment of
severe hypertension during pregnancy
ORAL HYPOGLYCEMICS because it can be given orally.

• Oral hypoglycemics are used commonly to treat type 47 DISORDERS RELATED TO THE MENSTRUAL
2 diabetes in nonpregnant women. CYCLE

• With more than half of pregnancies being unplanned,  POLYCYSTIC OVARY SYNDROME
many discover their pregnancy status while taking
these medications.  DYSMENORRHEA

• A switch to insulin therapy is recommended before  ENDOMETRIOSIS

conception, if possible, or at the time the pregnancy  PREMENSTRUAL SYNDROME AND
is confirmed because many patients have inadequate PREMENSTRUAL DYSPHORIC DISORDER
control with oral hypoglycemic agents.
POLYCYSTIC OVARY SYNDROME
• Control of blood glucose levels during the
preconception period and early first trimester is of - aka: Stein-Leventhal syndrome, polycystic ovary,
utmost importance to decrease the risk of congential polycystic ovarian disease, hyperandrogenic chronic
malformations. anovulatory syndrome, and functional ovarian
hyperandrogenism.
HYPERTENSION - leading cause of anovulatory infertility and the most
• Hypertensive disease occurs in 5% to 10% of all common endocrine abnormality for this age group.
pregnancies and is a major cause of maternal and - Excessive male patterned hair growth and obesity
perinatal morbidity and mortality. were added later to the description of this syndrome

• Hypertension in pregnancy is defined as a systolic BP The name “polycystic ovary syndrome” has been most
≥140 mm Hg or a diastolic BP ≥90 mm Hg on two widely accepted because it best describes the
separate occasions at least 6 hours apart. heterogeneous nature of this disorder.

ANTIHYPERTENSIVE DRUG THERAPY DIAGNOSTIC CRITERIA

• The goal of antihypertensive therapy for women with  MAJOR CRITERIA

chronic hypertension during pregnancy is to 1. hyperandrogenism or hyperandrogenemia
minimize the risks to the mother of an elevated BP
without compromising placental perfusion. 2. oligo-ovulation

METHYLDOPA 3. exclusion of other known disorders such as

hyperprolactinemia, thyroid abnormalities, and
• Methyldopa (Aldomet) is a centrally-acting α-agonist congenital adrenal hyperplasia.
that decreases sympathetic outflow to decrease BP.

• It is the antihypertensive most commonly used for  inappropriate gonadotropin secretion

chronic treatment of hypertension in pregnancy.
 excessive androgen production
  insulin resistance with hyperinsulinemia. ENDOMETRIOSIS
Nonpharmacologic Treatment  Presence of functional endometrial tissue
 Impact of Weight Loss in PCOS occurring outside the uterine cavity.

 Diet Composition  most common cause of secondary dysmenorrhea

in young women, and can result in chronic
 Exercise pelvic pain, infertility, and dyspareunia.
Pharmacologic Treatment  A definitive diagnosis is only possible with
 Combined Oral Contraceptives visualization of endometriosis on laparoscopy.

 Insulin Sensitizers  Based on the location of the endometrial lesions,

the size of the lesions, the presence and extent of
 Agents for Hirsutism
the adhesions, and the degree of obliteration of
 Agents for Ovulation Induction the posterior cul-de-sac.
DYSMENORRHEA PATHOPHYSIOLOGY
 Painful cramping that occurs with the onset and first  Flow of menstrual fluid, endometrial cells, and
days of menstruation. other debris backward through the fallopian
 Categorized as either primary, without underlying tubes resulting in implantation in the peritoneal
uterine pathology, or secondary, owing to underlying cavity.
uterine pathology.
 Once endometrial cells reach the peritoneum,
 Primary dysmenorrhea occurs only with ovulatory stimulated angiogenesis appears to be a
cycles, which typically begin after the first year determinant of the development and growth of
following menarche lesions.
 Dysmenorrhea occurring several years after menarche  lesion stimulates an immune response, triggering
is most likely secondary dysmenorrhea, and should
the activation of macrophages, as well as
be investigated as such.
cytokine and growth factor release.
PATHOPHYSIOLOGY
Treatment
 prostaglandins are released by the endometrium
 Pain Management: Nonpharmacologic Therapy
in the late luteal phase
1. Definitive Surgery
 induce uterine smooth muscle contraction
2. Conservative Surgery
 slough off of endometrium
 Pain Management: Pharmacologic Therapy
 menstrual flow
1. NSAID
 primary dysmenorrhea - increased
prostaglandin secretion, inducing more intense 2. PROGESTINS
uterine contractions, leading to decreased uterine
blood flow and uterine hypoxia, which results in 3. ORAL CONTRACEPTIVES
the cramping and pain 4. GONADOTROPIN-RELEASING
Treatment HORMONE AGONISTS

 Nonpharmacologic Treatment 5. AROMATASE INHIBITORS

 Pharmacologic Therapy 6. DANAZOL

1. ANTI-INFLAMMATORY DRUGS PREMENSTRUAL SYNDROME AND

PREMENSTRUAL DYSPHORIC DISORDER
2. HORMONAL CONTRACEPTION
 Alterations in neurotransmitters, primarily
reductions in serotonin, triggered by normal
 hormonal fluctuations of the menstrual cycle SECTION 13 EYE DISORDERS
appear to be the most probable factors for the 51 EYE DISORDERS
development of PMS or PMDD GLAUCOMA
 The levels of estrogen, progesterone, and • A leading cause of blindness worldwide, is a
testosterone are normal in women with PMS, but nonspecific term used for a group of diseases that can
they may be more vulnerable to normal irreversibly damage the optic nerve resulting in visual
fluctuations. field loss.

Treatment: PMS Types of Glaucoma:

 Calcium 1. Open-Angle Glaucoma - In patients with primary

open-angle glaucoma (POAG), aqueous humor
 Magnesium outflow from the anterior chamber is continuously
subnormal primarily because of a degenerative
 Pyridoxine process in the trabecular meshwork.
 Chastberry Signs and symptoms:
 Mind-body Approaches 1. Hazy or blurred vision.

 NSAIDS and Diuretics 2. The appearance of rainbow-colored circles around

bright lights.
Treatment: PMDD
3. Severe eye and head pain.
 Selective Serotonin Reuptake Inhibitors
4. Nausea or vomiting (accompanying severe eye pain)
 Other Psychotropic Agents
5. Sudden sight loss.
 Combination Oral Contraceptives
PREVENTION
48 THE TRANSITION THROUGH MENOPAUSE
• Early detection and careful, lifelong treatment can
 Perimenopause, or climacteric – is the phase in the maintain vision in most people. In general, a check
female aging process between the reproductive and for glaucoma should be done:
nonreproductive years and is characterized by waning
1. before age 40, every two to four years
ovarian function and irregular menstrual cycles
2. from age 40 to age 54, every one to three years
 Menopause - is the last spontaneous episode of
physiologic uterine bleeding confirmed by 12 months 3. from age 55 to 64, every one to two years
of amenorrhea and typically occurs 4 to 5 years after
the beginning of the perimenopause 4. after age 65, every six to 12 months

 Postmenopausal state - is characterized by 2. Angle-Closure Glaucoma - Angle-closure glaucoma,

significantly decreased hormone levels that may which is a medical emergency, usually presents as an acute
contribute to an increased risk of disease. attack with a rapid increase in IOP, blurring or sudden loss of
vision, appearance of haloes around lights, and pain that is
 Although menopause is a natural consequence of often severe.
aging, the concurrent decrease in estrogen production
can result in clinical symptoms, such as hot flushes Signs and symptoms:
and vaginal atrophy. Postmenopausal osteoporosis
1. Severe eye pain.
may also result from estrogen deficiency.
2. Nausea and vomiting.
 Hot Flushes
3. Headache.
 Genitourinary Atrophy
4. Blurred vision and/or seeing haloes around lights
(Haloes and blurred vision occur because the cornea
SECTION 12 ENDOCRINE DISORDERS
is swollen.)
49 THYROID DISORDERS
5. Profuse tearing.
50 DIABETES MELLITUS
Therapeutic Agents for Treatment of Primary Open-Angle a) Arterial tears (carotid or vertebral
Glaucoma: Initial Therapy dissections)

• β-ADRENERGIC BLOCKERS b) Blood clot (venous thrombosis) within the

brain — separate from stroke
1. Timolol (Timoptic) -Timolol, a nonselective
β1- and β2-adrenergic antagonist, is one of the c) Brain aneurysm (a bulge in an artery in your
most commonly prescribed glaucoma medications. brain)

2. Timoptic XE -Timoptic XE, a timolol d) Brain AVM (arteriovenous malformation)

ophthalmic gel-forming solution, is administered — an abnormal formation of brain blood
once daily. vessels

3. Levobunolol (Betagan) e) Brain tumor

4. Carteolol (Ocupress) f) Carbon monoxide poisoning

5. Betaxolol (Betoptic) and Levobetaxolol (Betaxon) g) Chiari malformation (structural problem at

the base of your skull)
6. Metipranolol (Optipranolol)
h) Concussion
• PROSTAGLANDIN ANALOGS
i) Dehydration
-Latanoprost (Xalatan), travoprost (Travatan), and
bimatoprost (Lumigan), are all prostaglandin analogs. j) Dental problems

• α2-ADRENERGIC AGONISTS REMEDIES TO RELIEVE HEADACHE

-Apraclonidine (Iopidine) and brimonidine • Drink Water

(Alphagan) are selective α2-adrenergic agonists similar to
clonidine. • Take some Magnesium

TOPICAL CARBONIC ANHYDRASE INHIBITORS • Limit Alcohol

-Carbonic anhydrase inhibitors (CAIs) lower IOP is • Get Adequate Sleep

by decreasing bicarbonate production and, therefore, the flow • Avoid Foods High in Histamine
of bicarbonate, sodium, and water into the posterior chamber
of the eye resulting in a 40% to 60% decrease in aqueous • Use essential oils
humor secretion. Eg. Pilocarpine (IsoptoCarpine), Epinephrine
• Try a B-complex medicine
(Glaucon, Eppy/N, Epitrate), Carbachol (Isopto-Carbachol)
• Soothe pain with a cold compress
SECTION 14 NEUROLOGIC DISORDERS
52 HEADACHE • Try an elimination diet
Primary Causes of Headaches • Get some exercise
1. Lifestyle factors: 53 PARKINSON’S DISEASE AND OTHER
a) Alcohol, particularly red wine MOVEMENT DISORDERS

b) Certain foods, such as processed meats that any disorder associated with two or more features of tremor,
contain nitrates rigidity, bradykinesia, or postural instability.

c) Changes in sleep or lack of sleep CAUSES

d) Poor posture - caused by a loss of nerve cells in the part of the brain
called the substantia nigra
e) Skipped meals - Genetics
- Environmental factors
f) Stress - medication (drug-induced parkinsonism)
Secondary Causes of Headache - other progressive brain conditions
- cerebrovascular disease

PREVENTIVE MEASURES

- Avoid using herbicide and pesticides

 - Eat vegetables (dark green vegetables) Cerebral haemorrhage
- Incorporate Omega 3 fatty acids to your diet
- Regular exercise • Involves escape of blood from blood vessels into the
brain and its surrounding structures.
MEDICATION/ TREATMENT
CAUSES
1. Carbidopa levodopa
- Damage to blood vessels
Levodopa is combined with carbidopa (Lodosyn), which - Low oxygen supply
protects levodopa from early conversion to dopamine outside - Inflammation in the arteries
your brain. This prevents or lessens side effects such as nausea
PREVENTIVE MEASURES
2. Dopamine Antagonist
quitting smoke, getting regular physical exercise, eating a
Unlike levodopa, dopamine agonists don't change into heart-healthy, low-fat diet, avoiding obesity, controlling blood
dopamine. Instead, they mimic dopamine effects in your brain. pressure and hypertension, lowering cholesterol, and avoiding
chronic stress or anger.
3. Mao B Inhibitors
MEDICATION/ TREATMENT
They help prevent the breakdown of brain dopamine by
inhibiting the brain enzyme monoamine oxidase B (MAO B). 1. CAROTID ENDARTERECTOMY
This enzyme metabolizes brain dopamine.
Carotid endarterectomy (CEA) is a common surgical
4. COMT Inhibitors procedure for correcting atheromatous lesions responsible
for causing a TIA.
This medication mildly prolongs the effect of levodopa
therapy by blocking an enzyme that breaks down dopamine. 2. ASPIRIN

54 SEIZURE DISORDERS Because platelets play a key role in the formation of

atheromatous clots various antiplatelet drugs, such as
A seizure is a sudden, uncontrolled electrical disturbance in aspirin, sulfinpyrazone, dipyridamole, ticlopidine, and
the brain clopidogrel have been tried to prevent ischemic strokes.
CAUSES : 3. DIPYRIDAMOLE
brain injury, such as trauma, stroke, brain infection, or a brain Two pharmacologic actions of dipyridamole prompted
tumor. investigations into its use in preventing TIAs and
PREVENTIVE MEASURES ischemic stroke. Dipyridamole weakly inhibits platelet
aggregation and platelet phosphodiesterase and has
- Get plenty of sleep each night potential vasodilating properties through its inhibition of
- Learn stress management and relaxation techniques. adenosine uptake in vascular smooth muscle.
- Avoid drugs and alcohol.
- Take all of your medications as prescribed by your 4. TICLOPIDINE
physician Ticlopidine (Ticlid) is an antiplatelet agent approved only
55 CEREBROVASCULAR DISORDERS for the prevention of TIA and stroke for patients with a
- refers to a group of conditions that can lead to a prior cerebral thrombotic event.
cerebrovascular event, such as a stroke. SECTION 15 INFECTIOUS DISEASE
Transient ischemic attack 56 PRINCIPLES OF INFECTIOUS DISEASES

• Describes the clinical condition in with the patient

experiences a temporary focal neurologic deficit such Approaching the problem
as speech, aphasia, weakness or paralysis of a limb or • The proper selection of antimicrobial therapy is based
blindness on several factors:
Cerebral infarction • establish the presence of infection
• A permanent neurologic disorder characterized by • site of infection, signs and symptoms must be
symptoms similar to TIA. identified
• Caused by the death of neurons in the focal area of • laboratory tests
the brain
• drug selection
 • dosage must be based on patient's size, age, site of • antimicrobial prophylaxis should be given for
infection. surgical procedures: a) with high rate of infection b)
involving implantation c) infections that would have
A. Establishing the presence of an infection catastrophic consequences
B. Establishing the severity of an infection Wound Classifaction
C. Problems in the diagnosis of an infection 1. clean- no acute inflammation or entry into GI,
-confabulating variables (major surgery, acute myocardial respiratory
infarction), initiation of corticosteroids can increase WBC 2. clean-contaminated- elective, controlled opening of
-drug effects (dexamethasone can reduce inflammation) GI, respiratory, biliary

D. Establishing the site of an infection 3. contaminated- penetrating trauma, major technique

break or major spillage from the GI tract
-most likely sources of infection
4. Dirty- penetrating trauma
-respiratory-bronchitis (H. influenzae)
Suggested Prophylactic Antimicrobial regimens
-skin and soft tissue- cellulitis (E. coli)
1. Clean
E. Determining likely Pathogens
cardiac-S. aureus-cefazolin-1g IV
-(bacteria, fungi,viruses, chlamydiae, rickettsiae,
mycoplasmas, spirochetes,mycobacteria) thoracic-S. aureus-cefazolin-1g IV

F. Microbiologic tests and susceptibility of organisms 2. Clean-contaminated

- Culture and susceptibility head and neck- S. aureus-cefazolin- 2g IV

1. Disk diffusion (Kirby-Bauer) colorectal- gram-negative enterics- oral neomycin-

erythromycin- 1g each at 1pm, 2pm and 11pm day
-uses agar plate before the surgery
- if antimicrobial is active against pathogen, a zone of appendectomy(uncomplicated)-B. fragilis- cefoxitin-
inhibition is observed 1-2g IV
2. Broth dilution Principles of surgical antimicrobial
-involves placing bactrial inoculum into test tubes 1. Decision to use antimicrobial prophylaxis
-cloudy- bacterial growth occured - selected prophylactic agent should be directed
against infecting organisms but not to eradicate every
G. Antimicrobial dosing
potential pathogen
-site of infection requires differing dosage requirements
2. Timing of antimicrobial administration
-anatomic and physiological barriers (penetration into CNS
- for maximal efficacy, an antibiotic should be
requires high doses)
present in therapeutic concentrations at the incision
-route of elimination (eliminated via renal or norenally) site as early as possible during decisive period and
until wound is closed
-patient age
3. Route of administration
eg. aminoglycosides
- oral admin is not recommended because of
57 ANTIMICROBIAL PROPHYLAXIS FOR SURGICAL unreliable or poor absorption
PROCEDURES
- oral regimen against fecal flora is 1g each of
• Prophylactic antibiotics are used in surgical nonabsorbable neomycin sulfate and erythromycin
procedures and account substantial antibiotic use in base
many hospitals
-parenteral regimens are effective in colorectal
• reduce the prevalence of postoperative wound procedures
infection at or around the surgical site
4. Duration of adminstration
 - the shortest effective prophylactic course of • can lead to permanent damage or brain disability
antibiotics should be used
• spreads by: coughing or sneezing
- postoperative doses after wound closure are usually
not required and may increase resistance • treatment available: antibiotics as per causative agent

5. Selection of an Antimicrobial Agent • causative agents: S. pneumonia, N. meningitis, H.

influenza
- cefazolin is considerably less expensive than
broader-spectrum agents and is currently Tubercular meningitis
recommeded by the American College of • caused by M. tuberculosis
Obstetricians and Gynecologists
• infection begins in the lungs
58 CENTRAL NERVOUS SYSTEM
INFECTIONS • progresses very slow and symptoms are vague

Meningitis Viral meningitis

meninges- layers of tissue that separates the skull and • aka aseptic meningitis
the brain
• more common than bacterial meningitis and less
meningitis- acute inflammation of the meninges serious
caused by virus or bacteria
• less likely to have permanent damage
Route of entry in the CNS
• treatment: no specific treatment avalable
• skull or back bone fractures (trauma)
• patients recover on their own
• medical procedures
• causative agents: enterovirus, adenovirus, arbovirus
• along peripheral nerves
Fungal meningitis
• blood or lymphatic system
• less common than the two infections
Etiology
• rare in healthy people but it is more likely in persons
The causes can be classified into: who have impaired immune system

-bacterial infections • risk factors: systemic infections, tobacco use, over

crowding
-viral infections
Clinical manifestations
-fungal infections
• Infants: fever, vomiting, high pitch moaning cry,
neck retraction, pale and blotchy complexion
Pathophysiology • Adults: stiff neck, headache, fever, vomitting, joint
• bacteria enters blood stream/trauma pain

• enters mucosal cavity Medical management

• breakdown of normal barries • Bacterial meningitis

• crosses blood brain barrier - third generation cefalosporins such as cefotaxime or

cetriaxone
• proliferates in the CSF
-vancomycin is added in case of resistance
• inflammation of the meninges
-dexamethasone
• increase in ICP
-fluid therapy
Bacterial meningitis
-phenytoin for seizure management
• aka septic meningitis
• Tubucular meningitis:
• extremely serious that requires immediate care
 -are started with Rifampicin, Pyrazinamide and PROSTHETIC HEART VALVES
Streptomycin
Onset
-Second line drugs: Aminoglycosides, Fluoroquinolones
within 2 months of surgery early and usually hospital
-conventional therapy is given for 6-9 months acquires

- in children BCG vaccine offer protective effect 12 months post surgery late onset and usually community
acquired
59 ENDOCARDITIS
NOSOCOMIAL INFECTIVE ENDOCARDITIS
INFECTIVE ENDOCARDITIS
• half of the cases is linked to intravascular devices
• Inflammation of the endocardium, the membrane
lining the chambers of the heart and covering the • other sources: surgical wound infection
cusps of the heart valves
ETIOLOGICAL AGENTS
CHARACTERISTICS
1. Streptococci
• vegetation
- S. viridans/ alpha-hemolytic streptococci like S.
- pathological lesion composed of platelets, fibrin, mitis, S. sanguis, S. oralis
microorganisms and inflammatory cells
-S. bovis
• Acute/Subacute-chronic
2. Enterococci
• by organism
-E. faecalis and E. faecium
native valve or prosthetic valve
-associated with GIT procedures
Acute Endocarditis
3. Staphylococci
• toxic progression
-most common cause of INFECTIVE
• progressive valve destruction- days to weeks ENDOCARDITIS

• Commonly caused by S. aureus -S. aureus: Native valves and acute endocarditis

Sub-acute -Coagulase-negative staphylococci: Prosthetic valve

endocarditis
• mild toxicity
PATHOGENESIS
• weeks to months
• Altered valve surface
• caused by: S. viridans or enterococcus
• deposition of platelets and fibrin
epidemiology and etiology
• bacteremia- attaches to platelet-fibrin deposits
• mean male-to-female ratio is 1.7:1
-covered by more fibrin
Risk factors
-protedted from neutrophils
• presence of prosthetic heart valve (highest risk)
-division of bacteria
• previous endocarditis
-mature vegetation
• hypertrophic cardiomyopathy
SITE OF INFECTION
• presence of IVDA
• Aortic valve more common than mitral
• increased longevity leads to more degenerative
valvular disease, placement of prosthetic valves and • Aortic
increased exposure to nosocomial bacteremia
- dynfxn of the valve

MItral

- dysfxn by rupture of chordae tendineae

CLINICAL MANIFESTATIONS -vancomycin

• fever INDICATIONS FOR SURGERY

• anorexia. weight loss, night sweats • HF

• heart murmur • uncontrolled infection

• petechiae on the skin • prevention of embolism

• oral mucosa 60 RESPIRATORY TRACT INFECTIONS

• Janeway lesions 61 TUBERCULOSIS

• Splinter hemorrhages HISTORY :Tuberculosis is an ancient disease, and evidence
of TB dates back as far as prehistoric times with evidence
• Osler nodes being found in pre-Columbian and early Egyptian remains.
However, TB did not become a problem until the 17 th and 18th
Investigations
centuries when crowded living conditions of the industrial
• blood culture revolution contributed to its epidemic numbers in Europe and
the United States.
• TTE/TOE
Early physicians referred to Tb as Phthisis, derived from the
• ESR/CRP Greek term for wasting, because its clinical presentation
consisted of weight loss, cough, fevers, and hemoptysis.
TTE
1882- Robert Koch isolated and cultured Mycobacterium
• TRANS- THORACIC ECHOCARDIOGRAPHY
tuberculosis and demonstrated its infectious nature.
-obesity, COPD, and chest wall deformities
ETIOLOGY: Tuberculosis is caused by M. tuberculosis, an
TOE aerobic, non-spore-forming bacillus that resists decolorization
by acid alcohol after staining with basic fuchsin. For this,
• Transesophageal echo season the organism is often referred to as an acid-fast bacillus
(AFB). It is also different from other organisms in that it
-evaluate myocardial invasion
replicates slowly once every 24 hours instead of every 20 to
-more cost effective in those with S. aureus 40 minutes as do some other organisms. M. tuberculosis
thrives in environments where the oxygen tension is relatively
COMPLICATIONS high, such as the apices of the lung, the renal parenchyma, and
• Congestive heart failure-valvular damage, higher the growing ends of bones.
mortality Pathogenesis
• Systemic emboli Latent infection vs Active disease
GOALS OF THERAPY Latent infection occurs when the tubercle bacilli are inhaled
• Eradicate infxn into the body. After inhalation, the droplet nuclei containing
M. tuberculosis settle into the bronchioles and alveoli of the
• treat sequel of destructive intra-cardiac and extra- lungs.
cardiac lesions
Persons with latent TB infection are not infectious and cannot
THERAPY spread TB infection to others.

• Antimicrobial therapt A person with Latent TB infection

• Surgery  Usually has a skin test or blood test result indicating

TB infection
ANTIBIOTICS
 Has a normal chest x-ray and a negative sputum test
• Penicillin G- 12-18 million units/ day IV in 6 doses
 Has TB bacteria in his/her body that are alive, but
• amoxicillin 4-6 doses per day inactive
• ceftriaxone with gentamycin/ netilmicin  Does not feel sick
in beta lactam allergic px  Cannot spread TB bacteria to others
 Needs treatment for latent TB infection to prevent TB  Of limited effectiveness in people over the age of 35
disease; however, if exposed and infected by a person
with multidrug-resistant TB or extensively drug-  Early diagnosis
resistant TB, preventive treatment may not be an early diagnosis and treatment is the most effective
option. way to prevent the spread of tuberculosis.
 Active disease  Managing you environment
 In some people, TB bacteria overcome the defenses As TB is an airborne infection, TB bacteria are
of the immune system and begin to multiply, released into the air when someone with infectious TB
resulting in the progression from latent TB infection coughs or sneezes. The risk of infection can be reduced by
to TB disease. Some people develop TB disease soon using a few simple precautions:
after infection, while others develop
 Good ventilation
GENERAL SYMPTOMS OF TB DISEASE
 Natural light
 Unexplained weight loss
 Good hygiene
 Loss of appetite
TREATMENT
 Night sweats
Drugs use in Tuberculosis
 Fever
First line drugs
 Fatigue
 Rifampin
 Chills
 Isoniazid
 TB disease later when their immune system becomes
weak.  Pyrazinamide

THE SYMPTOMS OF TB OF THE LUNGS  Ethambutol

 Coughing for 3 weeks or longer  Streptomycin

 Hemoptysis (coughing up blood) Alternative drug

 Chest pain  Amikacin

DIAGNOSTICS:  Ciprofloxacin

 Mantoux test (purified protein derivative test)  Ethionamide

measure the induration. It reveals only the exposure
 P-aminosalycylate
of TB.
 Rifampin
 Direct sputum smear microscopy- primary diagnostic
tool MOA: inhibits DNA-dependent and RNA polymerase
(encoded by rpo gene)
 Chest X-ray severity of lung lesions brought about by
the bacteria. Resistance MOA: resistance via changes in drug sensitivity of
the polymerase after emerges rapidly if the drug is used alone.
PREVENTIVE MEASURES

 BCG vaccination
Toxicity:
Bacille Calmette-Guerin is a live vaccine against
tuberculosis. The vaccine is prepared from a strain of the  Commonly cause light chain proteinuria and may
weekened bovine tuberculosis bacillus, Mycobacterium impair antibody response
bovis.
 Strongly induces liver drug metabolizing enzymes
BCG is: and enhances the elimination rate of many drugs
including:
 80% effective in preventing TB for 15 years
 Anticonvulsants
 More effective against complex forms of TB in
children  Contraceptive steroids
 Cyclosporine  Hyperuricemia occurs commonly but is usually
asymptomatic
 Ketoconazole
 Other adverse effects are
 Methadone
 Myalgia
 Terbinafine
 GI irritation
 Warfarin
 Maculopopular rash
 Rash
 Hepatic dysfunction
 Nephritis
 Porphyria
 Thrombocytopenia
 Photosensitivity reactions
 Flu like syndrome with intermittent dosing
 Should be avoided in pregnancy
Isoniazid
 Ethambutol
MOA: inhibition of the synthesis of myolic acid, essential
components of mycobacterium cell walls.  MOA: inhibits arabinosyltranferases (encoded by the
embCAB operion) involved in the synthesis of
Resistance MOA: arabinogalactan, a component of mycobacterial cell
 High level resitance is associated with deletion in the walls.
KatG gene that codes for a catalase-peroxidase  Resistance MOA: resistance occurs rapidly via
involved in the bio activation of INH. mutations in the emb gene if the drug is used alone.
 Low level resistance occurs via deletion in the inhA Toxicity:
gene that encodes the target enzyme an acyl carrier
protein reductase.  The most common adverse effectsd are dose
dependent visual disturbances
Toxicity:
 Decreased visual acuity
 Neurotoxic effects are common and include
peripheral neuritis, restlessness, muscle twitching and  Red-0green color blindness
insomnia. These effects can be alleviated by
administration of Pyridoxine ( vitamin B6 ) 25-50  Optic neuritis
mg/d, orally  Possible retinal damage (from prolonged use as high
 Hepatotoxic doses)

 Inhibit the hepatic metabolism of drugs  Other adverse effects includes

 Carbamazepine  Headache

 Phenytoin  Confusion

 warfarin  Hyperurecemia

 Pyrazinamide  Peripheral neuritis

 MOA: bacteriostatic action appears to require ALTERNATIVE DRUG

metabolic conversion via pyrazinamide's (encoded by  Amikacin is indicated for the treatment of
the pncA gene) present in M. tuberculosis. tuberculosis suspected to be cause by streptomycin
 Resistance MOA: resistance occurs via mutations in resistant or multidrug resistance.
the gene that encodes enzymes involved in the bio  Ciprofloxacin and ofloxacin are often active against
activation of pyrazinamide and by increased strains of m. tuberculosis resistance to first line
expression of drug efflux systems. agents.
toxicity  Ethionamide is a congener of INH, but cross
 Approximately 40% of patients develop nongouty resistance does not occur.
polyarthralgia
 Standard regimens • Entamoeba histolytica

 Initial 3 drug regimen (R, I, P)

63 INTRA-ABDOMINAL INFECTIONS
 If the organism are fully susceptible pyrazinamide PERITONITIS
can be discontinued after 2 months with a 2 drug
regimen. - Inflammation of the peritoneum, the tissue that lines
that lines the inner wall of the abdomen and covers
Alternative regimens and supports most of your abdominal organs.
 INH + Rifampin for 9 months Peritonitis is usually caused by infection from
bacteria and fungi.
 INH + ethambutol for 18 months intermittent (2-3 x - If left untreated, peritonitis can rapidly spread into
weekly) high-dose the blood (sepsis) and the other organs.
 4drug regimen are also effective Symptoms of peritonitis
62 INFECTIOUS DIARRHEA • Poor appetite

• Nausea
Infectious diarrhea is caused by th ingestion of food or water
contaminated with pathogenic microorganism or their toxins. • Dull abdominal ache

Diarrhea is often defined as three or more episodes of loose • Abdominal tenderness or distention
stool or any loose with blood during a 24-hour period.
• Chills
Classification of infectious diarrhea
• Fever
Noninflammatory diarrheas are generally a less severe illness
• Fluid in the abdomen
in which patients present with nonbloody, watery stools;
patients are afebrile and without significant abdominal pain. • Difficulty in passing gas or having a bowel
movement
Noninflammatory diarrheas are typically caused by:
• Vomiting
• Rotaviruses
Two type of peritonitis:
• Noroviruses
• Primary spontaneous peritonitis, an infection that
• Staphylococcus aureus
develops in the peritoneum.
• Bacillus cereus
• Secondary peritonitis, which usually develops when
• Clostridium perfringens an injury or infection in the abdominal cavity allows
infectious organisms into the peritoneum.
• Cryptosporidium parvum
Most common risk factors for primary spontaneous peritonitis
• Giardia lamblia include:
Inflammatory diarrheas are generally a more severe 1. Liver disease with cirrhosis such disease often causes
illness in which patients present with bloody diarrhea, a buildup of abdominal fluid (ascites) that can
severe abdominal pain, and fever, and examination of become infected.
stool specimens reveals the presence of large numbers of
fecal leukocytes. 2. Kidney failure getting peritoneal dialysis.

Inflammatory diarrheas are caused by invasive pathogens Common cause of secondary peritonitis include:
including, 1. a ruptured appendix, diverticulum or stomach ulcer
• Campylobacter jejuni 2. Digestive disease such as crohn’s disease and
• Shigella species diverticulitis.

• Salmonella species 3. Pancreatitis

• Clostridium difficile 4. Pelvic inflammatory disease

• Shiga toxin-producing E.coli (STEC) 5. Perforations of the stomach, intestine, gallbladder or

appendix.
Diagnostics test:
64 URINARY TRACT INFECTIONS
1. Blood and urine tests Is an infection of the body’s urinary system.
2. Imaging studies such as x-rays and computerized - It is an infection caused by microbes.
scans. urinary tract is made up of:
3. Exploratory surgery

o Kidneys
o Ureters
o Bladder
o Urethra

o Most UTIs only involve the urethra and bladder, in

the lower tract.

o UTIs can involve the ureters and kidneys, in the

upper tract. Although upper tract UTIs are more rare
than lower tract UTIs, they’re also usually more
severe.

CAUSES:

- Typically occur when bacteria enter the urinary tract

through the urethra and begin to multiply in the
bladder.
- When that happens, the bacteria take hold and grow
into a full-blown infection in the urinary tract.

Most common UTIs occur mainly in the women and affect the
bladder and urethra

Infection of the bladder (cystitis)

This type of UTI is usually caused by Escherichia

coli.
However, sometimes other bacteria are responsible.

Infection of the urethra (urethritis)

This type of UTI can occur when GI bacteria spread

from the anus to the urethra.

Also, because the female urethra is close to the

vagina and sexually transmitted infections can cause urethritis.

Herpes, gonorrhea, chlamydia and mycoplasma

 Frequent infections
SYMPTOMS
Urinary tract infection don’t always cause signs and o Low-doe antibiotics, initially for six month but
symptoms, but when they do they may include: sometimes longer
‐ A strong, persistent urge to urinate o Self-diagnosis and treatment, if you stay in touch
‐ A burning sensation when urination with your doctor
‐ Passing frequent, small amounts of urine
‐ Urine that appears red, bright pink or cola-colored – a o A single doe of antibiotic after sexual intercourse if
sign of blood in the urine your infections are related to sexual activity
‐ Strong-smelling urine
o Vaginal estrogen therapy if you’re posstmenopausal
‐ Pelvic pain, in women – especially in the center of
the pelvis and around the area of the pubic bone 65 SEXUALLY TRANSMITTED DISEASES
also called sexually transmitted infections, or STIs.
PREVENTIVE MEASURES
- are infections spread from person to person during
DIAGNOSIS
sex
- Sometimes these infections can be transmitted
nonsexually
- From mother to infant during pregnancy or childbirth
- Blood transfusion or shared needle
- Can be through vaginal, oral, or anal or close intimate
contact

Causes:

× Bacteria

× gonorrhea
o Analyze a urine sample
× Syphilis
• urinalysis
× chlamydia
o Growing urinary tract bacteria in the lab
× Parasites
• Urine culture
× trichimoniasis
o Creating images of your urinary tract
× Viruses
• CT scan
× Human papillomavirus
• MRI
× Genital herpes
o Using scope to see inside your bladder
× Human immunodeficiency virus
• Cystoscopy
Types of sexually transmitted disease:
TREATMENT
HIV (human immunodeficiency virus)
Simple infection
- is the virus that causes AIDS.
Drugs that are commonly recommended:
- HIV attacks the immune system by destroying CD4
o Trimethorprim/sulfamethoxazole positive (CD4+) T cells
o Fosfomycin (monurol) - The destruction of these cells leaves people infected
with HIV vulnerable to other infections, diseases and
o Nitrofurantoin (macrodantin, macrobid)
other complications
o Cephalexin
- Viral STD
o Ceftriaxone
Common symptoms:
Severe infection
× Flu-like illness
May need treatment with IV antibiotics in the hospital
× Swollen lymph nodes
× Skin rash - Valacyclovir (Valtrex)

Many people do not notice symptoms GONORRHEA

Treatments: (ANTIRETROVIRUS TREATMENT/ ART) Causative agent: Neisseria gonorrhoeae bacterium

× TDF (tenofivir) - infects the mucous membranes of the reproductive

tract, including:
× 3TC (lamivudine) or FTC (emitricitabine)
Cervix
× EFV (efavirenz)
Uterus
Chlamydia
Fallopian tubes (women)
Causative agent: Chlamydia trachomatis
Urethra (women and men)
- It can cause cervicitis in women and urethritis and
proctitis in both men and women.  can also infect the mucous membranes of the mouth,
throat, eyes, and rectum
- Bacterial STD
Common symptoms:
Common symptoms:
× Discharge from the vagina, penis or anus
× Discharge from the vagina, penis or anus
× Burning when urinating
× Burning when urinating
Women often do not notice symptoms
Often there is no symptoms
Men may have symptoms in the penis
Treatments:
Treatments:
Azithromycin (single or large dose)
There is no cure for Herpes.
Doxycycline (twice per day for 1 week)
However, there are some medication to treat or prevent
GENITAL HERPES
symptoms:
Causative agent: Herpes simplex viruses
- Acyclovir (Zovirax)
Type 1 (HSV-1) - cold sores
- Famciclovir (Famvir)
Type 2 (HSV-2) – genital herpes
- Valacyclovir (Valtrex)

PREVENTIVE MEASURES
- It causes herpetic sores which are painful blisters
× Abstain
Common symptoms:
× Stay with one uninfected partner
× Fever & flu-like symptoms
× Avoid vaginal or anal intercourse with new partners
× Muscle aches until you have both been tested for STIs

× Painful urination × Practice safer sex every time you have sex

× Tingling, burning or itching sensation in the area × Get vaccinated early, before sexual exposure
where the blisters are
× Don’t drink alcohol excessively or use drugs
Treatments:
× Consider male circumcision
There is no cure for Herpes.
× Consider truvada
However, there are some medication to treat or prevent
DIAGNOSIS
symptoms:
Blood sample
- Acyclovir (Zovirax)
Urine sample
- Famciclovir (Famvir)
Fluid sample • Bone surgery, including hip and knee replacements,
also increase the chance of bone infection.

PREVENTION

• The best way to prevent osteomyelitis is to keep

things clean.

• If you have chronic osteomyelitis, make sure your

doctor knows about your medical history so you can
work together to keep the condition under control.

• The sooner you treat osteomyelitis, the better.

Symptoms of Osteomyelitis
66 OSTEOMYELITIS AND SEPTIC ARTHRITIS • Acute osteomyelitis develops rapidly over a period of
67 TRAUMATIC SKIN AND SOFT TISSUE seven to 10 days. The symptoms for acute and
INFECTIONS chronic osteomyelitis are very similar and include:

• Fever, irritability, fatigue

OSTEOMYELITIS is an infection of the bone, a rare but
serious condition. • Nausea

Bones can become infected in a number of ways: • Tenderness, redness, and warmth in the area of the
infection
– Infection in one part of the body may spread
through the bloodstream into the bone, • Swelling around the affected bone

an open fracture or surgery may expose the bone to • Lost range of motion
infection
• Osteomyelitis in the vertebrae makes itself known
CAUSES : In most cases, a bacteria called Staphylococcus through severe back pain, especially at night.
aureus, a type of staph bacteria, causes osteomyelitis.
TREATMENT
• Certain chronic conditions like diabetes may increase
• Figuring out if a person has osteomyelitis is the first
your risk for osteomyelitis.
step in treatment.
Who Gets Osteomyelitis?
• It's also surprisingly difficult. Doctors rely on:
• The condition affects children and adults, although in
– X-rays, blood tests, MRI, and bone scans to
different ways. Certain conditions and behaviors that
get a picture of what's going on.
weaken the immune system increase a person's risk
for osteomyelitis, including: • A bone biopsy is necessary to confirm a diagnosis of
osteomyelitis.
• Diabetes (most cases of osteomyelitis stem from
diabetes) – This also helps determine the type of
organism, typically bacteria, causing the
• Sickle cell disease
infection so the right medication can be
• HIV or AIDS prescribed.

• Rheumatoid arthritis MEDICATION

• Intravenous drug use • The primary treatment for osteomyelitis is parenteral

antibiotics that penetrate bone and joint cavities.
• Alcoholism
• Treatment is required for at least 4-6 weeks.
• Long-term use of steroids
• After intravenous antibiotics are initiated on an
• Hemodialysis inpatient basis, therapy may be continued with
intravenous or oral antibiotics, depending on the type
• Poor blood supply
and location of the infection, on an outpatient basis
• Recent injury
• The primary antibiotics in this scenario include
 • ceftazidime or cefepime. • People with a weakened immune system and those
with pre-existing conditions such as
• Ciprofloxacin is an alternative treatment.
– cancer, diabetes, intravenous drug abuse,
• For patients with osteomyelitis due to and immune deficiency disorders have a
trauma, the infecting agents include S higher risk of septic arthritis.
aureus, coliform bacilli, and Pseudomonas
aeruginosa. • Previously damaged joints have an increased
likelihood of becoming infected.
• Primary antibiotics:
SYMPTOMS of septic arthritis usually come on rapidly with
• nafcillin intense pain, joint swelling, and fever.
• ciprofloxacin Septic arthritis symptoms may include:
SEPTIC ARTHRITIS is inflammation of a joint caused by a • Chills
bacterial infection. It's also known as infectious or bacterial
arthritis. Any joint can be affected by septic arthritis, but it's • Fatigue and generalized weakness
most common in the knees and hips.
• Fever
CAUSES : Septic arthritis usually is caused by bacteria that
spread through the blood stream from another area of the • Inability to move the limb with the infected joint
body. • Severe pain in the affected joint, especially with
-caused by a bacterial infection from an open wound movement
or an opening from a surgical procedure, such • Swelling (increased fluid within the joint)
as knee surgery
• Warmth (the joint is red and warm to touch because
In adults and children, common bacteria that cause acute of increased blood flow)
septic arthritisinclude - staphylococcus and streptococcus.
TREATMENTS include using a combination of
These foreign invaders enter the bloodstream and infect the powerful antibiotics as well as draining the infected
joint, causing inflammation and pain. synovial fluid from the joint.
Other infections, such as those caused by viruses and fungi, • It's likely that antibiotics will be administered
can also cause arthritis. Viruses include: immediately to avoid the spread of the infection.
• Hepatitis A, B, and C • Intravenous (IV) antibiotics are given, usually
• Parvovirus B19 requiring admission to the hospital for initial
treatment.
• Herpes viruses
• The treatment, however, may be continued on an
• HIV (AIDS virus) outpatient basis at home with the assistance of a
home health nursing service.
• HTLV-1
• MEDICATION Intravenous therapy with
• Adenovirus flucloxacillin, with or without fusidic acid or
• Coxsackie viruses gentamicin, is one possible regimen.

• Mumps • Clindamycin or a third-generation cephalosporin may

be used in penicillin-allergic patients.
Fungi that can cause arthritis include histoplasma,
coccidiomyces, and blastomyces. These infections are usually Oral :
lslower to develop than bacterial infections. • flucloxacillin
RISK FACTORS • Clindamycin
• Young children and elderly adults are most likely to • cefalexin may be used after intravenous antibiotics
develop septic arthritis. are ceased.
• People with open wounds are also at a higher risk for
septic arthritis.
68 PREVENTION AND TREATMENT OF INFECTIONS • Pain near the anus.
IN NEUTROPENIC CANCER PATIENTS
NEUTROPENIA -a person who has a low level of neutrophils. • Pain or burning when urinating, or urinating often.

CANCER- is an abnormal growth of cells. • Diarrhea or sores around the anus.

RISK FACTORS FOR INFECTION • A cough or SOB.

Recommended treatment for low-risk patients includes:

 Neutropenia
1. combination oral antibiotic therapy with
 Damage to physical barrier
ciprofloxacin and amoxicillin-clavulanate
 Alterations in the immune system
(Co-amoxiclav).
 Colonization
Other orally administered regimens
 Hematopoietic Stem Cell Transplantation
commonly used in clinical practice are
 Radiation therapy
monotherapy with levofloxacin or
MOST COMMON PATHOGENS
ciprofloxacin and combination with
1. Bacteria- are the primary pathogens associated with
infection in febrile neutropenic patients. ciprofloxacin and clindamycin.

Bacteremia is most often caused by aerobic

69 PHARMACOTHERAPY OF HUMAN
Gram-negative bacilli (Escherichia coli, Klebsiella species, IMMUNODEFICIENCY VIRUS INFECTION
Pseudomonas aeruginosa)or aerobic
HIV - it is a virus spread through certain body fluids that
Gram positive cocci (coagulase-negative staphylococci, attacks the body's immune system
Staphylococcus aureus, enterococci, viridans streptococci)
AIDS - is the final stage of HIV infection, when the immune
S. aureus and Staphylococcus epidermidis, streptococci and system is damage and too weak to fight off ordinary infection.
Corynebacterium species have become important pathogens in
some cancer centers. Helper T Lymphocytes or helper t cells

Candida spp. were responsible for most invasive fungal  Type of White Blood Cell
infections.
 Use to fight Infections
Viral infections are generally a reactivation of latent infection.
AKA CD4 used to strengthen the immune system response to
These may include herpes simplex virus and varicella zoster
infections in 2 ways:
PROPHYLAXIS AGAINST INFECTION
• Helper T cells release chemicals that are trap other
- Exogenous contamination can be prevented by strict WBC to the site of the infection.
protective isolation of patients in specially designed • Helper T cells release chemicals that cause other
rooms that maintain a sterile environment. WBC to multiply.

INFECTION CONTROL The T cell loses its ability to protect the body from ongoing
infection and dies.
- Total protective isolation is accomplished by strict
isolation in conjunction with the administration of In this way HIV spreads and kills more of the helper t cells
sterile food and water, local skin care, and intensive weakening the immune system as a results other types of
microbial surveillance. infection would be able to take advantage of the bodies
inability to defend this infection which are called
CLINICAL SIGNS AND SYMPTOMS Opportunistic Infection.
• Fever, a temperature of 100.5°F or higher. Some of the common AIDS related OI are:
• Chills or sweating. 1. Inflammation of tissues covering the brain and spinal
• Sore throat, sores in the mouth, or a toothache. cord = Meningitis

• Abdominal pain. 2. Inflammation of the Brain = Encephalitis

3. Respiratory Illnesses such as:

  Pneumonia 4. general aches and pains

 Tuberculosis 5. skin rash

4. Intestinal Illnesses 6. sore throat

 Chronic diarrhea cause by 7. headache

infectious parasites
8. nausea
5. Cancers such as:
9. upset stomach
 Kaposi’s Sarcoma
Medication And Treatment
 Hodgkin Lymphoma ANTIRETROVIRAL DRUGS:
STAGES OF HIV • 1. Fusion/ Entry Inhibitors
1. Primary HIV Infection • 2. Nucleoside Reverse Transcriptase inhibitors
2. Asymptomatic phase • 3. Protease Inhibitors
3. AIDS • 4. Integrase inhibitors
TRANMISSION Starting HIV treatment:
1. Unprotected sex (semen, vaginal fluids, blood) 1. TDF (Tenofovir)
2. Sharing drug injection needles (blood) 2. 3TC (Lamivudine) or FTC (Emtricitabine)
3. Childbirth (blood, amniotic fluid, vaginal fluids) 3. EFV (Efavirenz).
4. Breastfeeding ( Breastmilk) 70 OPPORTUNISTIC INFECTIONS IN HIV-INFECTED
5. Contaminated blood and blood products PATIENTS

DIAGNOSIS - an infection caused by pathogens (bacteria, viruses,

fungi, or protozoa) that take advantage of an
1. Antibody/antigen tests opportunity not normally available, such as a host
with a weakened immune system, an altered
- are the most commonly used tests. They can show
microbiota or breached integumentary barriers.
positive results typically within 18–45 days after someone
initially contracts HIV. COMPLICATIONS
ANTIBODY- a type of protein the body makes to fight an - PNEUMOCYSTIS JIROVECI PNEUMONIA
infection.
- TOXOPLASMA GONDII ENCEPHALITIS
ANTIGEN- a part of the virus that activates the immune
system. - CYTOMEGALOVIRUS DISEASE

ANTIBODY TESTS- These test check the blood solely for - CRYPTOCOCCOSIS
antibodies. Between 23 and 90 days. after transmission, most - MYCOBACTERIUM TUBERCULOSIS
people will develop detectable HIV antibodies, which can be
found in the blood or saliva. - MYCOBACTERIUM AVIUM COMPLEX
DISEASE
NUCLEIC ACID TEST (NAT) - It is for people who have
early symptoms of HIV or have a known risk factor. This test - ESOPHAGEAL DISEASE
doesn’t look for antibodies; it looks for the virus itself. It takes
from 5 to 21 days for HIV to be detectable in the blood. This - HIV WASTING SYNDROME
test is usually accompanied or confirmed by an antibody test. - HIV-ASSOCIATED MALIGNANCIES
EARLY SYMPTOMS

1. swollen lymph nodes

2. fever

3. chills
 PNEUMOCYSTIS JIROVECI PNEUMONIA (PJP) Medication

• A form of pneumonia that can be a life threatening. treatment options exist for CMV retinitis:

• this organism has been reclassified from a protozoan • oral valganciclovir

to a fungus on the basis of ribosomal RNA sequence
comparisons. • IV ganciclovir

• CD4 generally below 200 or Thrush • IV ganiclovir followed by oral valganciclovir

Standard Primary Prophylaxis • IV foscarnet

1. Trimethoprim-Sulfamethoxazole • IV cidofovir
(Cotrimoxazole) • Ganciclovir intraocular implants with Valganciclovir
-DOC for PJP. for induction and maintenance therapy

Alternative Prophylaxis Alternatives

2. Pentamidine isethionate • combined IV ganciclovir plus foscarnet

3. Trimetrexate + leucovorin • intraocular injections of ganciclovir

4. Atovaquonea • foscarnet, cidofovir, or fomivirsen sodium

(Vitravene).
5. TMPa + dapsone
Ganciclovir
6. Clindamycin + primaquine
 an acyclic nucleoside with CMV activity
7. Prednisone (adjuvant corticosteroid therapy) superior to acyclovir.

TOXOPLASMA GONDII ENCEPHALITIS Alganciclovir

• is a parasitic protozoan that can infect people and  an oral monovalyl ester prodrug that is
spread by environmental factors, such as the rapidly hydrolyzed to ganciclovir.
consumption of raw or undercooked meats and
contact with cats. Cidofovir

• two major routes of transmission of Toxoplasma to  a nucleotide analog that is phosphorylated

humans are oral and congenital. intracellularly to an active diphosphate
metabolite. It is the most potent of all the
• CD4 <100 and Toxoplasma IgG positive available anti-CMV compounds and is
active against herpes simplex virus (HSV)
TREATMENT: and VZ
Rx: Sulfasalazine+ Pyrimeth. + Folinic acid Foscarnet
• Repeat MRI to make sure lesions smaller.  a pyrophosphate analog that acts by
• Maintenance therapy after induction. selectively inhibiting viral DNA
polymerases and reverse transcriptase
• Consider steroids and anticonvulsants
CAUSES
• TMP-SMX is adequate 1 prophylaxis
Very Subtle presentation at times
- dapsone and pentamidine is not protective
– Headache, fever, lethargy, nausea
- Should protect when CD4 < 100 if IgG+
CSF glucose is decreased, whereas CSF proteins are usually
CYTOMEGALOVIRUS DISEASE elevated
• is a viral infection that can affect one part of the CSF Cryptococcal antigen titer and CSF culture are frequently
body, such as the eyes, or it can spread throughout positive
the body.
TREATMENT
• Although CMV can cause colitis, pneumonitis,
esophagitis, hepatitis, and neurologic disease, retinitis • Most induce with Amphotericin B +/- FC
is the most common manifestation of active infection.
 • Can be use high dose Fluconazole. CANDIDA ESOPHAGITIS

• Will need chronic maintenance to control infection as • 10-20% patients with AIDS.
can’t be generally cured.
• NO oral thrush in 38% of patients.
• High risk for recurrent elevated ICP which can result
hydrocephalous • Empiric azole trial appropriate for mild symptoms.

• May require periodic removal of CSF • Definitive diagnosis by endoscopy.

MYCOBACTERIUM TUBERCULOSIS • Initial Therapy

• TB is a leading cause of death in HIV-infected -Fluconazole 200-400 mg/d 14-21 days.

persons worldwide, and pulmonary TB is an AIDS- -Itraconazole 200mg PO QD
defining illness.
• Refractory/Resistant Disease
• M.tuberculosis strains resistant to isoniazid and
rifampin, with or without resistance to other agents -Amphotericin B 0.3mg/kg/d x 10-14

TREATMENT days

*Standard regimens -Capsofungin 70 mg IV x 1 then 50 mg

• Initial 3 drug regimens IV QD

INH, rifampicin & Pyrazinamide CMV ESOPHAGITIS

• If the organisms are fully susceptible pyrazinamide  Patient who do not respond to a 1-week course of an
can be discontinued after 2 mo’s & treatment antifungal.
continued for a further 4 mo’s w/ a 2 drug regimen.
 confirmed via endoscopic biopsy demonstrating
*Alternative regimens erythema and single or multiple discrete erosive
lesions, usually located distally.
• In case of sully susceptible organisms:
 poor prognosis
INH + Rimfampin= 9 months’
ACUTE TREATMENT
INH + Ethambutol= 18 mo’s; intermittent (2 or 3 x weekly)
high doses. -ganciclovir 5 mg/kg IV per dose BID or foscarnet 40 to 60
mg/kg IV per dose Q 8 hours for 2 to 3 weeks.
• 4 drug regimens are also effective
• Maintenance therapy
MYCOBBACTERIUM AVIUM COMPLEX
-usually half the dose used for induction treatment.
• Not uncommon when CD4 <75.
APHTHOUS ULCERS
• Chronic constitutional symptoms such as fever,
sweats, and weight loss. • are similar in appearance and location to CMV, and
negative results for Candida, HSV, and CMV
• Labs may reveal anemia, leukopenia, and elevated
alkaline phosphate. • Acute treatment

TREATMENT – prednisone 40 mg/day for 7 to 10 days,

tapered to 10 mg/wk.
- requires a minimum of 2 meds chronically as it is quite
resistant. – Thalidomide, 200 mg/day, is a promising
regimen.
-Macrolide,Ethambutol
HIV WASTING SYNDROME
(Amikacin, Rifabutin, Ciprofloxacin)
• The unintentional weight loss of >10% of baseline
• Primary Prophylaxis body weight plus chronic diarrhea (more than two
Clarithromycin or Azithromycin loose stools a day for >30 days) or chronic weakness
with unexplainable fever that is intermittent or
w/ or w/o rifabutin. constant for >30 days.
 • characterized by depletion of both adipose and lean men
body tissue.
-presents with three types of lesions:
HIV WASTING REGIMEN
flat, raised, or nodular.
MEGESTROL ACETATE -an oral synthetic progestin related
to progesterone. -The lesions occur primarily on the skin, oral mucosa, GIT,
-used for the treatment of hormone-responsive malignancies, and lungs. lesions may be asymptomatic or painful;
but it is also approved for HIV-infected patients who have lost LOCAL THERAPY
at least 10% of their ideal body weight.
• Topical liquid nitrogen cryotherapy, intralesional
SIDE EFFECTS : injections of vinblastine 0.01-0.02 mg/lesion every 2
• Hypergonadism weeks for 3 doses, and low-dose radiation therapy.

• Diabetes • used in slowly progressive KS without life-

threatening organ involvement.
• Adrenal insufficiency
SYSTEMIC THERAPY
DRONABINOL (delta-9 tetrahydrocannabinol) -the
psychoactive component of marijuana, 2.5 mg BID has been • Interferon-α, 18 to 36 million IU daily IM or SC for
approved for treating AIDS-related weight loss. significantly 10-12 weeks, followed by 18 million units/day with
increases appetite, increases body weight, and improves mood. additional chemotherapeutic agents.

CYPROHEPTADINE -is an antihistamine reported to • These include:

stimulate appetite in HIV-infected patients. • Paclitaxel (Taxol) 100 to 135 mg/m2 IV every 2 to 3
Anabolic steroids and testosterone weeks;
- used to increase muscle mass and strength in people • Doxorubicin (Adriamycin), bleomycin, plus either
with HIV wasting syndrome vincristine or vinblastine or bleomycin plus
OXANDROLONE vincristine
-it increases body weight but does not improve body strength. • Liposomal daunorubicin (DaunoXome) 40-60 mg/m2
at a dosage of 15 mg/day. IV every 2 weeks; or liposomal
-drug has a low androgenic effect, so it is particularly useful in
women. • Doxorubicin (Doxil) 10 to 20 mg/m2
Usual dosage:
2. CERVICAL INTRAEPITHELIAL NEOPLASIA
Males is 10 to 20 mg BID
Women at increased risk of precancerous cervical
Females is 5 to 20 mg/day.
cytology include those with HIV infection or HPV
NANDROLONE -increases body weight, muscle mass, and infection and cigarette smokers.
strength. It has a high anabolic effect and a low androgenic
the greater the degree of immunosuppression (CD4+ count
effect
<200), the higher the risk for cervical intraepithelial neoplasia.
Usual dosage:
• All HIV-infected women should have Pap smears
Males is 100-200 mg IM every 1 to 2 every 6 months in the first year of diagnosis.
• Low-grade squamous intraepithelial lesions progress
weeks to high-grade lesions, including moderate to severe
Females 25 mg IM per week or 50 mg dysplasia or carcinoma in situ

IM every 2 weeks. TREATMENT

OXYMETHOLONE -is not recommended for use in women INTERFERON BETA

because of its high androgenic potential. • 2 million IUs IM daily for 10 days, and their
-Hepatic toxicity is common, so LFTs must be carefully outcomes were compared with 15 women treated
monitored with saline.

HIV-ASSOCIATED MALIGNANCIES • After >6 months, 14-15 of the treated women had a
complete response compared with 6 of 15 of the
1. Kaposi Sarcoma controls. In a placebo-controlled trial using the same
dosage regimen,
-predominantly in homosexual
PATIENT EDUCATION 4- Use of human feces (night soil) for soil fertilizer

• Best way to prevent Ois is to keep immune system 5- contamination of foodstuffs by flies, and possibly
strong. cockroaches

• Appropriate medication at certain CD4 cell levels can The symptoms often are quite mild and can include
prevent many OIs (prophylaxis)
1. loose stools
• Treatment options available if OIs develop
2. stomach pain
• After recovery from OIs on going maintenance
treatment is still needed. 3. stomach cramping.

• Can stop prophylaxis or maintenance treatment if TREATMENT

CD4 cell count goes up. macrolide antibiotics (Flagyl)
• Shouldn’t discontinue any treatment without nitroimidazole antibiotics (erythromycin)
discussing first with doctor.
animalarials (chloroquine)
71 FUNGAL INFECTIONS
and antiprotozoals (paromomycin)
72 VIRAL INFECTIONS
GIARDIASIS
73 VIRAL HEPATITIS Giardia intestinalis (Protozoal parasite)
74 PARASITIC INFECTIONS Also known as: Giardia lamblia, Lamblia intestinalis
,Giardia duodenalis
MALARIA considered the world’s most important parasitic Isolated from humans, domestic animals, and wild animals
disease, responsible for an estimated 300 to 500 million case.
TRANSIMISSION -Cysts
- is a life-threatening disease.
Direct transmission -Fomites
Malaria parasites (genre: Plasmodium)
- Contaminated water and/or food
Female mosquitoes (genre: Anopheles) - Ingested cysts release trophozoites
- Trophozoites multiply and encyst in intestines
SIGNS AND SYMPTOMS:
- Excreted in feces
- Headache, fever, fatigue, muscle pain, back pain,
DISEASE IN HUMANS
chills, sweating, dry cough, enlargement, nausea,
vomiting Incubation period: 1-25 days
PREVENTION: Symptoms of clinical disease
MOSQUITOES – indoor residual spraying, environmental Mild to severe gastrointestinal signs
interventions , larvicides
Sudden onset diarrhea / Foul-smelling stools/ Abdominal
VS VECTOR – HUMAN CONTACT – insecticides treated cramps/ Bloating, flatulence/ nausea, fatigue/ Weight loss
bed nets
TREATMENT
VS PARASITES – DRUGS
Anti-protozoal drugs
AMEBIASIS Entamoeba histolytica
Metronidazole/Tinidazole/Ornidazole
Causes amebic dysentery and hepatic abscess.
Chronic cases-May be resistant
TRANSMISSION
Prolonged therapy may be necessary
1-driect contact of person to person( fecal-oral)

2- Veneral transmission among homosexual males( oral-anal

3- Food or drink contaminated with feces containing the E.his.

cyst
ENTEROBIASIS tching of head – may or may not occur due to the saliva of the
louse as it bites the scalp.
The cause of enterobiasis, or pinworm infection, is
Enterobius vermicularis Tickling sensation of something moving in the hair

A small (1 cm in length), white, threadlike nematode. Diagnosis is made by observing nits, nymphs, or adults

typically inhabits the cecum, appendix, and adjacent TREATMENT

areas of the ileum and ascending colon consult pediatrician/pharmacist about a pediculocidal
shampoo
Gravid females migrate at night to the perianal and
perineal regions. use shampoo according to package directions

Human infection occurs by the fecal-oral route . do not rewash with regular shampoo or use a
conditioner after pediculocide has been used for 1-2
CLINICAL MANIFESTATIONS days

The most common complaints include itching and retreat according to package directions in 7-10 days
restless sleep secondary to nocturnal perianal or
manually remove nits with bright light and fine tooth
perennial pruritus.
nit comb after shampooing
occasionally may lead to appendicitis, pelvic inspect hair daily, and remove nits as they are found
inflammatory disease, peritonitis, hepatitis, and
ulcerative lesions in the large or small bowel.
75 TICK-BORNE DISEASES
TREATMENT LYME DISEASE Borrelia burgdorferi

mebendazole (100 mg PO for all ages) repeated in 2 wk Spirochete: slender helical shaped bacteria
results in cure rates of 90–100%
Gram negative Motile
single oral dose of albendazole (400 mg PO for all ages) Extracellular pathogen
repeated in 2 wk
Aerobic or microaerophilic
single dose of pyrantel pamoate (11 mg/kg PO,
maximum 1 g). TRANSMISSION :Vector-borne disease- is deer or black-
legged tick (Ixodes scapularis) or by the western black-legged
PEDICULOSIS tick (Ixodes pacificus) on the Pacific Coast.

HEAD LICE PEDICULUS CAPITUS Transmits B. burgdorferi while feeding on an uninfected host

BODY LICE PEDICULUS HUMANUS the spirochetes are present in the midgut and migrate during
blood feeding to the salivary glands, from which they are
PUBIC LICE PTHIRUS PUBIS transmitted to the host via saliva.

B. burgdorferi cannot penetrate intact skin

PARASITIC INSECT- feeds on hair’s blood supply and SYMPTOMS OF B. BURGDORFERI
excretes a substance that prevents blood from clotting
Stage 1 -Localized erythema migrans (EM)
does not transmit a pathogen
-Red macule/papule and Round lesion that measures
size of a sesame seed 5cm to 15cm.
6 legs with hook-like claws that are suitable for gripping hair Stage 2 -Early disseminated infection
shaft
-multiple secondary erythema migrans lesions
habitat remains near scalp
-systemic non specific symptoms
in order to maintain body temperature
Persistent or late infection
moves by crawling
Symptoms of neurologic disease

Symptoms of musculoskeletal disease

SIGNS AND SYMPTOMS
Symptoms of cardiac disease Affected by strain virulence, dose

Chronic inflammatory eye disease Six disease forms in humans

Stage 3 All forms start with:

-6 months after primary skin lesion Sudden fever,Chills,Headache, Myalgia

Swelling and pain in large weight-bearing joints, especially in Antibiotic treatment : Streptomycin (drug of choice)
the knee.
RICKETTSIAL DISEASES - true bacteria, gram-negative,
Chronic arthritis and cultivable only in living tissues.

Years after infection, if left untreated: Transmitted by lice and ticks, they cause disease in humans
and domestic animals but are also found in the cytoplasm of
Late neurological syndrome tissue cells of lice, fleas, ticks and mites, which may act as
TREATMENT -Antibiotic therapy reservoirs and vectors

Doxycycline and amoxicillin are used for two to four weeks in SYMPTOMS – Fever,Anemia, Edema, Icterus (jaundice)
early cases Hemorrhages of mucous membranes, Enlarged spleen
Doxycycline is also effective against human granulocytic SECTION 16 PSYCHIATRIC DISORDERS
Cefuroxime acetyl or erythromycin can be used for patients 77 SLEEP DISORDERS
who are allergic to penicillin or who cannot take tetracycline.
SS : Consistent failure to get enough sleep or restful sleep
More developed cases, may require treatment with intravenous
ceftriaxone or penicillin for 4 weeks or more. Consistently feeling tired upon waking &/or waking with a
headache
TULAREMIA
Chronic fatigue, tiredness, sleepiness during the day
TRANSMISSION- Reservoirs
Struggling to stay awake while driving or doing something
Mammals, ticks, and some birds passive, e.g. watching TV
Ticks and rabbits most important Difficulty concentrating at work or school
Rodent-mosquito cycle in Russia, Sweden Slowed or unusually delayed response to stimuli or events
INFECTIOUS DOSE- Small for inoculation or inhalation Difficulty remembering things or controlling emotions
(10-50 organisms) -Large for oral (108 organisms)
Frequent urge to nap during the day
Vector-borne
Snoring or ceasing to breathe during sleep
TICKS- MTransovarial transmission
78 SCHIZOPHRENIA
14 species
₋ debilitating and emotionally devastating illness with
Dermacentor andersonii long-term impact on patients’ lives.
Dermacentor variabilis ₋ most severe expression of psychopathology,
Amblyomma americanum encompassing significant disruptions of thinking,
perception, emotion, and behavior.
MOSQUITOES, FLIES -Infrequent
₋ usually a lifelong psychiatric disability.
Chrysops discalis (deer fly)
 affects men and women with equal frequency, there
DIRECT- Contact with tissues of rabbits or other infected are differences in the age of onset and course of
mammals/Skinning, necropsy/Handling contaminated skins, illness.
paws/ Bite wounds
 during late adolescence or early adulthood.
Ingestion-Undercooked meat,Contaminated water

HUMAN DISEASE

Incubation: 3 to 15 days
 CAUSES * rigid posture

1. Genetics – “runs in the family” * sometime too much movement

2. Prenatal Damage 3. Paranoid

* Malnutrition * strong delusions

* Viruses * strong hallucinations

3. Environment TREATMENT

* Family Stress Schizophrenia is a chronic disease for which there is no

cure.
* Poor Social Interactions
Pharmacotherapy can reduce symptoms to improve social and
* Infections or Viruses at an early age cognitive functions; however, patients have multiple relapses
* Trauma at an early age and experience residual symptoms throughout their lives.

4. Neurotransmitters (Biological) Treatment can decrease acute symptoms, decrease the

frequency and severity of psychotic episodes, and optimize
* too much dopamine, low levels of serotonin and psychosocial functioning between episodes.
glutamate
79 MOOD DISORDERS I: MAJOR DEPRESSIVE
5. Brain Abnormalities (Biological) DISORDERS
* reduced number of neurons Classification of Mood Disorders
* enlarged ventricles
A. Depressive Disorders
* thalamus abnormalities 1. Major Depressive Disorder, Single Episode
2. Major Depressive Disorder, Recurrent
Characteristic Symptoms 3. Dysthymic Disorder
At least two of the following, each present for a significant 4. Depressive Disorder Not Otherwise Specified
portion of time during a 1-month period :
1. Delusions Individuals must possess at least five symptoms, one of
2. Hallucinations which is either depressed mood. The other seven symptoms
3. Disorganized speech are as follows:
4. Grossly disorganized or catatonic behavior
1. Change in appetite
5. Negative symptoms
2. Change in sleep
Note: Only one “A symptom” is required if delusions are 3. Low energy
bizarre or 4. Poor concentration (or difficulty making decisions)
hallucinations consist of a voice keeping up a running 5. Feelings of worthlessness or inappropriate guilt
commentary 6. Psychomotor agitation or retardation
on the person’s behavior or thought, two or more 7. Recurrent thoughts of suicide
conversations with
Selected Medications That May Induce Depression
each other.

TYPES
Cardiovascular Agents
1. Disorganized β-blockers
Clonidine
* lack of emotion Methyldopa
Reserpine
* disorganized speech
Central Nervous System
* silly/childlike behavior Agents
Barbiturates
* makes no sense when talking Benzodiazepines
Chloral hydrate
2. Catatonic
Ecstasy (MDMA)
* waxy flexibility Ethanol

* reduced movement
Hormonal Agents Psychodynamic therapy
Anabolic steroids
Corticosteroids
Gonadotropin-releasing hormone (b) somatic interventions
Progestins
Tamoxifen ECT ( Electroconvulsive therapy )
Others
Efavirenz
- Safe, rapid acting highly effective therapeutic intervention
Interferon
that continues to suffer, from a poor public shaming
Isotretinoin
-done under general anesthesia in which small electric currents
Mefloquine
are passed through the brain
Levetiracetam
TMS (Trans magnetic stimulation)
Selected Medical Conditions That May Mimic Depression
- non-invasive procedure involving the application of
Central Nervous System an electrical stimulus across the scalp, which ultimately
Alzheimer disease generates an electrical field in the cerebral cortex
Cerebrovascular accident
(c) lifestyle adjustments
Epilepsy
Multiple sclerosis - Reverse unhealthy or destructive lifestyle habits
Parkinson disease

- Alcohol, recreational drug use, and excessive caffeine

Cardiovascular consumption should be minimized in patients suffering from
Cerebral arteriosclerosis depression or anxiety disorders.
Congestive heart failure
Myocardial infarction - Sleep habits should be evaluated and improved to
ensure optimal rest.

Endocrine - Dietary factors should be modified to promote

Addison disease diverse, balanced, and nutritional eating habits
Diabetes mellitus (types I and II)
- Increased physical activity and sustained cardiovascular
Hypothyroidism
exertion can impart a variety of health benefits.
Women’s Health
Premenstrual dysphoric disorder
80 MOOD DISORDERS II: BIPOLAR DISORDERS
Antepartum/postpartum
Perimenopause LITHIUM DRUG INTERACTIONS OF CLINICAL
SIGNIFICANCE
Other
Chronic fatigue syndrome Drugs That May Increase Lithium Levels
Chronic pain syndrome(s)
Fibromyalgia – NSAIDs
Irritable bowel syndrome
Many NSAIDs have been reported to increase lithium levels
Malignancies (various)
as much as 50%–60%. This probably is due to an enhanced
Migraine headaches
reabsorption of sodium and lithium secondary to inhibition of
Rheumatoid arthritis
prostaglandin synthesis.
Systemic lupus erythematosus
– Diuretics
NON DRUG THERAPIES
All diuretics can contribute to sodium depletion. Sodium
Most experts now advocate a three-pronged
depletion can result in an increased proximal tubular
approach to relieving and preventing depressive symptoms,
reabsorption of sodium and lithium. Thiazidelike diuretics
involving
cause the greatest increase in lithium levels, whereas loop
(a) psychotherapy diuretics and potassium-sparing diuretics seem to be
somewhat safer
cognitive – behavioural therapy
– ACE inhibitors
Interpersonal therapy

Psychoanalytic
ACE inhibitors and lithium both result in volume depletion with antidepressant activity in bipolar
and a reduction in glomerular filtration rate. This results in depression.
reduced lithium excretion.
• Lamotrigine
• Drugs That May Decrease Lithium Levels
– considered a first-line agent for bipolar
– Theophylline, caffeine depression by all North American
guidelines.
Theophylline and caffeine may increase renal clearance of
lithium and result in a decrease in levels in the range of 20%. • Antidepressants

– Acetazolamide – use in bipolar depression is controversial

and current guidelines suggest that they
Acetazolamide may impair proximal tubular reabsorption of should be used only when other preferred
lithium ions. treatments such as lithium, lamotrigine,
– Sodium quetiapine, or olanzapine–fluoxetine
combination have failed.
High dietary sodium intake promotes the renal clearance of
lithium. MAINTENANCE THERAPY OF BIPOLAR DISORDER

• Drugs That Increase Lithium Toxicity • Lithium

– Methyldopa – Maintenance therapy with lithium clearly

reduces the frequency and severity of mood
Cases of sedation, dysphoria, and confusion owing to the episodes in patients with bipolar disorder
combined use of lithium and methyldopa have been reported.
– Target levels for maintenance therapy with
– Carbamazepine lithium should be in the range of 0.5 to 0.8
mEq/L.
Cases of neurotoxicity involving the combined use of lithium
and carbamazepine have been reported in patients with normal Anticonvulsants
lithium levels.
– Valproate and lamotrigine are reasonable
– Calcium channel antagonists alternatives that have shown efficacy in
bipolar maintenance therapy.
Cases of neurotoxicity involving the combined use of lithium
and the calcium channel blockers verapamil and diltiazem – Lamotrigine has been studied rigorously in
have been reported. Lithium does interfere with calcium the maintenance treatment of bipolar I
transport across cells. disorder.
– Antipsychotics

Cases of neurotoxicity (encephalopathic syndrome, 81 ATTENTION DEFICIT HYPERACTIVITY

extrapyramidal effects, cerebellar effect, EEG abnormalities) DISORDER IN CHILDREN, ADOLESCENTS, AND
have been reported due to the combined use of lithium and ADULTS
various antipsychotics. The interaction may be related to
increase in phenothiazine levels, changes in tissue uptake of INATTENTION FACTOR
lithium, and/or dopamine-blocking effects of lithium. 1. careless mistakes or inattention to detail
– Serotonin-selective reuptake inhibitors 2. reduce attention span
Fluvoxamine and fluoxetine have been reported to result in 3. poor listener
toxicity when added to lithium. Sertraline has been reported to
cause nausea and tremor in lithium recipients. 4. cannot follow instructions and does not complete
tasks
TREATMENT OF ACUTE BIPOLAR DEPRESSION
5. difficulty organizing tasks and activities
• Lithium
6. avoid and/or dislikes chores or homework
– this agent remains one of the drugs of
choice. 7. loses things needed for tasks and activities

– Higher serum lithium concentrations (≥0.8 8. easily distracted by extraneous stimuli

mEq/L) may be required and are associated
9. forgetful in daily activities
HYPERACTIVITY/ IMPULSIVITY FACTOR
82 EATING DISORDERS
• HYPERACTIVITY
- serious medical illnesses marked by severe
1. fidgets with hands/ feet or squirms in chair disturbances to a person’s eating behaviors.
2. cannot remain seated in the classroom Obsessions with food, body weight, and shape may be
3. uncontrollable/ inappropriate restlessness signs of an eating disorder.

4. difficulty in engaging in play or leisure Anorexia nervosa, bulimia nervosa, binge-eating, and obesity
activities quietly are examples of eating or metabolic disorders that evolve as a
result of weight loss behaviors and/or by a complex interaction
5. often on the go and appearing driven by a of social, developmental, and biological factors.
motor
These disorders can affect a person’s physical and mental
6. excesssive talking health; in some cases, they can be life-threatening. But
eating disorders can be treated.
• IMPULSIVITY
DIAGNOSIS of eating disorders is based on weight,
7. blurts out answer prior to completion of question
engagement inweight loss behaviors (e.g., restricting or
8. difficulty waiting in turn avoiding food, vomiting, laxative and diuretic abuse, use of
appetite suppressants, over exercising), binge-eating
9. interrupts or intrudes on others behaviors, abnormal attitudes and preoccupation with weight,
shape, and food, and medicaconsequences.
• ADHD is classified into 3 subtypes: hyperactive-
impulsive, innattentive or combined CAUSES OF EATING DISORDERS
• approx 2.5 times more frequent among males than • GENETIC studies show that 80% of children with
females two obese parents are obese compared with 40% of
children with one obese parent, and 10% of children
• high rate on conduct disorder, oppositinal defiant
with two normal-weight parents.31 Genetic risks for
disorder, depression, major affective disorder and
obesity are associated with a higher “set-point” for
anxiety disorders including OCD and Tourette
appetite and food intake, which causes individuals to
syndrome.
eat more before feeling full.
• Diagnosis:
• DOPAMINE
• exclude: head injuries, absence seizures,
Disturbances in dopamine activity and feedback regulation at
cerebral infection, substance abuse,
different receptors have been postulated as a cause of anorexia
hyperthyroidism, anxiety disorders and
nervosa.
mood disorders.
Agents that increase dopamine activity (e.g., apomorphine, a
• physical examination, neurological
dopamine agonist; levodopa, a metabolic precursor of
examination, social, family, school and
dopamine; and amphetamine, a releaser of dopamine from
medical history
presynaptic stores) have been shown to have anorexic effects.
PHARMACOTHERAPY
Dopamine agonists increase dopaminergic transmission and
• CNS stimulant or psychostimulant medications are motor activity, which causes loss of appetite and
the DOC hyperactivity; at higher doses, these agents may cause
psychosis (hallucinations and delusions) and
• tricyclic antidepressants (TCAs) repetitive/stereotypical behaviors.
• atomexetine • SEROTONIN- plays an important role in postprandial
satiety, anxiety, sleep, mood, obsessive-compulsive, and
• bupropion
impulse control disorders.
• clonidine
Serotonin activity in the region of the medial hypothalamus
• norepinephrine and/or dopamine agonists has an inhibitory effect on appetite and is responsible for
satiety or the feeling of fullness after food Intake.

Pharmacologic treatments that increase intrasynaptic

serotonin or those that directly activate serotonin receptors
cause satiety and reduce food consumption.
• NOREPINEPHRINE- The hypothalamus is innervated • This binge-eating is followed by behaviors that
by noradrenergic pathways; thus, norepinephrine is compensate for the overeating, such as forced
involved in the regulation of eating behavior, the vomiting, excessive use of laxatives or diuretics,
hypothalamic control of thyrotropin-releasing hormone fasting, excessive exercise, or a combination of these
secretion, corticotropin-releasing hormone (CRH) release, behaviors. Unlike those with anorexia nervosa,
and gonadotropin secretion.47 d-Amphetamine, which people with bulimia nervosa may maintain a normal
inhibits the reuptake of norepinephrine, decreases hunger weight or be overweight.
sensations and food intake
SYMPTOMS
• BRAIN CHANGES
Chronically inflamed and sore throat
Brain imaging studies have found generalized atrophy and/or
ventricular dilation in patients with anorexia nervosa that • Swollen salivary glands in the neck and jaw area
reverse with weight gain. • Worn tooth enamel and increasingly sensitive and
Reduced regional cerebral blood flowing the temporal lobe decaying teeth (a result of exposure to stomach acid)
has been reported in childhood onset anorexia, indicating a • Acid reflux disorder and other gastrointestinal
possible functional abnormality of the brain. problems
ANOREXIA NERVOSA avoid food, severely restrict food, or • Intestinal distress and irritation from laxative abuse
eat very small quantities of only certain foods. Even when
they are dangerously underweight, they may see themselves as • Severe dehydration from purging
overweight. They may also weigh themselves repeatedly.
• Electrolyte imbalance (too low or too high levels of
There are two subtypes of anorexia nervosa: a restrictive sodium, calcium, potassium and other minerals),
subtype and binge-purge subtype. which can lead to stroke or heart attack

Restrictive: People with the restrictive subtype of anorexia BINGE- EATING DISORDER
nervosa place severe restrictions on the amount and type of
• People with binge-eating disorder lose control over
food they consume.
their eating. Unlike bulimia nervosa, periods of
Binge-Purge: People with the binge-purge subtype of anorexia binge-eating are not followed by purging, excessive
nervosa also place severe restrictions on the amount and type exercise, or fasting. As a result, people with binge-
of food they consume. In addition, they may have binge eating eating disorder are often overweight or obese.
and purging behaviors (such as vomiting, use of laxatives and
diuretics, etc.). SYMPTOMS

SYMPTOMS • Eating unusually large amounts of food in a specific

amount of time, such as a 2-hour period
• Extremely restricted eating and/or intensive and
• Eating fast during binge episodes
excessive exercise

• Extreme thinness (emaciation) • Eating even when full or not hungry

• A relentless pursuit of thinness and unwillingness to • Eating until uncomfortably full

maintain a normal or healthy weight • Eating alone or in secret to avoid embarrassment
• Intense fear of gaining weight • Feeling distressed, ashamed, or guilty about eating
• Distorted body image, a self-esteem that is heavily • Frequently dieting, possibly without weight loss
influenced by perceptions of body weight and shape,
or a denial of the seriousness of low body weight OBESITY

• Over time, these symptoms may also develop: • Obesity is a major public health concern worldwide
and is the leading cause of numerous medical
• Thinning of the bones (osteopenia or osteoporosis) conditions (e.g., cardiovascular disease, hypertension,
• Mild anemia and muscle wasting and weakness dyslipidemia, diabetes, sleep apnea) and premature
death.
BULIMIA NERVOSA

• People with bulimia nervosa have recurrent episodes

of eating unusually large amounts of food and feeling
a lack of control over these episodes.
TREATMENT • Physiological addiction or Psychological dependence

• Fluoxetine • maladaptive pattern of substance use leading

to clinically significant impairment or
 Is a SSRI antidepressants that have been used disease.
successfully to reduce binge eating behavior, but this
is not always associated with weight loss. • Habituation

• LIPASE INHIBITORS such Orlistat (Xenical) • a state of either chronic or periodic drug use
characterized by a desire (but not a
 is an FDA-approved weight loss medication, works compulsion) to continue using the drug, no
to reduce dietary fat absorption by inhibiting GI tendency to increase the dose, and an
(stomach and pancreas) lipase activity. absence of physical addiction despite some
 Orlistat does not exert appetite suppressant effects, degree of physiological dependence.
has no CNS effects, and has no systemic absorption. 2 Groups for Substance-Related Disorders
It is most effective if combined with a reduced fat
and calorie diet and is indicated to reduce the risk of 1. Substance use disorders
weight regain after prior weight loss.
- distinguishing between substance dependence and
MISCELLANEOUS AGENTS substance abuse

 Topiramate is a second-generation antiepileptic 2. Substance-induced disorders

agent which acts as an agonist at γ -aminobutyric acid
(GABAA) receptors and as an antagonist at non–N- - intoxication, withdrawal
methyl-d-aspartic acid glutamate receptors. It has URINE SCREENING AND ITS PITFALLS
been shown to produce a dose dependent weight loss
between 1 and 8 kg and may also produce weight loss • exercise and hydration
in patients with bipolar affective disorder.
• enhancing secretion
 SEROTONIN/NOREPINEPHRINE REUPTAKE
• drinking vinegar or cranberry juice
INHIBITORS
• taking vitamin C
 Sibutramine (Meridia), a prescription medication
marketed for weight loss, is structurally related to • taking saunas
amphetamines (β- phenylethylamine) and is classified
as a schedule IV controlled agent. Sibutramine and its • buying clean urine from a drug-free individual
two active metabolites inhibit the reuptake of
• adding bleach, isopropanol or salt to urine sample
serotonin and norepinephrine and, to a lesser extent,
dopamine, thereby increasing concentrations of these • dehydration
neurotransmitters in the brain.
• adding water to specimen
• SURGERY - should be used only for morbidly obese
individuals (BMI ≥40 or ≥35 kg/m2 with comorbid I. OPIOIDS
conditions) in whombehavioral or pharmacologic
a. Heroin
treatments have failed. For severely obese patients
(>100% over normal weight), the most effective b. Rx drugs
treatment is a surgical procedure to reduce the size of
the stomach. Surgical procedures either reduce the II. Sedative-Hypnotics
absorptive surface of the GI tract resulting in
a. Ethanol
malabsorption, or reduce the stomach volume so that
the person feels full after a smaller meal. b. Benzodiazepines
SECTION 17 SUBSTANCE ABUSE c. Carisoprodol

83 DRUG ABUSE d. GHB

• Physical addiction or dependence III. CNS stimulants
• repeated administration of a drug which a. Cocaine
causes an altered physiologic state
(neuroadaptations) b. Amphetamines
 IV. Dissociative Drugs Carisoprodol

a. Phencyclidine • a nonscheduled skeletal muscle relaxant, has

an active metabolite meproamate with
b. Ketamine known abuse potential.
c. Dextromethorphan Txn of withdrawal:
V. Hallucinogens • decreasing doses of the drug of dependence
a. LSD • substituting of phenobarbital for the drug of
b. MDMA dependence

VI. Marijuana • substituting of a long acting benzodiazepine

for the drug of dependence
VII. Inhalants
Phenobarbital method
OPIOIDS
• the one most generally applicable; widely
HEROIN used in drug treatment programs because it
is the best choice used for patients who have
• Addiction: noticeably opioid physical
lost control of their benzopdiazipine use or
dependence
who are polydrug users
• Withdrawal: (after 6-12 hrs) anxiety,
• involves calculating a phenobarbital
hyperactivity, restlessness and insomnia;
replacement dose for the total daily dose of
(after 48-72 hrs) anorexia, nausea, vomiting
the sedative-hypnotic being used.
abdominal cramps and diarrhea
CENTRAL NERVOUS SYSTEM STIMULANTS
• During withdrawal: heart rate and BP may
elevate, marked weight loss, dehydration, Cocaine
cardiovascular collapse
• a naturally occuring alkaloid derived from
• The more dramatic symptoms of heroin the Erythroxylon coca plant
withdrawal subside after 7-14 days of
abstinence without treatment; however, a • second to marijuana as the most frequently
return to complete physiologic equilibrium used drug of abuse
may require months or longer; seldom life- • a CNS stimulant and has vasoconstrictive
threatening and local anesthetic properties
• Iatrogenic dependence: after 2-10 days • stimulant effect are caused by blockade of
• Overdose Treatment: airway management, reuptake of dopamine, norepinephrine, and
cardiorespiratory support and opioid reversal serotonin
with naloxone (IV, IM or SC) • associated with compulsive use
• Treatment of Opioid Dependence: • snorting (2 min), smoking (6-8 sec) with 30
detoxification programs, methadone min half-life
(treatment of choice)
• A/E: hypertension, arrythmias, myocardial ischemia
SEDATIVE-HYPNOTICS and infarction, dilate and hypertrophic
Ethanol cardiomyopathy, myocarditis, aortic dissection and
acceleration of artherosclerosis
• most widely abused substance
• Withdrawal syndrome: “crash”, depression, fatigue,
Benzodiazepines craving, hypersomnolence and anxiety; can be
resolve within 1-2 weeks
• prototypical sedative-hypnotic drug of abuse
• Txn of addiction: dopamine agonist, antidepressants,
GHB (Gamma-hydroxybutyric acid)
carbamazepine, methylphenidate (maintenance
• a putative neurotransmitter abused for its treatment), cocaine vaccine (UI)
euphoric and sedative-hypnotic effect
AMPHETAMINES
 • Caffeine • mild to moderate sympathomimetic effects,
profound visual hallucnosis, and the
• consumed worldwide in a usually socially sensation of disordered integration of
acceptable manner in the form of coffee and sensory input
cola soft drinks
• A/E: mental state of acute anxiety and fear
• Methamphetamine aka “bad trip”
• produces CNS stimulation by enhancing the • therapy: “reality therapy”, “talking down”
effects of noepinephrine, serotonin ad
dopamine • long term effect: Hallucinogen persisting
perceptual disorder (HPPD)
• accomplished by both blocking reuptake
and stimulating release of neurotransmitters MDMA

• half-life is 6-15 hours • produces a very manageable and

comfortable entactogenic effect
• tolerance develops very rapidly after
continued use • the experience can be recalled in detail, and
the insights gained during the session can be
• A/E: chronic users characteristically develop complex incorporated into normal life
paranoid delusional systems with hallucinations
during extended periods of intoxication that may • onset of action: 30-60 min, booster shot after
involve several sleepless days and nights of 2 hours
continuous methamphetamine administration.
• duration of action: 4-6 hours; half life of 8
• Txn of withdrawal: no effective pharmacologic hours
treatments have been proved effected for meth
dependence; most effective is cognitive-behavioral • warning: hyperthermia which led to
therapy rhabdomyolysis and acute renal and hepatic
failure, disseminated intravascular
DISSOCIATIVE DRUGS: PHENCYCLIDINE, coagulation (DIC) and death
KETAMINE AND DEXTROMETHORPHAN
• txn: benzodiazepines, cooling measures and
Ketamine IV fluids

• commonly used as “club drug” MARIJUANA

Dextromethorphan • most widely used illicit substance

• antitussive agent; a d-isomer of the codeine • THC is the main psychoactive ingredient
analog of levorphanol
• therapeutic potential:
• when ingested in large doses, it produces
similar effect to ketamine or PCP • relief of N/V, appetite stimulation, treatment
of pain, epilepsy, glaucoma, migraine,
• 300-1800 mg, 3-6 hours “high” anxiety, depression and movement disorders
and providing neuroprotection after brain
PCP injury or cerebral iscehmia
• typical dissociative drug and review of its pharmacological effects:
effects largely applies to ketamine and
dextromethorphan • sedation, mental relaxation, euphoria and
mild halluconogenic effects
• amnesia can occur following intoxication
A/E:
HALLUCINOGENS
• anxiety, paranoia, depersonalization,
• LSD disorientation and confusion
• a drug that could facilitate psychotherapy Treatment:
• one of the most potent hallucinogens known • “talk down”, oral benzodiazepine therapy
(25-250 mcg)
INHALANTS
anesthetics 1. Recurrent substance use resulting in a failure to fulfill
major role obligations at work, school, home
3 main categories:
2. Recurrent substance use in situations in which it is
• volatile solvents (hydrocarbons) physically
• volatile nitrites (amyl, butyl, isobutyl, hazardous
cyclohexyl)
3. Recurrent substance-related legal problems
• nitrous oxide (laughing gas)
4. Continued substance use despite having persistent or
effects: CNS depressant effect recurrent social

or interpersonal problems caused or exacerbated by the

84 ALCOHOL USE DISORDERS effects of the substance
- is produced by yeast during the process of DSM-IV defines dependence as a maladaptive pattern of
fermentation. substance use, leading to clinically significant impairment
- the amount of alcohol in the finished liquid depends or distress, as manifested by three (or more) of the
on the amount of sugar initially present for the yeast following, occurring at any time in the same 12-month
to convert into alcohol. period:
- 0.5% alcohol by volume can be called nonalcoholic.
- beer sold in supermarket chains and convenience 1. Tolerance, as defined by either of the following: *A need
stores must be <3.2% alcohol. for markedly increased amounts of the substance to achieve
intoxication or desired effect
Light beers range from 2% to about 4%.
*Markedly diminished effect with continued use of
beers range from 4% to 6% ales, stouts, and specialty the same amount of substance
brews can be as high as 10%
2. Withdrawal, as manifested by either of the following: The
Depending on the strain of yeast, wines are produced at about characteristic withdrawal syndrome for the substance
14% to 16%
The same (or a closely related) substance is taken to
Alcohol dependence relieve or avoid withdrawal symptoms
– is a chronic disorder with genetic, 3. The substance is often taken in larger amounts or over a
psychosocial and environmental factors longer period than was intended
influencing its development and
manifestations. 4. There is a persistent desire or unsuccessful efforts to cut
down or control substance use
– Treatment of alcohol dependence consists
mainly of psychological, social, and 5. A great deal of time is spent in activities to obtain the
pharmacotherapy interventions aimed at substance, use the substance, or recover from its effects
reducing alcohol-related problems.
6. Important social, occupational or recreational activities are
– -Treatment usually consists of two phases: given up or reduced because of substance use
detoxification and rehabilitation.
7. The substance use is continued despite knowledge of having
– Detoxification a persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by the
– -manages the signs and symptoms of substance (e.g., continued drinking despite recognition that an
withdrawal. ulcer was made worse by alcohol
– Rehabilitation consumption)
– -helps the individual avoid future problems RISKS AND BENEFITS OF ALCOHOL CONSUMPTION
with alcohol.
• development of medical problems such as
DIAGNOSTIC CRITERIA FOR ALCOHOL ABUSE cardiovascular disease, hepatic cirrhosis, and fetal
AND DEPENDENCE abnormalities is well documented.
DSM-IV defines abuse as a maladaptive pattern of • Alcohol use and abuse contribute to thousands of
substance use leading to clinically significant impairment injuries, auto collisions, and violence.
or distress, as manifested by one (or more) of the
following, occurring within a 12-month period:
ACUTE ALCOHOL INTOXICATION: SYMPTOMS Fixed-Schedule Regimens (Provide additional medication
AND TREATMENT as needed when symptoms are not controlled (i.e.CIWA-
Ar = 8 10)
Respiratory acidosis
Mild: CIWA-Ar 8–10; SBP >150 mmHg or DBP >90
Endotracheal intubation for respiratory support mmHg; HR >100; T >100◦F. Titrate dose.
Coma Drug: lorazepam 1–2 mg PO every 4–6 hours as needed
Gastric lavage, naloxone (Narcam) 1 mg, repeat for 1–3 days
every 2 to 3 minutes up to 10 doses, depending on Moderate: CIWA-Ar 8–15; SBP 150–200 mmHg or DBP
response and suspicion of ingestion. Dialysis possible 100–140 mmHg; HR 110–140; T = 100◦F to
Hypotension 101◦F; Tremors, Insomnia and agitation. Titrate dose.
IV fluid replacement Drug: lorazepam on days 1 and 2 give 2–4 mg PO
Hypoglycemia four times a day. On days 3 and 4 give 1–2 mg PO four
times a day. On day 5 give 1 mg by mouth twice a day.
50% glucose (50 mL) by IV push
Severe Withdrawal Symptoms: CIWA-Ar >15; SBP >200
ALCOHOL WITHDRAWAL SYNDROME mmHg or DBP >140 mmHg; HR >140; T >101◦F;
Tremors, Insomnia and agitation. Endpoint is sedation
• may occur on cessation or reduction of alcohol
consumption. Drug: lorazepam give 1–2 mg IV every 1 hour while
awake for 3–5 days.
• Depending directly on the degree of physical
dependence PSYCHOSOCIAL AND BEHAVIORAL
INTERVENTIONS USED WITH AUD
• AWS can range from creating significant discomfort
to mild tremor to alcohol withdrawal-related 1. Cognitive Behavioral Therapy (CBT)
delirium, hallucinosis, seizures, and potentially death.
The foundation is the belief that by identifying and
Diagnosis requires cessation or reduction in alcohol use monitoring maladaptive thinking patterns, patients can
that has been heavy and prolonged, and two or more of reduce or eliminate negative feelings and substance use.
the following developing within several hours to a few
days after the first criterion: autonomic hyperactivity, 2. Motivational Enhancement Therapy (MET)
increased hand tremor, insomnia, nausea or vomiting, Brief treatment is characterized by an empathetic
transient hallucinations or illusions (tactile, visual, or approach in which the therapist helps to motivate the
auditory), psychomotor agitation, anxiety, and grand mal patient by asking about the pros and cons of the target
seizures. behavior (e.g., substance use).
These symptoms must cause significant distress or 3. Medical Management (MM)
impairment of important areas of functioning, and not be
caused by a general medical condition or another mental Brief 20-minute intervention by a health care
disorder. Withdrawal-related seizure is considered a more professional (e.g., nurse, pharmacist, or physician).
severe manifestation of withdrawal, as is alcohol
withdrawal delirium (AWD), or delirium tremens as 4. Brief Behavioral Compliance EnhancementTherapy
traditionally called. AWD is estimated to have a mortality (BBCET)
rate of approximately 5% of patients who go into alcohol Brief 10-minute intervention by a health care
withdrawal professional.
SUGGESTED TREATMENT STRATEGIES FOR 5. 12-Step Facilitation
ALCOHOL WITHDRAWAL SYNDROME
Any support group that is a self-help group.
SYMPTOM-TRIGGERED REGIMEN based on CIWA- Commonly called Alcoholics Anonymous, for example
Ar (Score assessed as medically appropriate)
DRUG THERAPY
Assess patient and administer one of these drugs
every hour until CIWA-Ar = 8–10 for 24 hrs. NALTREXONE- blocks the action of endorphins when
alcohol is consumed, and this results in an attenuation of
Drugs: Chlordiazepoxide 50–100 mg, Diazepam 10– dopamine release at the nucleus accumbens thought to be
20 mg, and Lorazepam 2–4 mg crucially important to positive reinforcement, reward, and
craving.
 ACAMPROSATE- interacts with GABA and glutamate • Ascorbic acid
to restore the imbalance of neuronal excitation and
inhibition caused by chronic alcohol use. – increases ethanol clearance and serum
triglyceride levels and improves motor
DISULFIRAM- is an irreversible acetaldehyde coordination and color discrimination after
dehydrogenase inhibitor that blocks alcohol metabolism ethanol consumption
leading to an accumulation of acetaldehyde.
• Barbiturates
– reinforces an individual’s desire to stop
drinking by providing a disincentive – Phenobarbital decreases blood ethanol
associated with increased acetaldehyde concentration; acute intoxication inhibits
levels, resulting in headache, palpitations, pentobarbital metabolism; chronic
hypotension, flushing, nausea, and vomiting intoxication enhances hepatic pentobarbital
when patients consume alcohol. metabolism

TOPIRAMATE- is an FDA-approved medication found to • Benzodiazepines

have multiple mechanisms of action, including enhanced – Psychomotor impairment increased with the
GABAA inhibition that results in decreased dopamine combination
facilitation in the midbrain thought to be of potential benefit in
the treatment of addiction • Bromocriptine

BALCOFEN- promotes a balance between inhibition of – Ethanol increases gastrointestinal side

release of GABA, mediated by presynaptic GABAB receptors effects of bromocriptine
and inhibition of neuronal excitability mediated by
• Caffeine
postsynaptic GABAB receptors.Putatively, agonism of
GABAB receptors also modulates mesolimbic dopamine – has no effect on ethanol-induced
neurons. Baclofen is approved for use in the United States to psychomotor impairment.
reduce cramping, spasms, and muscle tightness.
85 TOBACCO USE AND DEPENDENCE
ETHANOL DRUG INTERACTIONS
SECTION 18 HAMATOPOIETIC DISORDERS
• Acetaminophen
ANEMIA is a reduction in red cell mass
– Chronic excessive alcohol consumption
increases susceptibility to acetaminophen- • It is described as a decrease in the number of red
induced hepatotoxicity. Acute intoxication blood cells (RBC) per cubic millimeter, or as a
theoretically protects against acetaminophen decrease in the hemoglobin concentration in blood to
toxicity because less hepatotoxic metabolite a level below the normal physiologic requirement for
is generated. adequate tissue oxygenation.

• Anticoagulants (oral) • It can be a symptom t many pathologic conditions

– Chronic ethanol consumption induces • Highly associated with nutritional deficiencies and
hepatic metabolism of warfarin, decreasing acute and chronic diseases.
hypoprothrombinemic effect. Very large
MANIFESTATIONS:
acute ethanol doses (>3 drinks/day) may
impair the metabolism of warfarin and - It is caused by increased red cell destruction, or
increase hypothrombinemic effect. Vitamin increased red cell loss
K-dependent clotting factors may be reduced
in alcoholics with liver disease, also • it may also be a result of disturbances in stem cell
affecting coagulation proliferation or differentiation

• Antidepressants • Anemias associated with acute blood loss, those that

are iron related, and those caused by chronic dse
– Enhanced sedative effects of alcohol and
psychomotor impairment are possible. Acute TYPES:
ethanol impairs metabolism. Fluoxetine,
- IRON-DEFICIENCY ANEMIA
paroxetine, fluvoxamine, and probably other
serotonin reuptake inhibitors (SSRI) do not - MEGALOBLASTIC ANEMIA
interfere with psychomotor or subjective
effects of ethanol. - SICKLE CELL ANEMIA
IDA - Iron is an essential mineral that is needed to form IDA CLINICAL MANIFESTATIONS
hemoglobin, an oxygen carrying protein inside red blood
cells. • IRON-DEFICIENCY ANEMIA CAN CAUSE:

• Iron deficiency anemia is a condition in which the • brittle nails

body lack enough red blood cell to transport oxygen- • cracks in the sides of the mouth
rich blood to body tissues
• Extreme fatigue (tiredness)
• Iron deficiency anemia is the most common form of
anemia and it develops over time if the body does not • chest pain
have enough iron to manufacture red blood cells.
• Fast heart rate
• Without enough iron, the body uses up all the iron it
• Headache
has stored in the liver, bone marrow and other organs.
• an enlarged spleen
• Once the stored iron is depleted, the body is able to
make very few red blood cells. • Cold hands and feet
• If erythropoietin is present without sufficient iron, • frequent infections.
there is insufficient fuel for red blood cell production
• Irritability
• The red blood cells that the body is able to make are
abnormal and do not have a normal hemoglobin- • shortness of breath
carrying capacity, as do normal red blood cells.
• swelling or soreness of the tongue
Iron-deficiency anemia is usually due to :
• Some signs and symptoms of iron-deficiency anemia
• blood loss are related to the condition's causes.

• poor diet • A sign of intestinal bleeding is bright red

blood in the stools or black, tarry-looking
• an inability to absorb enough iron from stools.
food.
• Very heavy menstrual bleeding, long
Blood Loss periods, or other vaginal bleeding may
• Blood lost causes iron depletion suggest that a woman is at risk for iron-
deficiency anemia.
• In women, long or heavy menstrual periods
or bleeding fibroids in the uterus. • Severe iron-deficiency anemia can lead to:

• Childbirth • problems with growth and development in

children
• Internal bleeding
• angina (chest pain)
• Poor Diet
• leg pains (intermittent claudication)
• Low iron intake.
IDA TREATMENT:
• During some stages of life, such as
• Iron deficiency anemia is treated with oral or
pregnancy and childhood.
parenteral iron preparation. Oral iron corrects the
• Inability To Absorb Enough Iron anemia just as rapidly and completely as parenteral
iron in most cases if iron absorption from the GIT is
• Even if you have enough iron in your diet, normal.
your body may not be able to absorb it. This
can happen if you have intestinal surgery or • Different iron salt provide different amount of
a disease of the intestine. elemental iron.

• Prescription medicines that reduce acid in • In iron deficient individual, about 50-80mg of iron
the stomach also can interfere with iron can be incorporated in hemoglobin daily and about
absorption. 25% of oral ferrous salt can be absorbed.
MEGALOBLASTIC ANEMIA • 2. Malabsorption- coeliac disease, tropical spure,
small bowel resection, malabsorption syndrome
• Megaloblastic anemias are associated with defective
DNA synthesis and therefore, abnormal RBC • 3. Drug Effect- Sulfa drugs, MTX, OCP,
maturation in the bone marrow (a nuclear maturation anticonvulsants
defect)
• 4. Increased folate turnover- pregnancy progressive
• However, the primary defect in DNA replication is fall, breastfeeding, skin disease(psoriasis &
usually due to depletion of thymidine triphosphate exfoliation), hemodialisis, PNH, hemoglobinopathy,
which leads to retarded mitosis, and therefore autoimmune hemolytic anemia
retarded nuclear maturation
Pernicious Anemia
• The depletion of thymidine triphosphate is usually
due to a deficiency of vitamin B12 or folic acid • Most common cause of cobalamin deficiency caused
by failure of the gastric mucosa to secrete intrinsic
• RNA synthesis is less impeded than is DNA synthesis factor
hence cytoplasmic maturation and growth continues
accounting for enlargement of the cells • Abnormality is genetically determined & manifested
late in life >40 years
• Increase in total erythropoiesis that may be up to
three times normal Immune Abnormalities

• Decreased rate of appearance of iron in the Hb of 1. Anti–parietal cell antibodies

circulating erythrocytes and reticulocytopenia 2. Anti–intrinsic factor antibodies -Two types
indicate ineffective erythropoiesis
• Blocking” antibodies, which block the binding of
• Increased destruction of defective erythroid cobalamin to IF
precursors in the marrow, survival of circulating
erythrocytes is short, indicating hemolysis • Binding” antibodies, which bind to the cobalamin–IF
complex and prevent the complex from binding to
Causes of Cobalamine Deficiency receptors in the ileum
• 1. Reduced intake SICKLE CELL ANEMIA
• 2. Malabsorption – Addisonian pernicious anemia, • Sickle cell anemia is a serious disease in which the
• Gastrectomy, pancreatic dysfunction, Tropical sprue, body makes sickle-shaped red blood cells. “Sickle-
Zollinger Ellison syndrome shaped” means that the red blood cells are shaped
like a "C."
• 3. Food cobalamine malabsorption- Atrophic gastritis
with achlorhydria • Normal red blood cells are disc-shaped and look like
doughnuts without holes in the center. They move
• 4. Abnormal transport protein- Tco I/II deficiency easily through your blood vessels. Red blood cells
contain the protein hemoglobin. This iron-rich
• 5. Inborn error of cobalamine metabolism protein gives blood its red color and carries oxygen
• 6. Acquired drug effects from the lungs to the rest of the body.

Diagnosis of Cobalamin Deficiency • Sickle cells contain abnormal hemoglobin that causes
the cells to have a sickle shape. Sickle-shaped cells
Established by one of methods don’t move easily through your blood vessels.
They’re stiff and sticky and tend to form clumps and
• 1. Therapeutic trial
get stuck in the blood vessels. (Other cells also may
• 2. Serum cobalamin assay play a role in this clumping process.)

• 3. Methylmalonic Acid and Homocysteine Assay • The clumps of sickle cells block blood flow in the
blood vessels that lead to the limbs and organs.
• 4. Deoxyuridine Suppression test Blocked blood vessels can cause pain, serious
infections, and organ damage.
• 5. Serum holotranscobalamin
• The signs and symptoms of sickle cell anemia vary.
Causes of Folate Deficiency
Some people have mild symptoms. Others have very
• 1. Reduced Intake severe symptoms and often are hospitalized for
treatment.
 • Sickle cell anemia is present at birth, but many ■ THERE ARE THREE WAYS THAT CHRONIC
infants don’t show any signs until after 4 months of DISEASE MAY CAUSE ANEMIA:
age.
1) Suppression of the production of red blood cells in
• Other signs and symptoms of sickle cell anemia the bone marrow.
include: 2) Decrease in the lifespan of red blood cells
• Shortness of breath 3) Problems with how the body uses iron.

• Dizziness ■ Suppression of red blood cell production is usually

not severe, so anemia develops slowly and is evident
• Headache only after time.
When there is a problem with how the body uses
• Coldness in the hands and feet
iron, the bone marrow is unable to use stored iron to
• Pale skin create new red blood cells.

• Chest pain ■ Because the anemia of chronic disease develops

slowly and is generally mild, it usually causes few or
TREATMENT: no symptoms. When symptoms do occur, they
usually result from the disease causing the anemia
Sickle cell anemia has no widely available cure. However,
rather than from the anemia itself.
treatments can help relieve symptoms and treat
complications. The goals of treating sickle cell anemia are DIAGNOSIS:
to relieve pain; prevent infections, eye damage, and
strokes; and control complications (if they occur). ■ Blood tests
There are no specific laboratory tests to diagnose
• Bone marrow transplants may offer a cure in a small anemia of chronic disease, so the diagnosis is
number of sickle cell anemia cases. Researchers typically made by excluding other causes. In people
continue to look for new treatments for the disease. who have disorders that are known to cause anemia
These include gene therapy and improved bone of chronic disease, doctors may do blood tests to
marrow. diagnose the disorder causing the anemia.
• Bone Marrow Transplant TREATMENT- Because no specific treatment exists for
this type of anemia, doctors treat the disorder causing it. If
A bone marrow transplant can work well for treating
the disorder causing the anemia does not respond to
sickle cell anemia. This treatment may even offer a
treatment, erythropoietin or darbepoietin, drugs that
cure in a small number of cases.
stimulate the bone marrow to produce red blood cells,
• Gene Therapy may be given. Iron supplements are usually given when
using erythropoietin or darbepoietin to ensure the body
Gene therapy is being studied as a possible treatment reacts appropriately to these drugs. Taking additional iron
for sickle cell anemia. Researchers want to know or vitamins does not help if erythropoietin or darbepoetin
whether a normal gene can be put in the bone marrow is not used.
of a person who has sickle cell anemia. This would
cause the body to make normal red blood cells.

ANEMIA OF CHRONIC DISEASE 87 DRUG-INDUCED BLOOD DISORDERS

(Anemia of Chronic Inflammation) HEMOLYTIC ANEMIA- large group of conditions

characterized by accelerated destruction of red blood cells.
In anemia of chronic disease, inflammation caused by a The average lifespan of a red blood cell is 120 days. At the
chronic disorder slows the production of red blood cells and end of 120 days, the red blood cell is broken down and the
sometimes decreases survival of red blood cells. parts of it are recycled to make new ones. When your red
blood cells are broken down faster than this, it is called
■ Chronic disease often leads to anemia, especially in
hemolysis.
older adults. Conditions such as infections,
autoimmune disorders (especially rheumatoid SIGNS AND SYMPTOMS:
arthritis), kidney disorders, and cancer most often
cause anemia of chronic disease. • Jaundice, yellowing of the skin

• Dark (tea or cola colored) urine

• Pallor, pale coloring of the skin

 • Fatigue, tiredness •Bleeding when you brush your teeth
•Easy bruising
• Dizziness •Pinpoint red spots on the skin (petechiae)
• Elevated heart rate The first step is to stop using the medicine that is causing the
• Shortness of breath problem.

• Splenomegaly, enlarged spleen For people who have life-threatening bleeding, treatments may
include:
DIAGNOSIS of drug-induced hemolytic anemia starts
•Immunoglobulin therapy (IVIG) given through a vein
like most forms of anemia, with the complete blood count •Plasma exchange (plasmapheresis)
(CBC). Anemia is indicated by a low hemoglobin and/or
•Platelet transfusions
hematocrit. In hemolytic anemia, the red blood cell
•Corticosteroid medicine
production is accelerated resulting in an increased number
of reticulocytes, immature red blood cells. This test is APLASTIC ANEMIA
commonly called the retic and may be reported as a
percentage or absolute reticulocyte count (ARC). - Rare disease in which the bone marrow and the
hematopoietic stem cells that reside there are
CAUSES: damaged.
• There are several medications that associated with - occurs when damage to stem cells in the bone
drug-induced hemolytic anemia. marrow (spongy core of many bones) leads to an
inability to produce an adequate supply of red
•Cephalosporins, a common antibiotic, including ceftriaxone blood cells, white blood cells, and platelets.
•Penicillins, in particular piperacillin
•Diclofenac, a non-steroidal anti-inflammatory - It is more frequent in people in their teens and
•Oxaliplatin, a chemotherapeutic medication twenties, but is also common among the elderly.
TREATMENT: Treatment options are determined by how - The definitive diagnosis is by bone marrow
severe your anemia is. First, the medication/toxin that is biopsy; normal bone marrow has 30–70% blood
causing the hemolytic anemia should be stopped. Blood stem cells, but in aplastic anaemia, these cells are
transfusions can be given if necessary. If the hemolysis is mostly gone and replaced by fat.
severe, it may cause kidney injury. Fortunately, this is
typically temporary and improves once the hemolysis resolves, CAUSES:
but this may require dialysis for a period of time. - Heredity, immune disease, or exposure to chemicals,
THROMBOCYTOPENIA is any disorder in which there are drugs, or radiation.
not enough platelets. Platelets are cells in the blood that help - Exposure to ionizing radiation from radioactive
the blood clot. A low platelet count makes bleeding more materials or radiation-producing devices is also
likely. associated with the development of aplastic anemia.
When medicines or drugs are the causes of a low platelet - Aplastic anemia is also sometimes associated with
count, it is called drug-induced thrombocytopenia. exposure to toxins such as benzene, or with the use of
Causes certain drugs,
including chloramphenicol, carbamazepine, felbamat
Drug-induced thrombocytopenia occurs when certain e, phenytoin, quinine, and phenylbutazone.
medicines destroy platelets or interfere with the body's ability
to make enough of them. PREVENTIVE MEASURES:

There are two types of drug-induced thrombocytopenia: There is no known way to prevent aplastic anemia. Avoiding
immune and nonimmune. exposure to toxic chemicals, radiation, and drugs known to
cause the disorder, such as the antibiotic chloramphenicol or
•If a medicine causes your body to produce antibodies, which the nonsteroidal anti-inflammatory phenylbutazone, may be
seek and destroy your platelets, the condition is called drug- helpful.
induced immune thrombocytopenia.
SYMPTOMS:
•If a medicine prevents your bone marrow from making
enough platelets, the condition is called drug-induced Increased susceptibility to infection
nonimmune thrombocytopenia. - Ulcers in the mouth, throat, and rectum
SYMPTOMS: Decreased platelets may cause
•Abnormal bleeding
 - Unusual bruising or bleeding (including spontaneous PREVENTIVE MEASURES
unexplained bleeding from the nose, gums, rectum, or
vagina and prolonged bleeding from cuts) - Early genetic testing could help prepare the parents
become aware of the situation prior to the birth of the
- Small red dots (petechiae) under the skin, indicating baby and be counseled on what needs to be done
bleeding; paleness (pallor)
- PRCA as an illness associated with other conditions
- Weakness, fatigue, and breathlessness could potentially be prevented by treating the
underlying cause(s)
- Rapid heart rate
- Avoiding medications and drugs that could
- Pale skin and skin rash potentially lead to PRCA could help prevent the
- Fever disease from developing

- Headache SIGNS AND SYMPTOMS:

- Coldness in the hands or feet - Generalized weakness in the body

MEDICATION - Changes in skin tone

- Cyclosporine and anti-thymocyte globulin are often - Excessive bleeding that may lead to easy bruising
used in combination. Corticosteroids, such as - Heart conditions that may lead to the development of
methylprednisolone (Medrol, Solu-Medrol), are often a stroke
given at the same time as these drugs.Immune-
suppressing drugs can be very effective at treating - Anemia
aplastic anemia.
- Developing an infection
TREATMENT
- Cough
- Treatments may include medicines to suppress your
immune system, blood transfusions, or a blood and - Changes in eye color (yellow)
bone marrow transplant. A blood and bone marrow - Negative effect on the growth spurt
transplant may cure the disorder in some people.
Removing a known cause of aplastic anemia, such as MEDICATIONS:
exposure to a toxin, may also cure the condition.
Immunosuppressive agents used in PRCA include
AUTOIMMUNE PURE RED CELL APLASIA cyclophosphamide, 6-mercaptopurine, azathioprine, and
cyclosporine A.
- Pure red cell aplasia (PRCA) is a syndrome
defined by a normocytic normochromic anemia Rituximab has been reported to be effective in
with severe reticulocytopenia and marked managing PRCA.
reduction or absence of erythroid precursors
Antithymic globulin (ATG) is another therapeutic
from the bone marrow.
option.
- A typical life span of a red blood cell ranges
from approximately100 to 120 days. The red NEUTROPENIA
blood cells get released from the bone marrow
and circulate in the body to deliver oxygen People with neutropenia have an unusually low number of
- Pure Red Cell Aplasia is an inherited disorder, it cells called neutrophils. Neutrophils are cells in your immune
develops during very early stages of life, system that attack bacteria and other organisms when they
including the fetal stage. invade your body.

CAUSES: Having autoimmune disorders, such as rheumatoid It is most commonly seen--and even expected--as a result
arthritis, hepatitis or having a large population of clonal large of chemotherapy used to treat cancer.
granular lymphocytes which attack the red cell precursors in
CAUSES
the marrow
- Cytotoxic chemotherapy can cause a predictable and
- Tumors of the thymus or thymomas
dose-related decrease in neutrophil count.
- Viruses such as the parvovirus B19 - viral infections often lead to mild or moderate
neutropenia.
- Certain inherited genetic disorders, appearing mostly - Problem in the production of neutrophils in the bone
in early childhood marrow
 - Destruction of neutrophils outside the bone marrow 1. Immunologically mediated, either through peripheral
- Infection destruction of circulating neutrophils or immune suppression
- Nutritional deficiency of marrow precursors.

PREVENTIVE MEASURES: 2. Through a direct, toxic effect on marrow precursors

Avoid infections to prevent Neutropenia SECTION 19 NEOPLASTIC DISORDERS

88 NEOPLASTIC DISORDERS AND THEIR
- Avoid crowded areas TREATMENT GENERAL PRINCIPLES
- Good hygiene, including frequent hand
washing and good dental care, such as 89 ADVERSE EFFECTS OF CHEMOTHERAPY AND
regular tooth brushing and flossing TARGETED AGENTS
- Avoiding unpasteurized dairy foods;
undercooked meat; and raw fruits, 90 HEMATOLOGIC MALIGNANCIES
vegetables, grains, nuts, and honey 91 SOLID TUMORS
TREATMENT 92 HEMATOPOIETIC STEM CELL
TRANSPLANTATION
- Antibiotics for fever. In neutropenic fever, the
assumption is made that there is an infection causing
the fever even when the source can't be found. SECTION 20 PEDIATRICS
- A treatment called granulocyte colony-stimulating
factor (G-CSF). This stimulates the bone marrow to 93 PEDIATRIC CONSIDERATIONS
produce more white blood cells. It is used for several
types of neutropenia, including low white cell count 94 NEONATAL THERAPY
from chemotherapay. 95 PEDIATRIC IMMUNIZATIONS
- Changing medications, if possible, in cases of drug-
induced neutropenia 96 PEDIATRIC INFECTIOUS DISEASES
- Stem cell transplants may be useful in treating some
OTITIS MEDIA
types of severe neutropenia, including those caused
by bone marrow problems. • an inflammation of the middle ear, is one of the most
common childhood illnesses
DRUGS TO TX NUETROPENIA
• peaks between 6months and 3 years of age and is
Filgrastim (Neupogen, tbo-filgrastim, Granix,
thought to be most likely due to Eustachian tube
Zarxio, filgrastim-sndz)
obstruction and secondarily to the decreased
Filgrastimis a granulocyte colony-stimulating factor (G- immunocompetence present in young children
CSF) that activates and stimulates the production,
• has been associated with upper respiratory tract
maturation, migration, and cytotoxicity of neutrophils.
infections (URIs) and allergies
DRUG INDUCED N:
• caused by S. pneumoniae,H.influenza,and
Is a potentially serious and life-threatening adverse event that M.catarrhalis
may occur secondary to therapy with a variety of agents.
• Risk Fractors: Genetics, Lack of influenza and
Characterized by a decline in absolute neutrophil counts conjugate pneumococcal vaccine inoculations, Winter
precipitated by exposure to a medication. or early spring season, siblings with URIs, household
overcrowding,and exposure to pollutants
Neutropenia can occur at any time during the course of
treatment but most commonly occurs within the first few PREVENTION
weeks after initiation of drug therapy.
A- treatment Influenza vaccine
Leukopenia - simply denotes a total WBC count of
B- Minimizing risk factors
<3,000/mm3.
C- Oseltamivir of influenza
Granulocytopenia - Describes a granulocyte count of <1,500
granulocytes/mm3. (including eosinophils and basophils) BRONCHIOLITIS
Agranulocytosis - severe form of neutropenia, with total • a common illness of the small airways (bronchioles)
granulocyte counts <500/mm3. caused by an infection, usually from a virus, resulting
in inflammation of the bronchioles and subsequent
Drugs cause neutropenia by two basic mechanisms.
mucus production
 • It is the most common lower respiratory tract • A severe, complex, hereditary disease that is caused
infection in infants by mutations in the Cystic Fibrosis Transmembrane
Regulator Protein (CFTR)
• causes edema, inflammation, mucus production,
necrosis, and cell sloughing within small airway TREATMENT
epithelium, resulting in bronchospasm
CONTROL OF MALABSORPTION
TREATMENT:
 Caloric needs
• Bronchodilators
 Vitamins and minerals supplementation
• Corticosteroids
 Enzyme supplementation
• Supportive Care
CONTROL OF INFECTION
• Antivirals
 Mucociliary clearance
• Antibacterials
 Immunizations
• Palivizumab- But increases mortality in patients with
congenital heart disease  Antibiotic therapy

KAWASAKI DISEASE

- also known as mucocutaneous Lymph Node 97 PEDIATRIC NUTRITION

Syndrome 98 CYSTIC FIBROSIS
- is an inflammatory vasculitis with multiple clinical SECTION 21 GERIATRIC THERAPY
features
- leads to local dilatation, ectasia, and aneurysm 99 GERIATRIC DRUG USE
formation
Age- Related Physiological, Pharmacokinetic and
- A potentially life-threatening disease
Pharmacodynamic Changes
SIGNS AND SYMPTOMS
• Absorption – Gastric pH increases, intestinal blood
• Fever flow diminishes, and some impairment of both active
and passive transport mechanisms occur.
• bilateral bulbar conjunctival injection
• Distribution- declined in Cardiac output is
• oral mucous membrane changes (e.g., injected or accompanied by an increase in peripheral vascular
fissured lips, injected pharynx, strawberry tongue, resistance and a proportional decrease in hepatic and
periungual desquamation during the subacute and renal blood flow.
convalescent phases)
• Metabolism- may affect due to factors shown to
• peripheral extremity changes (e.g., painful erythema influence hepatic dug metabolism, which include
of palms or soles, edema of hands or feet) especially disease state, concurrent drug use, nutritional status,
during the acute phase environmental compounds, genetic differences,
• polymorphous rash gender, liver mass, and blood flow.

• cervical lymphadenopathy (at least one lymph node • Excretion- age- related changes in renal function
>1.5 cm in diameter) result in more adverse drug events (ADEs) than any
other age-related physiological alterations.
TREATMENT:
PROBLEMS:
• Analgesics and antipyretics- to provide comfort to the
patient • Polymedicine

• Intravenous immunoglobulin • Adverse drug events

• Corticosteroids Predictors of ADR

URINARY TRACT INFECTION  More than four prescription medications

• Infection in the Urinary Tract mostly caused by E.  Length of stay in hospital longer than 14 days
coli  history of alcohol use
  Admission to a general medical unit vs. a specialized • Older patients may be at increased risk of depression
geriatric ward due to the high prevalence of comorbid medical
conditions (i.e., stroke, cancer, MI, rheumatoid
Lower Mean Mini-Mental Status Examination score arthritis, dementia, Parkinson disease, DM).
(confusion, dementia)
Atypical Depressive Symptoms in the Older Adult:
Twenty-four new medications added to medication regimen
during hospitalization • Agitation/anxiety/worrying

DISEASE- SPECIFIC GERIATRIC THERAPY • Reduced initiative and problem-solving capacities

• HEART FAILURE- is a common cause of morbidity • Alcohol or substance abuse

and mortality in older patients.
• Paranoia
• STANDARD DRUG THERAPY:
• Obsessions and compulsions
 Diuretics
• Irritability
 B-Blockers
• Somatic complaints
 ACE inhibitors
• Excessive guilt
Coronary Heart Disease/ Hyperlipidemia
• Marital discord
• elevated cholesterol levels have been shown to
increase the risk for CHD in older adults. • Social withdrawal

• the no.1 cause of death in women older than age 65. • Cognitive impairment

STATINs- DOC for lowering LDL. • Deterioration in self-care

NIACIN- combined with statins because it raise the HDL Antidepressant Dosing in Older Adults
level.

FIBRATES- can also be combined with statins to further Initial Dosage Maximum Dosage
reduce the levels of LDL and TG.
Citalopram HBr 10 mg QD 40 mg QD
HYPERTENSION
Escitalopram 5 mg QD 20 mg QD
• Is present in more than two-thirds of individuals
Oxalate
older than 65 years of age.
Fluoxetine HCL 5 mg QD 40 mg QD
• Drug used to treat HTN:
Fluvoxamine 25 mg QHS 200 mg QHS
– ARBs
Paroxetine HCL 10 mg QD 40 mg QD
– ACE inhibitors

– Calcium channel blocker (CCB) Sertraline HCL 25 mg QD 150 mg QD

– Beta-blockers Mirtazapine 7.5 mg QD 45 mg QD

– Diuretics Bupropion 37.5 mg BID 75 mg BID

DM - with diabetes have the highest rates of major Duloxetine 20 mg QD 40 mg QD

lower-extremity amputation, myocardial infarction (MI),
Venlafaxine 25 mg BID N/A
visual impairment, and end-stage renal disease of any
age-group

• In general, the elderly are more susceptibl.e to ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY
hypoglycemia DISEASE IN THE ELDERLY
Metformin- with lifestyle modification is the initial Symptoms of asthma:
management approach.
 wheezing
DEPRESSION
 Cough
  chest tightness ARTHRITIS- is the most common cause of disability in
people older than 75 years of age, with prevalence rates up to
 dyspnea 30%.
SIDE EFFECTS OF B AGONIST OSTEOARTHRITIS- also called degenerative joint disease
 tremor - is the most common type of joint disease in the
 tachycardia older population.

 Hypokalemia TREATMENT

 Arrhythmias Acetaminophen- is the drug of choice for mild to

moderate arthritis pain.
Inhaled corticosteroids- are the preferred treatment for all
forms of persistent asthma and, in general, are well tolerated Acetaminophen is preferred over NSAIDs in the elderly
by older patients. because of its low renal and GI toxicity.

THEOPHYLLINE Nonacetylated salicylates- (salsalate)

• should be used with caution in the elderly because of can be used if acetaminophen does not provide
the potential for CNS stimulation, nausea, vomiting, adequate pain relief.
and, in higher doses, arrhythmias and seizures selective COX-2 inhibitor celecoxib- is preferred in older
COPD- is a lung disease caused by chronic bronchitis and/or patients because it is less likely to cause GI side effects than
emphysema seen largely in those older than 65 years. nonselective agents; however, the risk of adverse renal events
is equivalent.1
INFECTIOUS DISEASES IN THE ELDERLY

PNEUMONIA- leading infectious cause of mortality in the

elderly, who have a 5- to 10-fold increased risk of developing 100 GERIATRIC DEMENTIAS
pneumonia compared with younger adults. ALZHEIMER DISEASE
VIRAL PNEUMONIA- is the second most common cause of • is the most common cause of dementia, accounting
lower respiratory infection in older ambulatory patients. for approximately half of all diagnosed cases.
INFLUENZA VIRUS- damages respiratory epithelial cells, Genetics play a significant role in the development of
decreases cell-mediated immunity, and exacerbates or worsens Alzheimer-type dementia.
many chronic underlying medical conditions common to the
older population TREATMENT:

TREATMENT • TACRINE -the first agent approved for the

symptomatic treatment of mild to moderate AD, is an
 Amantadine- only active versus influenza A. aminoacridine derivative that reversibly inhibits both
 Rimantadine-only active versus influenza A. AChE and butyrylcholinesterase (BChE)

 Oseltamivir- active versus both influenza A and B

Pneumococcal vaccination- is generally given one time COMMON DEMENTIAS:

UTI  Vascular dementias (VaDs)

• elderly are caused primarily by Escherichia coli.  dementia with Lewy bodies (DLB)

• fluoroquinolones are significantly better tolerated  Parkinson disease with dementia (PDD)
than trimethoprimsulfamethoxazole for the treatment Dementia -is a syndrome that exhibits impaired short- and
of UTI in elderly women. long term memory as its most prominent feature
• fluoroquinolone may be the preferred agent for a
broad range of UTIs in the elderly and should be
considered as initial therapy in the majority of the 101 GERIATRIC UROLOGIC DISORDERS
older population.
SEXUAL DISORDER - refers to a problem occurring during
OSTEOARTHRITIS PAIN any phase of the sexual response cycle that prevents the
individual or couple from experiencing satisfaction from TREATMENT
the sexual activity.
-Bromcriptine
Major factors that correlate w/ reduced sexual activity
includes: -Yohimbine

- Older spouse - Prostaglandin E1

- Poor mental or physical health - Sildenafil

- Marital difficulties - Tadalafil

- Previous negative sexual experiences - Vardenafil

- Negative attitudes toward sexuality in the aged - ApomorphinE

MALE SEXUAL DYSFUNCTION VASCULOGENIC ERECTILE DYSFUNCTION

- Aging men may experience andropause, a Drugs Mechanism

syndrome consisting of weakness, fatigue, Papaverine Phosphodiesterase
reduced muscle and bone mass, impaired inhibitor
hematopoiesis, oligospermia, sexual dysfunction
and psychiatric symptoms. Phentolamine -Adrenergic blockade
- inability to achieve a satisfactory sexual
relationship, may involve inadequacy of erection Prostaglandin E1 -Blockade
or problems with emission, ejaculation, or
Atropine Antimuscarinic
orgasm.

ERECTILE DYSFUNCTION
BENIGN PROSTATIC HYPERPLASIA
 Is the inability to achieve and maintain a firm
erection sufficient for satisfactory sexual - also called prostate enlargement, is a noncancerous
performance. increase in size of the prostate
PREMATURE EJACULATION A common cause of urinary dysfunction symptoms in elderly
men, results from proliferation of the stromal and epithelial
 Refers to uncontrolled ejaculation before or shortly
after entering a vagina. UI Type Description
ETARDED EJACULATION Urge Incontinence Occurs when involuntary voiding is preceded by
a warning of a few seconds to a few minutes.
 Synonymous with delayed ejaculation.

RETROGRADE EJACULATION Stress Incontinence Occurs when an abrupt increase in intra-

abdominal pressure overcomes urethral
 Denotes backflow of semen into the bladder resistance.
during ejaculation caused by an incompetent
bladder neck mechanism. Overflow Incontinence Occurs when the weight of urine in a distended
bladder overcomes outlet resistance.
CAUSES OF ERECTILE DYSFUNCTION
Functional Incontinence Occurs when a continent individual is unable or
VASCULAR – Atherosclerosis, Penile Raynaud’s unwilling to reach the toilet to urinate.
phenomenon
cells of the prostate gland.
NEUROLOGIC – Cerebrovascular accident, Spinal Cord
Damage, Autonomic Neuropathy, Peripheral neuropathy SIGNS AND SYMPTOMS

ENDOCRINE- Diabetes mellitus, Hypogoandism, - frequent urination

Prolactinomas, Hyperthyroidism, Hypothyroidism - trouble starting to urinate
IATROGENIC – Pelvic radiation, Lumbar sympathectomy, - weak stream
prostatectomy, Renal transplantation, Spinal cord resection
- inability to urinate
PSYCHOGENIC – Performace anxiety, depression,
widower’s syndrome - loss of bladder control
RISK FACTORS Derived from the Greek words osteon (bone) and poros (pore).

- family history It is a disease “characterized by low bone mass and

microarchitectural deterioration of bone tissue leading to
- obesity enhanced bone fragility and a consequent increase in fracture
- type 2 diabetes risk.

- not enough exercise SIGNS AND SYMPTOMS

- erectile dysfunction may have signs and symptoms that include:

TREATMENT Back pain, caused by a fractured or collapsed vertebra.

-Adrenergic Receptor -Reductase

URINARY INCONTINENCE Antagonist Inhibitors

- the involuntary leakage of urine. It means a person Terazosin Finasteride

urinates when they do not want to. Doxazosin Dutasteride
- Control over the urinary sphincter is either lost or
weakened. It is a common problem that affects many Tamsulosin
people.
Alfuzosin
CAUSES - resnick’s mnemonics – DIAPPERS
Androgen Suppression
D – delirium and dementia
Loss of height over time.
I – infections
Often there are no symptoms until the first fracture
A – atrophic vaginitis, atropic urethritis, atonic baldder occurs.
P- psychological disease, CLASSIICATIONS:
P- pharmacologic agents  Type I (Postmenopausal osteoporosis)
E- endocrine - is associated with increased cortical and cancellous
bone loss resulting from increased boned resorption.
R- Restcited mobility
- occurs in women during the first 3 to 6 years after
S- Stool impaction
menopause.

 Type II (Senile osteoporosis)

- occurs in both women and men 75 years of age and

TREATMENT older with a female

Anticholinergic Agents: TREATMENT

Oxybutynin chloride  A variety of medicines can be prescribed to lower

fracture risk in osteoporosis.
Tolterodine tartrate
 commonly used for osteoporosis treatment:
Darifenacin
› Alendronate (Fosamax)
Solifenacin
› Risedronate (Actonel)
Propantheline bromide
› Ibandronate (Boniva)
Dicyclomine HCl
› Zoledronic acid (Reclast)
Flavoxate HCl
PREVENTION:
β-Adrenergic Agents:
 Healthy lifestyle choices (such as proper diet,
Terbutaline
exercise)
102 OSTEOPOROSIS
 Vitamin D

 Calcium intake

 Smoking cessation