L6: Common Communicable Diseases

Disease Malaria Dengue Cholera Enteric Fever

Organism Plasmodium falciparum, Plasmodium vivax Flavivirus Vibrio cholera Salmonella typhi
Plasmodium ovale, Plasmodium malariae (DENV 1 – 4) (O1 & O139) Salmonella paratyphi A
Plasmodium knowlesi Salmonella paratyphi B
IP 7 – 30 days 4 – 7 days 2 hours – 5 days 1 – 21 days
Transmission Anopheles mosquitoes Aedes aegypti, Aedes albopictus Infected water, Stool, Vomit Faecal-Oral route
Clinical Uncomplicated Severe Prodrome (2 – 7 days) • Watery diarrhoea Typhoid fever
Features • Headache • Coma Highlighted, Arthralgia, Backache, Pain on eye • Rice-water stools 1st week
• Fatigue • Hyperpyrexia movement, lacrimation, Maculo-papular rash, • Fishy odour to stools Highlighted, bradycardia, constipation,
• Abdominal • Convulsions prostration, depression, lymphadenopathy, • Rapid heart rate diarrhea
discomfort • Hypoglycaemia bradycardia, scleral injection (red eye) • Low BP
• Myalgia • Severe anemia Critical phase (3rd day, lasts 24-48 hours) • Dry mucous membranes End of 1st week
• Athralgia • Acute pulmonary edema - Rapid drop in temperature Skin rash, cough, bronchitis, epistaxis,
• Fever • Acute Renal Failure - May lead to DHF/DSS diarrhea, tender abdomen, splenomegaly
• Chills • Spontaneous bleeding & Reabsorption phase (24-46hrs after CP)
• Perspiration coagulopathy - Plasma leakage stops à reabsorption of fluid End of 2nd week
• Anorexia • Metabolic acidosis Warning Signs (DHF) LAMP HATI Delirium à Coma à Death
• Vomiting • Shock Lethargy, Abdominal pain, Mucosal bleeding,
• Worsening • Aspiration pneumonia Persistent vomiting, Hepatomegaly, Ascites, Paratyphoid fever
malaise • Hyperparasitemia Thrombocytopenia, Increased haematocrit • Shorter & milder than typhoid
• Abrupt onset of fever+ acute
enteritis & skin rash
Investigation • Giemsa-stained thick & thin blood films • Rapid Combo Test Suspect when • Stool dark-field 1st week
• Full Blood count • ELISA ↑ fever + either 2 microscopy • WBC count – leukopenia
• Blood urea & creatinine - NS1 antigen • Severe headache - Shooting star motility • Blood culture
• Serum electrolytes - Dengue IgM • Pain behind eyes • Rectal swab or stool
• C-reactive protein (CRP) • CBC • Muscle & joint cultures 2nd week and 3rd week
• Liver Function Test (LFT) • LFT – elevated pains • Serum electrolytes, urea • Faecal culture
• Arterial Blood Gas Analysis • Serum albumin • Nausea and creatinine
• Polymerase Chain Reaction • RT-PCR • Vomiting The Widal test
• Rapid Diagnostic Test • CXR – pleural • Swollen glands - TO antigen >1:160
- Immunochromatographic tests for malaria antigens effusion • Rash - TH > 1:160 past infection/immune
Management Uncomplicated • Antipyretics • IV Ringer-lactate • Antibiotics
• Riamet: 20mg artemether / 120mg lumefantrine • Avoid Aspirin & other NSAIDS due to solution or cholera - Cephalosporins (Ceftriaxone or
bleeding risk saline Cefotaxime)
Severe • Volume replacement & blood transfusion • Vomiting stop à oral - Azithromycin
• Artesunate (IV) + Doxycycline (Po) may be indicated in patients with shock rehydration salts
- Day 1 & All stages of pregnancy • Monitor FBC, Blood urea & creatinine, Serum • Antibiotics • Chronic carriers
• Early & appropriate anti-malarial chemotherapy electrolytes - Tetracycline - Ciprofloxacin for 4 weeks
• Active treatment of complications - Doxycycline - Cholecystectomy
• Correction of fluid, electrolytes & acid-base - Ciprofloxacin
balance

Drug resistance
p. falciparum is now resistant to chroloquine &
sulfadoxine-pyrimethamine (Fansidar)

*Avoid Doxycycline & Artemether in all pregnancy

 L6: Common Communicable Diseases
Disease Melioidosis Leptospirosis Syphilis Gonorrhoea
Organism Burkholderia pseudomallei Leptospira interrogans Treponema pallidum Neisseria gonorrhoeae
IP 1 – 21 days 1 – 2 weeks Primary: 14 – 28 days, Secondary: 6 – 8 weeks, Latent : 2 years 2 – 10 days
Transmission Inoculation, Inhalation Skin lesions and abrasions Sex, Kissing, Blood transfusion, Percutaneous injury, Transplacental Sex, Transplacental
Clinical Acute illness Early Male
Features • High fever Primary Secondary Latent • Mucopurulent or
• Prostration • Chancre • Mild fever, Malaise, Skin rash, Early purulent urethral
• Diarrhoea • Enlarged Headache +ve syphilis discharge & dysuria
• Pneumonia LN • Chondylomata lata serology • Anal discomfort,
• Osteomyelitis • Painless • Snail track ulcers/mucosal patches CSF abnormalities discharge or rectal
• Septic arthritis • Usually • Painless lymphadenopathy Late bleeding
• Cellulitis genital • CNP, MNG, Hep/Gas/Periostitis, GNP No longer infectious • Proctitis on
• Hepatosplenomegaly proctoscopy
• Liver or splenic abscess Late
Benign Tertiary Syphilis (3 – 10 years after infection) Female
Chronic illness Gumma (chronic granulomatous lesion) • Urethra,
• Duration of symptoms > >Nodular/Ulcerative skin lesion, SC lesions ulcerate + gummy discharge paraurethral
2 months >Mucosal lesions : Punched-out ulcers (Mouth, Pharynx, Larynx, Septum) glands/ducts,
• Chronic skin infection Bartholin’s
• Skin ulcers Cardiovascular Syphilis gland/ducts,
• Lung nodules Aortitis (valve / Cor. Ostia), Aortic incompetence, Angina, Aortic aneurysm endocervical canal
• Chronic pneumonia may be infected
• Multiple SC abscess Neurosyphilis • Vaginal discharge or
• Muscle wasting Bacteraemic : High fever, Weakness Meningovascular disease, tabes dorsalis, general paralysis of the insane dysuria
• Culture • PMN leucocytosis Quaternary syphilis : Coexistence of cardiovascular & neurosyphilis
Investigation • Microscopy smears
• Indirect • Thrombocytopenia - Gram -ve diplococci
haemagglutination • ↑ creatine kinase Congenital Syphilis
Miscarriage/Stillbirth or birth of baby with latent infection
may be seen
• Direct immunofluorescent • ↑ Liver enzymes • Culture
test • Little prolonged PT Hepatosplenomegaly, bullous rash & pneumonia
• NAAT
• Latex agglutination • CSF : Moderately elevated protein, Non-Treponemal (non-specific) tests Complications
• Chest X-ray normal glucose • Venereal Diseases Research Laboratory (VDRL) test • Acute proctitis
• Ultrasound or CT • Blood cultures • Rapid Plasma Reagin (RPR) test (+ve in HIV, Lyme, Malaria, SLE) • Epididymo-orchitis
abdomen • Serological test
• Bartholin’s gland
- Liver/Spleen/Prostatic - Microscopic Agglutination Test (MAT) Treponemal (specific) antibody tests abscess
abscess à honeycomb - IgM ELISA • Treponemal antigen-based enzyme immunoassay (EIA) for IgG & IgM • PID à
appearance - Immunofluorescent techniques • Treponema pallidum Haemagglutination assay (TPHA) ectopic/infertility
- Rapid Immunochromatographic tests • Treponema pallidum Particle Agglutination assay (TPPA) • Disseminated
• PCR (early-blood, 8th day-urine) • Fluorescent treponemal antibody-absorbed (FTA-ABS) test gonococcal infection
Management • IV injection for • Fluid & electrolyte balance Treatment for Syphilis Uncomplicated
- Ceftazidime • Renal failure is reversible with dialysis • Benzathine penicillin (IM) • Ceftriaxone (IM)
- Imipenem • Antimicrobial regimen - Early: single dose of 2.4 megaunits • Cefixime
- Meropenem - Doxycycline (Po) - Late: 3 doses weekly intervals • Ciprofloxacin (Po)
- Cefoperazone- - Penicillin (IV) • Doxycycline or Erythromycin can be given if allergic to penicillin • Ofloxacin (Po)
sulbactam - Parenteral Ceftriaxone • Amoxicillin
(Sulperazone) • Uveitis treated with systemic antibiotics Treatment Reaction +Probenecid (Po)
• Doxycycline & local corticosteroids • Anaphylaxis
• Co-trimoxazole • Prophylactic Doxycycline 200mg • Jarisch-Herxheimer reaction – Prednisolone Po 3 times daily for 3 days Quinolone resistance
• Co-amoxiclav weekly • Procaine reaction • Ceftriaxone (IM)
• Surgical treatment - Immediately after IV à fear of impending death, hallucinations or fits • Spectinomycin (IM)
Jarisch-Herxheimer Reaction – Primary syphilis symptoms(Highlighted), Fetal distress/premature labour, CA occlusion, Uveitis, Optic Neuritis, MI due to coronary ostia, Laryngeal stenosis
 SEMINAR NOTES : COVID 19
Transmission
• Respiratory Droplets Causative Agent:
• Aerosols (e.g. Nebulizers) SARS-CoV-2

Clinical Features
i. At least two of the ii. Any one of the following iii. Severe respiratory illness with at least
following: symptoms: one of the following:
• Fever • Cough • Clinical evidence of pneumonia
• Chills • Shortness of Breath • Acute respiratory distress syndrome
• Rigors • Difficulty in Breathing (ARDS)
• Myalgia • Sudden new onset of anosmia
• Headache (loss of smell)
• Sore Throat • Sudden new onset of ageusia
• Nausea or Vomiting (loss of taste)
• Diarrhea
• Fatigue
• Acute onset Nasal congestion
or running nose

Stages
Stage 1 – Testing positive without any symptoms
• Individuals in the first stage can usually perform their
daily routines without feeling ill. (asymptomatic)

Stage 2 – Testing positive with only mild symptoms

• This includes fevers, dry coughs, and a lack of physical
energy. Risk of transmission is thought to be the
greatest at this stage. (symptomatic)
Screening & Confirmatory
Stage 3 – Developing some form of pneumonia
*Samples – NP swab/OP swab • Pneumonia, hypoxemic respiratory failure, as well as
• Screening sepsis and septic shock.
- Rapid Test Kit (RTK)
• Confirmatory Stage 4 – Having breathing difficulties and requiring
- Real Time Polymerase Chain Reaction oxygen support
• Shortness of breath can make it extremely difficult for
Investigation those infected with COVID-19. According to the WHO, 1
out of every 6 people infected with COVID-19 start to
• Vital Signs
develop serious bouts of breathing difficulties.
• Physical examination
• FBC Stage 5 – Needing to be intubated and put on a
• Comprehensive Metabolic Panel ventilator
• Cardiac Biomarkers • If a patient reaches this stage, they will need to rely on
• Coagulation Screen a ventilator to keep breathing. (Multiorgan involvement)
• Serum Procalcitonin
• ABG test
• Radiology investigation à CXR, CT, Lung Ultrasound
• Other relevant investigation

General Treatment
• Symptomatic treatment – Antipyretics, Optimal nutritional support, Maintenance of fluid & electrolyte balance
• Close monitoring of vital signs
• Regular blood investigations & imaging
• In those requiring bronchodilators – Avoid nebulizers, instead Use MDI with spacer
• In those who require supplemental oxygen à Trial self-proning if tolerable

Health Measures
• Practice social distancing (≥1 meter)
• Wear a mask when going out (surgical/medical mask) – 2 or more layers
• Avoid 3 Cs – Crowded places, Confined space, Close conversation
• Basic good hygiene – Wash hands, Avoid touching eyes, nose & mouth, Cover mouth & nose with elbow or tissue
when coughing or sneezing, Clean & disinfect surfaces frequently
• Limit errands & Restrict Travel
• Monitor daily health
 L7 : Antibiotics
Penicillin Cephalosporin Tetracycline Macrolide
Pharmacokinetics Route : Oral, Parenteral (IV,IM) Route : Oral, Parenteral (IV,IM) Route : Oral, Parenteral Route : Oral, Parenteral (IV,IM)
Half-life: Usually < 2 hours Half-life: Usually 1 – 4 hours (IV,IM), Topical Absorption : food interferes
Elimination : Mainly renal Elimination : Renal Absorption: incomplete in gut Elimination : if large amount ,
Half-life: 6-8hrs, 12hrs, 16- then excreted in bile
18hrs
Elimination : Renal, Feces, Bile
Mechanism of • Bacteria has an outer cell wall • Similar to penicillin • Reversibly bind with 30s • Bind to 50s subunit bacterial
Action made up of peptidoglycan • More stable & broader subunits of bacterial ribosomal RNA
• Peptidoglycan consists of N-acetyl spectrum than penicillin ribosomes • Block movement of peptidyl
muramic acid (NAMA) & N-acetyl • Inhibits protein synthesis tRNA from acceptor to donor
glucosamine (NAG) site
• Penicillin linked with Penicillin • Next incoming tRNA cannot
binding protein prevent bind to the still occupied site
transpeptidase enzyme which • Protein synthesis stops
blocks peptidoglycan synthesis
Usage Long-acting Penicillin 1st generation • Mycoplasma infection : Erythromycin
• β-haemolytic streptococcal infection • Mainly gm(+ve) bacteria Pneumonia • Diphtheria & pertussis
• Early or latent syphilis • UTI,RTI, minor Staph • Cholera • Mycoplasma pneumoniae
• Gonorrhoea 2nd generation • Acne • Gastroenteritis
β-lactamase resistant penicillin • Most gm(+ve), Some gm(-ve) • Chloroquine resistant • Syphilis (penicillin allergic pt)
• Skin & soft tissue infections • Sinusitis, Otitis media, LRTI falciparum malaria Clarithromycin
• RTI (Pneumonia, lung abscess) • Peritonitis, H. influenzae • In combination with • H.pylori, M.avium
Broad spectrum penicillin 3rd generation aminoglycoside in plague • RTI & skin & soft tissue
• RTI, UTI & Meningitis • Most gm(-ve), Some gm(+ve) • GIT infections
• Gonorrhea, Typhoid fever - Nausea, Anorexia, Azithromycin
• Meningitis (can pass CNS) Diarrhea, Vaginal & Oral • Chlamydia
4th generation candidiasis • Non-gonococcal urethritis
• P. aeruginosa, S. aurerus • Bone & teeth • Acne
• Haemophilus, Neisseria - Fetal enamel dysplasia, • RTI
Adverse effects • Hypersensitivity • Hypersensitivity dental pigmentation, • Anorexia, Nausea, Vomiting
• Nephritis • Upset GIT dental carries • Diarrhea
• Upset GIT • Superinfection - Growth retardation and • Cholestatic jaundice
• Superinfection • Nephrotoxicity bone deformity • Fever, rash
• Thrombophlebitis • Photosensitization • Eryhtromycin à enzyme
• Hypoprothrombinaemia & • Hepatotoxicity inhibitor à increases effect
bleeding disorder • Vestibular reaction of Warfarin & Theopylline
- Dizziness, Vertigo