DOC WHAT ARE OCCUPATIONAL INFECTIONS?

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Occupational

Infections

An occupational Infection is an Infectious condition caused by biological agents such as bacteria, viruses, fungi and parasites at the work place.

These infections can occur from contact with infected people or animals or their tissues, secretions or excretions.

What are the Signs and symptoms of Occupational Infections?
The appearance of occupational Infectious disorder is no different from any other Infectious disorder.

Acute presentations may include:
1.fever
2.malaise
3.headache
4.vomiting
5.cough
6.diarrhea
7.rashes
8.breathing difficulty

Diagnostic Criteria of Work relatedness:
A good occupational history to determine the worker’s work process, materials, practice and habits is important in diagnosis of an occupational Infections disease.
The onset of the infection should co-related to:
1.duration of employment
2.occupational exposure to germs
3.history of a work related accident followed by the infection
4.Isolating of biological agent in a patient and correlated to the other workers exposed to patient.

Investigation to establish work relationship to infections:
Viruses:
1.AIDS, hepatitis B and C, SARS in health care workers, laboratory staff, biological waste handlers
2.Chickenpox, measles, rubella, hand mouth foot disease in healthcare workers, childcare workers, teachers
3.Chikungunya and dengue fever at construction sites, agriculture, and farms
4.Avian influenza in poultry houses with close contact with infected birds
5.Swine influeza, nipal virus in abbatoir workers, pork vendor, veterinary and healthcare workers
6.Rabies in animal handlers and veterinary workers

Bacteria:
1.Tuberculosis in healthcare workers, mortician and laboratory personnel
2.Tetanus and melioidosis in agriculture and farm workers, construction workers, military personnel
3.Anthrax in cleaning, preparation and treatment of hides and wool from animals
4.Leptospirosis in drainage and sewerage workers, veterinary workers, abattoir worker, waste and refuse collectors, road sweeping and military personnel.

Parasite:
1.Malaria in agriculture, farm and military personnel working in endemic areas.

Conduct the relevant diagnostic laboratory test to establish and confirm diagnosis of suspected infection and correlate this with presentation, incubation period and modes of transmission.

Inform the notifiable diseases department of the health ministry.

Management:

1.Isolate worker immediately to prevent spread of infection.

2.maintain good personal hygiene , wear personal protective equipment and  practice good work practices to prevent spread of infection.

3.followup on cases to monitor disease and whether the patient need hospitalization

4.Put in place a procedure for infection control allowing work restriction of infected workers and allowing time away from work during period of illness, promoting good health lifestyle and hygiene.

5.Have a schedule of immunizations in high risk personnel in workplace.

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DOC I HAVE SIALADENITIS

What is Sialadenitis?

Sialadenitis is an inflammation of the salivary glands .

There are 3 salivary glands:

1.Parotid – the largest salivary gland is located at the cheeks in front of the ears. An inflammation of the parotid gland is called parotitis.

2.Submandibular – this salivary gland is located at the back of the cheek below the lower jaw.

3.Sublingual – this salivary gland is located below the jaw near the front of the mouth below the  front of the tongue.

Inflammation of the salivary glands are usually viral  (example mumps) or bacterial.

They are common in most people and can recur after infections.

What is the cause of Sialadenitis?

1.Viral (mumps) infection

2.bacterial infection such as staphylococcus or pneumococcus

3.It can be associated with the presence of salivary stones (sialothiasis) in the duct.

It can occur as a result of poor oral hygiene or debilitating disease

Acute post operative parotitis used to be a common problem caused by ascending infection from the mouth but has been avoided by appropriate fluid therapy following surgery.

What are the symptoms of Sialadenitis?
Symptoms are:

1.acute swelling of the involved salivary glands or entire side of face

2.abnormal tastes , often foul

3.fever, general toxemia and malaise

4.pus or purulent saliva may discharge from the Stensen’s duct(opening of the salvary duct )

5.dry mouth

6.Pain  on opening of the mouth or eating food

How is the diagnosis of  Sialadenitis made?

Diagnosis:
1.presence of swelling of salivary gland especially the parotid

2.Xrays may show the presence of stones in the salivary duct

3.CT Scan or ultrasound may be necessary if there is suspected abscess or stones causing obstruction to the saliva duct

What are the complications of Sialadenitis?

The complications of Sialadenitis Fever are:

1.pneumonia

2.abscess formation

3.cellulitis or spread of infection to other parts of the face or neck

What is the treatment of Sialadenitis?

Treatment may not be necessary in mild cases.

1.Viral infections may only require symptomatic treatment such as for bed rest. anti fever medicine, pain killer, mouth rinses , oral hygiene and lots of fluid (water).

2.If the infection is suspected to be bacterial, antibiotics are given according to culture and sensitivity to antibiotics.

3. If there is abscess or blockage of the salivary duct, surgical drainage of pus or removal of stone may be necessary

What is the prognosis of Sialadenitis?

Prognosis depends on extent of disease.

Most viral mild salivary gland infections will disappear with symptomatic treatment . Bacterial infections are cured with antibiotic treatment.  Rarely there are complications such as difficulty in breathing or swallowing.

How do you prevent sialadentis?

1.Proper oral hygiene

2.Avoid smoking

3.Drink adequate fluids.

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DOC I HAVE BRUCELLOSIS

What is Brucellosis?
Brucellosis is an infectious disease caused by the Brucella bacteria which commonly cause infection in animals.

What is the cause of Brucellosis?

There are 5 forms of Brucella:
1.B.abortis present in cattle
2.B.melitensis -goat
3.B suis -pigs
4.B.canis dogs
5.B.ovis sheep

Infection occurs through contact with tissues of infected animals or by ingesting infected milk products of these animals

They are particularly found in farmers , veterinary surgeons and slaughter house workers.

They are usually found in young males.

The germs localize in the reticuloendothelial cells of liver, spleen, bone marrow, and lymph glands.

What are the symptoms of Brucellosis?

Incubation peroid is 2 to 4 weeks.
Symptoms are:

Mild flu-like attacks with symptoms of:
1.fever

2.headache

3.malaise

4.abdominal pain

5.chills

6.loss of appetite
sometimes episodes of infection can continue for months to years.

Relapses and recurring attacks of fever are usually seen in B.melitensis (or undulant fever -here the fever rises and falls in waves)
Symptoms in these cases are:
1.severe sweating

2.Abdominal pain

3.pains in limbs,back  and joints

4.headache

5.sore throat

6.irritability,insomnia

7.loss of appetite

8.erythematous rash

9.enlarged liver, spleen and lymph glands

10.loss of weight

In more severe cases there may be bleeding

Chronic brucellosis:
1.fever

2.fatigue and weakness

3.tremors

4.rheumatic and muscle pains

5.swollen lymph glands

How is Diagnosis of Brucellosis made?

Diagnosis of Brucellosis is made using:
1.blood, urine and bone marrow cultures

2.raised antibodies titers(more than 1:80) of brucella

3.radioimmunology of specific Brucella immunoglobulins

4.CSF Culture

What are the complications of Brucellosis?

The complications of Brucellosis Fever are:

1.arthritis

2.neurological disturbances and neuritis

3.meningoencephelitis

4.infective endocarditis

5.hepatitis

6.orchitis

What is the treatment of Brucellosis?

Treatment of Brucellosis is by:
1.antibiotic treatment such as tetracycline, septrin, streptomycin

2.continuous antibiotic for months

3.general supportive care:
a.rest
b.analgesics

4.corticosteroids in severe or chronic cases

What is the Prognosis of Brucellosis?

Prognosis:
1.acute uncomplicated disease may remit by itself

2.generally good if treated properly

3.rarely fatal

What are the preventive measures for Brucellosis?

Prevention:

Taking only pasteurized milk and cheeses is the most important way to prevent brucellosis. People who come in contact with animals should wear protective glasses and clothing to avoid  infection.Any skin breaks should be protected from contact with infected animals.

Vaccination is available for cattle but not humans.

Early detection of the disease in animals is important in isolation of animals and preventing infections.

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DOC I HAVE ERYTHEMA MULTIFORME      

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What is Erythema Multiforme?

Erythema Multiforme is an acute erythematous allergic skin reaction to a allergen or infection often associated with mucosal lesions.

A more severe erythema multiforme is Stevens-Johnson syndrome which can be potentially fatal.

What causes Erythema Multiforme?

The commonest cause is viral infections.

One third of cases occurs about 10 days after herpes simplex appears.

Other viral causes are viral pneumonia.

Bacterial infections causes are :
1.Hemophilic Streptococcus
2.Mycoplasma

Medications also causes lesions:
1.sulphonamides

2.barbiturates

3.phenylbutazone

4.Penicillins

5.Phenytoin

Radiation therapy for cancer can also cause the lesions.

The exact cause of erythema multiforme is unknown. It is believed that there is damage to the blood vessels of the skin and then damage to skin tissues.

Some forms of this condition are more severe than others.

Erythema multiforme minor is not very serious. Most erythema multiforme is caused by herpes simplex or mycoplasma infections

Erythema multiforme major which is very severe is known as Stevens-Johnson syndrome. The Steven Johnson’s syndrome is usually caused by reactions to medications  rather than infections.

Erythema multiforme occurs primarily in children and young adults.

What are the symptoms of Erythema Multiforme?

Erythema Multiforme symptoms is acute in onset .

1.lesions involve usually the face and flexor aspects of extremities;

palms and soles may be affected

2.lesions are raised pink papules annular in shape with purple center

3,the lesions are discrete and often described as target lesions

4.Sometimes the center is vesicular or bullous

5.In the mouth the mucosa is shed leaving raw red painful areas.
Tongue and lips may be similarly affected.

In severe cases also known as Steven Johnson syndrome general illness occurs with:
a.fever
b.headache
c.prostation
d.nose rashes
5.conjunctiva and eye lesions
6.vagina – sometimes weeping eczema of the mucosa
7.urethra – similar reaction may occur

6.Drug induced toxic epidermal necrosis (more severe Steven Johnson Syndrome) represents the serious form of erythema multiforme.

How is the diagnosis of Erythema Multiforme made?

The diagnosis of  Erythema Multiforme involve:
1.typical appearance of skin and mucosa

2.history of viral,bacterial and medical causes.

3.Nikolsky’s sign is a skin finding in which the top layers of the skin slip away from the lower layers when slightly rubbed.

4.Skin biopsy and microscopic examination of the tissue

What are the complications for Erythema Multiforme ?
1.danger of excessive shedding of cells from skin and mucosa leading to shock and death

2.chronic infections with pneumonia

What is the treatment for Erythema Multiforme?

Treatment for severe Erythema Multiforme :
1.Hospitalization and prevention of shock and dehydration with intravenous fluids

2.treatment of the condition with high doses of corticosteroids

3.treat chronic infections with antibiotics

4.Antihistamines for itch

5.Local toilet to eyes,nose, mouth, vagina important in severe cases

6.large bullae may incised for relief

7.analgesis for pain

8.treat underlying cause and remove offending drug or radiation

9.Intravenous immunoglobulins (IVIG) to heal the disease process

10.Skin graft may be necessary in cases where large areas of the body are affected.

In the Erythema Multiforme minor, the condition is milder. Treatment involve:

1.antihistamines to control itching

2.Oral antiviral medication if it is caused by herpes simplex

3.paracetamol to reduce fever and discomfort

4. Topical local anesthetic to apply to mouth lesions to reduce  discomfort when eating and drinking

What is the prognosis of Erythema Multiforme?

1.generally good in mild cases.

2.mortality rate with Stevens-Johnson syndrome and toxic epidermal necrolysis may be high without proper treatment.

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DOC I HAVE PURPURA

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Purpura is a physical sign of escape of red blood cells through the endometrial wall of the dermal capillaries resulting in purplish blotches under the skin.

A purpura is not a bruise which commonly called a hickey.

What is the cause of Purpura?

It is usually due to vacular wall defect, low platelets, infections or injury:

Vascular wall defect may be caused by:
1.Scurvy or lack of vitamin C
2.Fragilty of vascular wall due to age(senile purpura, anemia, diabetes or steroid therapy
3.Autoimmune disease such as Henoch Schonlein purpura
4.Blood cancer such as multiple myeloma

Infections:
1.Dengue fever – cause low platelets
2.Subacute bacterial endocarditis – cause low platelets
3.Typhoid fever
4.Rocky mountain fever

Low Platelets:
1.Aplastic anemia - low production of red blood cells, white blood cells and platelets from marrow
2.Megaloblastic anemia
3.Leukemia
4.Exposure to toxic drugs (chemotherapy) or radiation
5.Splenomegaly
6.Idiopathic thrombocytopenic purpura
7.Lymphoma
8.Neonatal thromocytopenia
9.Drug induced thrombocytopenia

Others:
1.Injury
2.Trauma
3.Burns
4.Dialysis
5.Blood thinners such as aspirin, warfarin, plavix
6.alcohol

What are the symptoms of Purpura?

Symptoms:

1.typical purple blotches under the skin
2.fever with purpura is a medical emergency
3.fundoscopic bleeding
4.abdominal pain may be a recurring symptom
5.splenomegaly
6.low platelets
7.bleeding time prolonged

How do you made the diagnosis of Purpura?

Diagnosis of Purpura is often based on
1. history of Purpura
2. history of drug allergy
3. history of blood thinners
4. Full blood count
5. Bone marrow biopsy

What are the complications of Purpura?

The complications of Purpura are:

1. Anemia

2. damage to liver , spleen and nerves

What is the treatment of Purpura?

Treat the underlying cause:
1.Blood transfusion of platelets in severe cases

2.Antibiotics for infections

3.Avoid causative agents especially drugs, vitamin deficiency,renal disease,radiation

4.corticosteroids is useful in idiopathic thrombocytopenic purpura

5.Splenectomy may be helpful

What is the prognosis of Purpura?

Prognosis depends on the cause of Purpura.
Patients with blood cancer has a poorer prognosis compared to injury.

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DOC I HAVE BEEN BITTEN BY BED BUGS

Adult bed bug, Cimex lectularius (Photo credit: Wikipedia)

What are Bed Bugs?

A Bed Bug is an insect called Cimex lectularius which is a small living insect that one can hardly see with the naked eye.

Bed bugs can be found in schools, hotels, apartments and houses. They can usually crawl and hide themselves in clothes, quilts, bed covers, pillow, furniture, cracks and crevices in the home.

Bed bugs are usually active at night. They mostly bite at exposed skin area such as face, neck, arms, hands feet etc. leaving swelling and redness at those bitten areas.

Their bites are characterized by itchiness and secondary skin infections.

Bed bugs are very flexible and tough insects because after they eat once in their life  they can spend their whole life span on that single meal.

The Life span of bed bugs is only one year.

Bedbugs can survive as long as up to one year without sucking blood.

The female bug can lay lay eggs three times in their life. and 300 eggs at one time. The eggs hatch in 6-10 days into adult bed bugs.

What are the Symptoms of Bed Bugs?

1.itching which is worse at night

2.rashes and abrasions on the skin due to scratching and secondary infections.

Rashes typically are present on legs and arms, sometimes on the body , seldom on the face. Rarely it may be present on the scalp.

Bedbug bites can not be felt immediately because of a sedative present in the saliva of the bedbug that keeps the blood from clotting and immunes the body for some time.

The process of sucking blood of a host lasts for 4-5 minutes.

The only good thing about these bugs is that they don not carry germs or bacteria that may cause harmful diseases to human body.

How do you confirm the diagnosis of Bed Bugs?

Skin scrapings can be examined microscopically for the Bed Bugs bites.

What is the Treatment of Bed Bugs?

Wash the infected area with an antibacterial liquid and apply calamine lotion afterward.

Pesticides (chemicals to treat Bed Bugs) actually contain mild insecticide :

Benzyl benzoate lotion

Malathion lotion

Gamma benzene hexachloride cream

Permethrin cream

Bathing is followed by application of the insecticide to the whole body from the neck to soles, left for 24 hours.

Treatment of contacts may be required if there is obvious signs of Bed Bugs.

While the Bed Bugs cannot live off the human skin for longer than 24 hours, each treatment with pesticide should be accompanied by washing, in hot water, of bedsheets, pillow cases and any clothes worn over the previous week.

Most people improve within a few days of treatment but it may take 4-6 weeks for the itch and rash of Bed Bugs to go away completely.

Prevention:
Keep your house clean and spray an effective pest control formula to eradicate these bugs completely.

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DOC I HAVE A COMMON COLD

Who has never have the common cold? The code words are “Ah Choo” or sneezing, dripping of nose, pain in the throat and occasional fever. Cold weather, rain, snow, freezer, air conditioner are the precursor of a common cold. Once one person gets the common cold, every one in a closed environment gets it. That is why they called it the common cold.

The Common Cold (A Simple Guide to Coryza(Common Cold))is one of the most common infections seen by the family doctor.


Unlike Influenza, the patient suffer more from inflammation of the mucous membranes of the nose and throat, with sneezing, sore throat, and usually mild coughing. 

There are over 200 different viruses which can cause a common cold: rhinovirus, respiratory syncytial virus (RSV), corona virus, rotavirus.


Generally the common cold viruses produces mild but uncomfortable symptoms which seldom last more than 1 week:

1.Runny nose
2.Sneezing
3.Nasal congestion
4.Tiredness
5.Headache especially around the eyes and forehead
6.Fever – low grade rare


Usually a common cold runs its course without complications in one week. Because there is no cure for a viral infection, I usually aim at relieving the symptoms:


1.Rest is the most important part of treatment. 
A rested patient will recover faster.


2.Adequate warm fluids keep the mucus membranes moist to allow infected mucus to flow better and also to replace wet mucus lost during the runny nose.


3.If there is any fever, headaches and pains, paracetamol can be given to relieve symptoms.


4.Oral (tablet or syrup) decongestants may also relieve nasal symptoms. 
Antihistamines may help to reduce mucus production.


5.Decongestant sprays can relieve block nose temporarily, but should not be used for more than three days. 
Longer use can lead to rebound congestion with more symptoms of congestion.


6.Antibiotics and vitamin C are not helpful in relieving symptoms of the common cold.


Very rarely young children may develop complications such as bronchitis, viral pneumonia, and croup.  
I would check the lungs of young children carefully to make sure there is no breathing problem.

Acute otitis media ( A Simple Guide to Otitis Media) , an infection of the middle ear occurs in 2% of patients with a cold. 
I would ask all patients with cold whether there is pain in the ear or blockage in the ear.

Bacterial Sinusitis (A Simple Guide to Sinusitis) occurs in 0.5% of people with a cold. I would ask them for pain in the cheek and forehead area. If necessary an X-ray of the Sinuses should be done.

People with chronic obstructive pulmonary disease ( A Simple Guide to Chronic Obstructive Lung Disease) who have a rhinovirus infection are more likely to have a more serious or longer duration of illness.

Prevention of the common cold is by :
1.Proper hygienic care of the hands and body
2.Well balanced diet with enough fluids
3.Adequate exercise

It is important to distinguish a Common Cold from Influenza which is usually more serious.

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DOC I HAVE A SKIN INFECTION

Pus oozing from an abscess caused by bacteria—pus contains millions of phagocytes (Photo credit: Wikipedia)

SKIN INFECTIONS are part and parcel of the types of diseases seen by family doctors.

Scratching of the skin is one of the causes of breakage of the protective skin layer and infection from germs caught in the finger nails can enter the broken skin and cause pus formation in the skin. 

Abscesses are easily formed in any part of the body. 
Most large abscesses require incision(cut into the abscess) and drainage to release the pus collected to prevent infection spreading further and causing septic shock.


One memorable case was a small 3 year old girl who developed a large abscess on her scalp. 
There was no other way except to incise and drain the large abscess. 
She was very brave and cried once when the needle for local anesthetic injection entered the skin to provide local anesthetic. Then the knife was used to open the abscess and the pus was allowed to drain out.
After that she had the wound bandaged and given antibiotics, painkiller and antibiotic cream. 
Although she was told to wash her hands and not use them to scratch her head, she had a recurrence 2 years later and had the same procedure done on her again. 
Since then she did not have any more skin infection.


Skin infections such as infected acne can occur in adolescent boy or girl through hand contact with the acne. 
Antibiotics and antibiotic creams may be necessary for the treatment of the skin infections. 
The best antibiotics are those of the tetracycline group and erythromycin. 


In women who are breastfeeding, engorgement of the breast may occur due to blocked breast milk ducts.
If this happened warm compress may soften the milk stuck in the breast milk duct. 
If this does not happened the accumulated milk stuck in the duct may become infected resulting in abscess formation . 
If safe antibiotics such as ampicillin does not clear the infection the abscess may require incision and drainage.

Other infection may also occur at the nipple due to infected skin and clogged milk ducts.

Skin infection may also occur in the vulval area of any women if unhygienic conditions are present during sexual intercourse, urination and defecation ( passing bowel motion). 
Very often infected Bartolin cysts in the vulva region may occur and require incision and drainage.

Infection of the penis may also occur due to traditional circumcision in children.
Some skin infection may also result from scratching the genital area and from sexual intercourse. 
In most cases blood tests and urethral (internal tube that leads from the bladder to the opening of the penis) swabs for bacteria may be done for sexual infections. 
Those sexually transmitted which can be treated  are given antibiotics and flagyl. 
Herpes infections can be treated with antiviral drugs sometimes successfully.
HIV infections however cannot be cured as yet.

 In housewives, a common skin infection is paronychia of the finger nails – infection of the side of the fingernail due to pressure or injury to the side of the nail. 
Very often the patient will have an abscess of the side of the nail by the time she sees a doctor. 
The abscess is usually pricked with a sterile needle to release the pus which normally cause pain due to pressure on the nail. 
This is followed by antibiotic and antibiotic creams.

Infection of the naval is very common in babies and are usually treated with antibiotic powder or creams.
Less often infection of the navels may occur in adults due to attempts at removing dirt in deep navels.

I had a elderly female patient who was actually referred to me by another family doctor who was unsuccessful in getting rid of the pus discharge from her navel in spite of  antibiotic treatment. There was an abscess in the lower part of the navel which was discharging pus. I had to incise the abscess completely and do daily antibiotic dressing of the navel until she was completely cured.


In Diabetic patient foot care is very important. 
Any skin infection or wound in the foot can developed into abscesses and carbuncles (collection of abscesses) which needed special control of his diabetic condition, removal of all the abscess and carbuncle, strong antibiotic and daily dressing of his foot wound.

One of my diabetic patient had to be treated for about 4 weeks before his infected wound in the foot finally cleared up. 
However the next time he had his foot wound, he was bought to the Hospital where the doctor immediately sent him to a surgeon to do an amputation of the leg below the knee.


The worst infection I had seen in my family practice was that of the infected toe of a lorry driver.

He was dirty and smelly and obviously had not bathed for several weeks.
He complained of pain and swelling in his right big toe which was obviously very infected. 
So what I did was removal of the pus in the wound. 
What came out besides the pus was maggots about almost a hundred of them. 
I had to catch these wriggling maggots one by one until I finally reach the bottom of his wound. 
I cleaned the wound and did daily antibiotic dressing for about 2 weeks before the wound finally recovered. 
I also advised the patient to bathe daily. 
It was obvious that there was total neglect of his wound that allowed flies to lay eggs in the wound resulting in the maggots.


All skin infections can be treated if you are persistent with daily cleaning and antibiotic dressing of the wound.
However in Diabetes there is always the danger of the wound spreading in uncontrolled diabetes which may require amputation to stop the infection from spreading. 

It is important to emphasize to any patient with skin infection never to scratch or touch their skin with hands which may be dirty and full of germs

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