วันพฤหัสบดีที่ 12 กรกฎาคม พ.ศ. 2555

Tropical disease

Typhoid fever/paratyphoid (less invasive)

Clinical: most 5-25 yr, flu-like symptoms, N/V, diarrhea (conspitation in adult), hepatosplenomegaly, relative bradycardia, MP rash 2-4 mm at chest/abdomen

Lab: normal-low WBC +/- anemia/thrombocytopenia, mild transaminitis

Diagnosis: clinical + C/S, PCR

Tx: ofloxacin 15-20 mg/kg/d, ciprofloxacin 20-30 mg/kg/d 5-14 d (depend on FQ resistant); ceftriaxone 40 mg/kg/d x 7-14 d, azithromycin 8-10 mg/kg/d x 7 d

**Non-typhoidal samonellosis: spontaneous recovery in 3-7 d; Tx with ATB if old age, immunocompromised host

Melioidosis

1) Septicemic melioidosis: septic shock, death

2) Pulmonary meliodosis: fever, cough, pus sputum > 1mo + concurrent UTI (differentiated from pulmonary TB)

3) Hepatosplenic abscess: abdominal pain, N/V, transaminitis; other localized infection: skin, lymohadenitis, pyomyositits, osteomyelitis, arthritis

Diagnosis: serology Ab IgG/IgM > 1:160

Tx: ceftazidime or carbapenam 10-14 d then cotrimazole + doxycycline or augmentin (higher relapsed rate) x total 20 wks

Rickettsia

Clinical (systemic vasculitis): fever (upto 3 wks), headache, myalgia, eschar, abdominal pain, diarrhea, pneumonitis, AIN, interstitial myocarditis, meningoencephalitis, DIC

• Spotted fever group (Thai tick typhus), epidermic typhus (louse), murine typhus (flea), scrub typhus

Lab: mild leukopenia, anemia, thrombocytopenia, hyponatremia, hypoalbuminemia, mild hepatic & renal abnormality

Diagnosis: IFA IgM/IgG > 1:400 or 4 fold rising in 10-14 d (> 1:200)

Treatment: doxy(100) 1x2 for 3 d; azithromycin(alternative in scrub typhus)

Leptospirosis

Clinical: fever, headache, myalgia (esp. back, calf, neck), conjunctival hyperemia

Lab: increaseTB(upto 20), mild transaminitis, renal failure, anemia, leukocytosis, thrombocytopenia, hematuria, hyaline/granular cast in urine

Diagnosis: IFA, MAT (>1:400 or 4-foled rising)

Tx: PGS 1.5-2 mU q 6 h for 7 d; doxy(100) 1x2; cef-3 1 gm IV OD; cefotaxime 1 gm IV q 6 h

Malaria

Clinical: fever with chill, hepatosplenomegaly, jaundice, pale

WHO criteria for severe malaria

Clinical
• Impaired consciousness
• Generalized weakness(unable to walk, failure to feed)
• Seizure > 2 times/24 h
• Respiratory distress
• Shock (SBP<70 mmHg inadult, < 50 in children)
• Jaundice + other vital organ dysfunction
• Spontaneous bleeding, haemoglobinemia
• Pulmonary edema
Lab
• BS < 40
• HCO3 < 15
• Hb < 5, Hct < 15%
• Hemoglobinuria
• Hyperparasitemia (> 2%/100000; > 5% or 250000 uL in high stable malaria transmission intensity)
• Lactate > 5 mmol/L
• Renal impairment (Cr > 3.0)

Diagnosis: thick/thin film, PCR

Treatment

Malaria: PF

Uncomplicated(6-5-3-2): artesunate (50) 6 tabs OD x 5d + mefloquine (250) 3 tabs stat, then 2 tabs 8-12h later

Severe: artesunate (60 mg/vial) 2.4 mg/kg IV at 0, 12, 24 h (D1), then 2.4mg/kg OD x 7 d + mefloquine

Pregnancy: quinine(10 mg/kg tid) + clindamycin for 7d (1st line) or artesunate + clindamycin

Malaria: Non-falciparum

• Chloroquine(250) 4-2-2-2 tabs (0, 6, 24, 48 h) + primaquine (15) 2 x OD for 14 d

• G6PD def : primaquine 30 mg once a wk x 6 wk

Parasite

Enterobius: Alben 400 once + repeat 2 weeks later
Trichuris: Alben 400 once
Ascaris: Alben 400 once
Capillaria: Alben 200 BID x 10d
Hookworm: Alben 400 once
Cutaneous larva migrans: Alben 400 BID x 3-5d
Strongyloides: Ivermectin 200 mcg/kg OD x 2d (6mg/tab), if disseminated infection x 5-7d +/- ATB cover gr neg sepsis
Trichinella: Alben 400-800/d until fever subsides + pred 40-60 mg/d
Gnathostoma: Alben 400-800 x 21d Angiostrongylus: No specific Rx, CSF removal to reduce ICP
Opisthorchis: Praziquantel 25mg/kg tid x 1d (600 mg/tab)
Paragonimus: Praziquantel 25mg/kg tid x 3d (600 mg/tab)
Schistosoma: Praziquantel 20 mg/kg tid x 1d
Taeniasis: Praziquantel 10 mg/kg once
Neurocysticercosis (T. solium): Alben 400 bid x 21d, steroid, AED
Giardia: Metro 750 tid x 5d
Entamoeba histolytica: Metro 500-750 tid x 5d
Isospora: Bactrim SS 2x4 x 10d
Cyclospora: Bactrim SS 2x4 x 10d
Cryptosporidium: No effective Rx; ARV
Scabies: 5% Permethrin or 1% Lindane apply to all areas of body from neck down, Wash off after 8 hours

Dengue

Severe dengue: fever d2-7 + evidence of plasma leakage (high Hct, pleural effusions or ascites, sign of shock (tachycardia, cold and clammy extremities, capillary refill > 3 sec, weak pulse, PP < 20), significant bleeding, alteration of consciousness, severe GI involvement (persistent vomiting, intense abdominal pain, jaundice), severe organ impairment (acute liver failure, ARF, encephalopathy or encephalitis, cardiomyopathy)

History and PE

Access I/O: oral intake, diarrhea, U.O.

Warning sign: abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy, restlessness, liver enlargment >2 cm, increase in HCT concurrent with rapid decrease in platelet count

Access host high risk & exposure risk(as undifferentiated fever)

Lab: CBC (leukopenia), BUN, Cr, electrolyte, BS, LFTs, lactate, cardiac enzyme, EKG, U. sp.gr.

Early dengue notification for prevent transmission: dengue-endemic area + fever >3 d + low WBC or thrombocytopenia

Mangement

Group A: no warning sign + adequate oral intake + pass urine q 6 h

     - Encourage oral intake (ORS, fruit juice); paracetamol for high fever (avoid ASA, NSAIDs) > q 6 h

     - F/U daily; monitor warning sign, urine frequency

Group B: warning sign, host high risk (pregnancy, infancy, old age, obesity, DM, renal failure, chronic haemolytic diseases), social circumstances

     - NSS 5–7 ml/kg/h x 1-2 h then 3-5 ml/kg/h x 2–4 h then 2–3 ml/kg/h(1.5-2 ml/kg/h if BW > 50kg) or less according to the clinical response; use ideal BW in obesity

     - Reaccess Hct if rising continue 2-3 ml/kg/h x 2-4 h then reaccess, If VS worsening or Hct rising: 5-10 ml/kg/h x 1-2 h

     - If no warning sign: Give minimum IV fluid (+/- glucose) to maintain good perfusion + U.O. 0.5ml/kg/h; usually for 24-48 h

     - Monitor VS and peripheral perfusion q 1–4 h; U.O. q 4-6 h, Hct before and after fluid replacement, then q 6–12 h; BS and other organ functions (renal profile, liver profile, coagulation profile, as indicated)

Group C: shock, severe hemorrhage, organ dysfunction(hepatic damage, renal impairment, cardiomyopathy, encephalitis)

Compensated shock: normal SBP, narrow PP, tachycardia, cool extremities, weak pulse, capillary refill > 2 s

     - NSS 5-10 mL/kg/h x 1 h and reaccess VS, capillary refill, Hct, U.O

          o Improved, gradually reduced IV NSS as group B

          o VS unstable then check Hct

      Hct rising or > 50%: 2nd bolus 10-20 mL/kg/h x 1 h then gradually reduced ( 7-10 mL/kg/h)

      Hct decrease (<45% in adult male; <40% in child/adult female): indicated bleeding, G/M and transfusion

     - Further NSS/colloid bolus as indicated, check Hct after IV bolus, stop IV fluid < 48 h

Hypotensive shock

     - NSS/colloid IV 20 mL/kg in 15 min

            o Improved: gradually reduced IV NSS (10 mL/kg/h x 1 h)

            o VS unstable then check Hct

      Hct high: change NSS to colloid 2nd bolus 10-20 mL/kg in 30 min -1 h then gradually reduced (change back to NSS 7-10 mL/kg/h)

      Hct decrease (<45% in adult male; <40% in child/adult female): indicated bleeding, G/M and transfusion

     - Further NSS/colloid bolus as indicated, check Hct before & after IV bolus then q 4-6 h

     - Monitor VS q 15-30 min until out of shock then q 1-2 h; U.O. q 1 h until out of shock than q 1-2 h; ABG/VBG, lactate, HCO3 q 30 min-1 h until stable; glucose before resuscitation and repeate as indicated

Hemorrhagic complication

Risk for bleeding: prolong shock, renal/liver failure, severe/persistent metabolic acidosis, Hx PU, trauma, on anticoagulant, NSAIDs

Sign of severe bleeding: overt bleeding + unstable VS, decrease Hct after fluid resuscitation + unstable VS, refractory shock that fails to IV fluid (40-60 ml/kg), hypotensive shock with low/normal Hct before fluid resuscitation, persistent or worsening metabolic acidosis esp. severe abdominal tenderness and distension

• PRC 5-10 mL/kg or whole blood 10-20 mL/kg, repeated if further blood loss or no appropriate rising Hct

• Lubricate OG > NG; US guide central line

Fluid overload

Early signs: respiratory distress, increase RR, wheezing, large pleural efflusion, tense ascites, increased JVP

Stable VS + out of critical phase: stop IV fluid, close monitoring +/- furosemide PO/IV 0.1–0.5 mg/kg/dose od/bid or IV drip 0.1 mg/kg/hr; Monitor serum K

Stable VS + within critical phase: reduce IV fluid, avoid diuretic

Shock with low/normal Hct: r/o occult haemorrhage, careful fresh whole blood transfusion

Goal of resuscitation: improve circulation (PR, BP, pulse volume, warm and pink extremities, and capillary refill time <2 s), stable conscious level (more alert or less restless), urine output > 0.5 ml/kg/hr, decreasing metabolic acidosis.

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