Dengue hemorrhagic fever shock syndrome

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(DH FS) A grave form of dengue fever characterized by shock, with collapse, and hemorrhages. The incidence of dengue hemorrhagic fever has increased dramatically in southeast Asia in the past 20 years, with major epidemics occurring in most countries every three to four years. DHF first occurred in the Americas in 1981, with a major epidemic in Cuba. A second major DHF epidemic occurred in Venezuela in 1989-90; smaller outbreaks have occurred in Brazil, Colombia, French Guiana, and Nicaragua.

Cause Although not completely understood, data suggest that the type of virus, together with the patient's age, immune status, and genetic background are the most important factors for developing DHF. In Asia, children under the age of 15 who are experiencing a second dengue infection appear to have the highest risk. Although adults can also develop DHF, most international travelers from the United States appear to be at low risk.

Symptoms Cold, clammy extremities; weak, thready pulse; respiratory distress; plus all the symptoms of dengue fever. Hemorrhage, bruises, and small red spots all indicate bleeding from skin capillaries; bloody vomitus, urine, and feces may occur and herald impending circulatory collapse.

Treatment Fluid and electrolyte replacement and fresh blood, plasma, or platelet transfusions. Oxygen and sedatives also may be given.

dermatophytes Superficial fungi (also called tineal infections, including RINGWORM) that infect the skin, hair, and nails, usually caused by the fungi Microsporum, Epidermophyton, and Trichophyton. This type of fungi can be spread from person to person or from an animal to a person. The infections they cause usually have a Latin name using the term tinea with the part of the body affected (such as tinea pedis for athlete's foot). Although there are many different kinds of dermatophytes, seven species cause more than 90 percent of all infections.

dermatophytosis A type of fungus infection (also called tinea) caused by Trichophyton, Epidermophyton, or Microsporum spp.

desert fever A popular name for coccidioidomycosis.

desert rheumatism A popular name for coccidioidomycosis.

diarrhea and infectious disease Many infectious diseases cause diarrhea, with frequent passage of loose, watery stools that may also contain pus, mucus, blood, or fat. In addition to frequent trips to the bathroom, a patient with diarrhea may complain of abdominal cramps and weakness, nausea, and vomiting.

Acute diarrhea affects almost everyone at some time, usually from eating contaminated food or drinking contaminated water. Diarrhea is not a disease in itself, but a symptom. While it may not seem to be a serious problem, if it remains untreated severe diarrhea can lead to dehydration and electrolyte imbalance. This is a particular concern among the very young and the very old.

Diarrhea usually starts suddenly and lasts between a few hours to two or three days. Diarrhea beginning within six horns of eating usually indicates that the food has been contaminated by toxins from Staphylococcus, clostridium, or E. coli bacteria. If it takes longer (between 12 to 48 hours after eating), the diarrhea is probably from contamination of food or water by bacteria such as CAMPYLOBACTER or SALMONELLA or by a virus such as rotavirus or norwalk virus. Infective gastroenteritis may be caused by inhaling droplets filled with adenovirus or echovirus. Less often, diarrhea may be related to shigellosis, typhoid, or amebic dysentery.

Treatment During a severe attack, water and electrolytes must be replaced to prevent dehydration. Drinking water with sugar and salt added is one way to do this (one teaspoon salt and four teaspoons sugar dissolved in one quart of water). antidiarrheal drugs should not be taken to treat diarrhea caused by infection, since they may in fact prolong the illness. See also cholera, cryptosporidiosis, enterovirus, ESCHERICHIA COLI, ESCHERICHIA COLI 0157:h7, giardiasis, marburg virus.

diarrhea, viral See gastroenteritis, viral.

diphtheria A preventable bacterial disease that affects the tonsils, throat, nose, or skin that was once feared throughout the world. Through the 1920s, diphtheria killed 13,000 babies and children in the United States each year and made another 150,000 sick. Today it is most common in low socioeconomic groups, where people live in crowded conditions; unimmunized children under age 15 are likely to contract the disease.

The conquest of diphtheria in modern times is one of the greatest vaccination success stories. In 1992, only four people in the United States were reported to have diphtheria, and no U.S. cases were reported in 1993 and 1994. This does not mean that the disease has been eliminated, however. Because so many Russian children did not get vaccines, a serious outbreak began in Moscow in 1990; by 1992, there were 4,000 cases in the Russian federation and 24 deaths in Moscow. The problem has gotten worse since then, spreading throughout Russia with 50,000 recorded cases and 1,100 deaths in 1994. Most of the victims are adults, but the outbreak has spread because many children had not been receiving their vaccines and adults who had been vaccinated were no longer immune. Today, the epidemic is most severe in cities on the Sea of Japan north of North Korea, where an immunization campaign has been going on at airports, hotels, and train stations.

Travelers to these areas must have completed a series of the vaccine and must have had a booster within the last five years. There is no risk if the traveler is fully immunized.

In the United States, confirmed cases of diphtheria must be reported to, and investigated by, the local and state health departments.

History Since the time of Hippocrates, periodic outbreaks of diphtheria occurred around the world, becoming more common during the 16th century. Italian physicians began to perform tracheotomies during the Naples epidemic of 1610 in an attempt to help patients breathe through the terrible swollen throat that is characteristic of the disease.

Some 50 years later, New England minister Cotton Mather described a disease he called "Malady of Bladders in the Windpipe," which was particularly deadly among Massachusetts children. A second epidemic began in New Hampshire in 1735, killing more than 1,000 citizens, most of them children. The Spanish called it garrotillo, after the executioner's garrotte, a string around the neck that could be tightened by twisting a stick.

The disease got its modern name during the French epidemic of 1826, when French physician Pierre-Fidele Bretonneau called it after the Greek word for leather, dipthera, a reference to the tough gray membrane that often formed across the back of the throat.

As the disease spread during the 19th century, it appeared to grow stronger and more deadly; fatalities in New York skyrocketed to more than 2,300 in 1872. The bacterium that caused the disease was identified in 1883, and seven years later scientists determined that a poison produced by the bacterium (an exotoxin) could be used in weakened form to trigger an immune response in humans called an antitoxin. This ability was similar to tetanus, which scientists were beginning to understand at about the same time.

Routine immunizations began in the 1920s.

Cause Diphtheria is caused by a bacterium (Corynebacterium diphtheriae) named for the Greek word koryne, meaning "club-shaped." The bacteria thrive in dark, wet places such as the mouth, throat, and nose of an infected individual and are easily transmitted to others during coughing or sneezing or through close contact with discharge from nose, throat, skin, eyes, and lesions. Bacteria don't travel very far through the air, and they infect only humans. Crowded unhealthy places help the germs spread from one person to another.

The infection can also be spread by carriers (those with the bacteria but who have no symptoms). Untreated patients who are infected can be contagious for up to two weeks, but not usually more than a month. Recovery from the disease does not always confer immunity.

Symptoms Once established in the tonsils, C. diphtheriae produce symptoms faster than almost any other organisms by forming a powerful exotoxin. Symptoms usually appear within two to five days of being exposed. There are two types of diphtheria; one type involves the nose and throat, and the other involves the skin.

Diphtheria usually develops in the throat, causing fever, red sore throat, weakness, and headache. There may be swelling and a gray membrane that completely covers the throat. This membrane can interfere with swallowing and talking and causes an unpleasant, distinct odor; if the membrane covers the windpipe, it can block breathing and suffocate the patient. Other symptoms include slight fever and chills. The exotoxin produced by the bacteria can spread throughout the body and can damage tissue in the kidneys, heart, or nervous system. Death often comes from an inflamed heart.

In the skin variety, skin lesions may be painful, swollen, and red.

Diagnosis A sample of the nose or throat discharge is cultured. Results may be available within eight hours.

Treatment Diphtheria is a preventable and treatable disease, but if treatment is inadequate or not begun in time, the powerful toxin produced by the bacteria may spread throughout the body. This poison may cause serious complications.

Intensive hospital care and prompt treatment with diphtheria antitoxin offers the best hope for cure. The antitoxin neutralizes the toxin if it has not yet invaded cells but is still circulating in the blood. Antibiotics (penicillin or erythromycin) can help destroy the bacteria and decrease infectiousness in the respiratory secretions. Patients are kept isolated and in bed for 10 days to two weeks, and fed a liquid or soft diet. Secretions in nose and throat must be suctioned; tube feeding may be necessary if swallowing is impossible. A tracheotomy may be necessary if the breathing muscles are paralyzed.

A person is infectious from two to four weeks, or until two to four days of antibiotic treatment. Anyone with a confirmed case must be isolated until negative results are obtained from two cultures from the nose and throat taken 24 hours apart, after completion of antibiotic treatment.

Complications If the bacteria has time to produce the toxin, its complications can include broncho-pneumonia, heart failure, or paralysis in the throat, eye, and breathing muscles. Severe paralysis of the breathing muscles or diaphragm can be fatal. The toxin will inflame the heart muscle (myocarditis), which can lead to heart failure and death. About 1 out of every 10 patients with diphtheria will die.

Prevention Diphtheria vaccine is almost always given to infants in a combination with pertussis and tetanus (DPT), given as a shot at ages two, four, and six months. The DTaP (diphtheria, tetanus, and acellular pertussis) is given again at 15 months and once more as a booster before entering school at ages four to six.

All infants should be immunized; boosters throughout life will prevent resurgence. The vaccine is made of a toxoid (weakened form of the toxin) that stimulates the immune system to make antibodies (called antitoxin) against the toxin. However, this immunity wanes; a booster is required every 10 years.

The toxoid comes in two strengths; children under age seven need a higher concentration to develop immunity. Older patients should get the lower concentration, since it has fewer side effects yet will still boost immunity. (See also diphtheria toxoid.)

Anyone exposed to diphtheria must receive a vaccine booster (DPT, DT, or Td) if one has not been given within five years. Exposed people must have a throat culture and be under observation for one week; anyone with a positive culture (even without symptoms) needs seven days of antibiotics.

Anyone with a high fever or serious illness should not get a vaccination until recovered, but children with mild colds and low fevers may be vaccinated.

Side effects Common side effects of the vaccine and booster include slight fever and irritability in the first 24 hours, with redness, swelling, or pain at the injection spot. Giving acetaminophen at the time of the shot may prevent a fever. A fever more than one day after the shot requires a call to the physician.

diphtheria, skin A bacterial infection common in the tropics, but also found in Canada and the southern United States, that causes a rash similar to impetigo. It is found in any area of crowded conditions and poor hygiene.

Cause Skin diphtheria is caused by the same organism that causes diphtheria

(Corynebacterium diphtheriae), found in the mucous membranes of the nose and throat and probably on human skin. Rarely, it is caused by food contaminated with the bacteria. A person can catch skin diphtheria by touching the open sores of a patient.

Symptoms Superficial ulcers on the skin with a gray-yellow or brown-gray membrane in the early stages that can be peeled off; later, a black or brown-black eschar appears, surrounded by a tender inflammatory area. Nasal discharge may also be present.

Treatment Antibiotics and specific antitoxin; oral penicillin V potassium is effective in mild cases. Whereas the antibiotics will inhibit the bacteria, diphtheria antitoxin is required to inactivate the toxin.

diphtheria toxoid A vaccine against diphtheria that is often combined with pertussis and tetanus toxoid vaccine (DPT) and given as a series of injections during infancy and childhood. The toxoid is prepared by mixing formaldehyde with the poisonous toxin produced by Corynebacterium diphtheriae, rendering the toxin harmless.

Alternatively, diphtheria toxoid may be combined with tetanus toxoid alone (DT) and given to children or combined with tetanus toxoid (Td) in an adult vaccine. The Td version only contains about 15 to 20 percent of the diphtheria toxoid found in the DPT vaccine and is used for older children and adults.

The vaccine, which was introduced more than 50 years ago, led to a dramatic reduction of the incidence of diphtheria throughout the world. Primary preventive programs aimed at immunizing all infants and children in the community have almost eliminated the disease.

Yet while the reported incidence of diphtheria has been almost the same since the 1960s, it still occurs in isolated epidemics, primarily because some countries have taken a complacent attitude toward vaccination. The disease continues to represent a serious public health problem because it is possible for even fully immunized people to carry the C. diphtheriae bacteria in nose and throat, transmitting it to nonimmunized individuals.

diphyllobothriasis A disease caused by broad fish tapeworm infection that occurs after eating infested fish. Rare in the United States, it was formerly common in the Great Lakes area, where it was known as "Jewish or Scandinavian housewife's disease" because the preparers of gefilte fish or fish balls tended to taste their food as they prepared it, before fish was fully cooked. The parasite is now supposedly absent from Great Lakes fish; recently, however, cases have been reported on the West Coast.

Foods are not routinely analyzed for this parasite. In 1980, an outbreak involving four Los Angeles physicians occurred when the four ate sushi made of tuna, red snapper, and salmon. At the time of this outbreak, there was also a general increase in requests for niclosamide (the drug used to treat the infestation). Interviews of 39 patients showed that 32 remembered eating salmon before becoming sick.

Cause The disease is caused by parasitic flatworms Diphyllobothrium latum and other members of this tapeworm genus. The larva is often found in the viscera of fresh and marine fishes. D. latum, a broad, long tapeworm often grows to lengths between 3 and 7 feet and is potentially capable of reaching 32 feet. It is sometimes found in the flesh of freshwater fish, or fish that migrate from salt water to freshwater for breeding. Bears and humans are the final hosts for this parasite. The closely related D. pacificum usually matures in seals or other marine mammals and grows to only half that length.

Symptoms Distended abdomen, flatulence, cramping, and diarrhea about 10 days after eating raw or poorly cooked fish. Those who are susceptible (usually those of Scandinavian heritage) may experience a severe ane

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