Common Conditions

Penetrating Stab Injuries

1. Immediate exploratory laparotomy if patient is in shock at the time of presentation with rigid distended abdomen, peritonitis or evisceration.
2. Wound exploration in operation theatre with good illumination in haemodynamically stable and cooperative patients. If anterior fascia (in obese patients) or peritoneum (in thin patients) is not breached, wound can be closed after irrigation and patient can be discharged and followed up in the OPD.
3. If wound exploration reveals breach of anterior fascia or peritoneum but the abdomen does not have evidence of peritonitis, the patient can be admitted and serially examined for 24 hours. This method can delay definitive operation in about 5-10% of patients. The other option is to perform diagnostic peritoneal lavage (DPL). DPL in stab injuries has slightly higher false positive results (as compared to blunt abdominal trauma) because of bleeding from the site of stab wound. It can also miss some hollow viscous injuries especially of colon if patient presents early and hence DPL is performed very early.
4. In the sub-group of patients in whom there is high suspicion of intraabdominal injury, but the patient is haemodynamically stable on presentation, perform diagnostic laparoscopy. It can confirm or rule out intra-abdominal injury without needing a laparotomy. However, it must be performed by a surgeon experienced in laparoscopy.

1. Abdominal Trauma and Indications for Celiotomy. In: Trauma. Moore EE, Mattox KL, Feliciano DV, Appleton & Lange (eds), 2nd Edition, 1991, pp 409-426.
2. Blunt & Penetrating Abdominal Trauma. In: Maingot’s Abdominal Operations, 10th Edn. Prentice Hall International, 1987, pp 763-786.

Status Epilepticus (SE)

1. Inj. Lorazepam 0.1 mg/kg at the rate of 2 mg/min IV (can be repeated after 10-20 min).
   Or
   Inj. Diazepam 0.2 mg/kg at 5 mg/min intravenously (can be repeated if seizures do not stop after 5 minutes).
2. If seizures persist and diazepam was used to stop the status, also give Inj. Phenytoin 15-20 mg/kg slow infusion (not more than 50 mg/min). In children: Inj. Phenytoin 1 mg/kg/min IV.
   (CAUTION: Phenytoin is incompatible with glucose containing solutions; purge IV line with normal saline before administering phenytoin infusion; IM absorption is erratic). If seizures are not controlled after 20 mg/kg of Phenytoin even after 40 minutes, give additional dose of Phenytoin 5-10 mg/kg to a maximal of 30 mg/kg.
   (CAUTION: Check BP as it can produce hypotension)

If status persists after 60 minutes (Refractory SE)

Identify the precipitating or underlying cause of SE and institute treatment accordingly and shift patient to a tertiary care hospital with a ICU or emergency care unit).

1. Intubate and ventilate patient, place EEG monitor, place arterial catheter and central catheter.
2. Inj. Phenobarbital 20 mg/kg IV at 50-100 mg/min (Risk of apnoea or hypopnea is high if given after diazepam).
3. If seizures persists after 10-15 minutes give additional dose of 5-10 mg/kg of phenobarbital.
4. If seizures persists after 70 minutes, give anaesthetic dose of Inj. Midazolam 0.2 mg/kg slow IV bolus followed by 0.5-2 mg/kg/h.
   Or
   Inj. Propofol 1-2 mg/kg bolus followed by 2-10 mg/kg/h.
   Or
   Inj. Pentobarbital 5-15 mg/kg over one hour followed by 0.5 -3.0 mg/kg/h.
   Continuous monitoring of EEG with the primary end point being suppression of spikes or a burst suppression pattern with short inter burst interval. Continue maintenance doses of phenytoin/phenobarbitone to avoid recurrence of SE. Taper infusion at 12 hours to observe for further seizure activity, restart infusion if seizure recurs. Simultaneously, identify and treat the underlying cause and give IV fluids and vasopressors (Inj. Dopamine infusion) to maintain the BP, if cardiovascular compromise occurs decrease dose of Midazolam/Propofol/Pentobarbitone. Reduce dose and administration in cardiovascular disease, elderly, renal failure, hypoalbuminemia, monitor BP and cardiac rhythm.

• Convulsive SE is a serious complication most often seen in patients with preexisting epilepsy & is most often precipitated by missing or discontinuing medication or associated medical illness.
• If patient continues to convulse for more than 5 min or does not regain consciousness after a seizure, the patient should be hospitalized.
• Patient should be transported in lateral position & mouth should be cleared from secretions/frothing.

Differential Diagnosis of Seizures. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 2362-2369.

Epilepsy

• Patient should preferably be controlled on a single drug (monotherapy)
• Start the drug with low dose. If seizure recurs, the dose can be increased after checking the compliance.
• If seizures remain uncontrolled despite reaching maximum dose of first drug, add another drug as above and gradually reach the maximum dose of second.
• If seizures are controlled by addition of second drug; always try withdrawal of first drug after few weeks of control of seizures.

1. Inj. ACTH 20-40 units/day.
   Or
   Tab. Prednisolone 2 mg/kg/day in 2-3 divided doses.
2. Syp. Sodium valproate 15-40 mg/kg/day in 2-3 divided doses.
   Inj. ACTH or Tab. Prednisolone is given for 2-4 weeks with gradual tapering while sodium valproate is continued (after seizures are controlled) for 2-3 years.

• Most parents are initially frightened by the diagnosis of epilepsy and require support and accurate information. The physician should anticipate questions, including inquiries about duration of the seizure disorder, side effects of medication and convulsions, aetiology, social and academic repercussions, and parental guilt.
• Parents usually wish to know if restrictions should be placed on the child and whether the teacher should be informed. Others inquire about the genetic implications, including the risk for future children.
• The parents should be encouraged to treat the child as normally as possible. For most children with epilepsy, restriction of physical activity is unnecessary except that the child must be attended by a responsible adult while the child is bathing and swimming.
• Most children with epilepsy are well controlled on medication, have normal intelligence, and can be expected to lead normal lives. However, these children require careful monitoring, as learning disabilities are more common in children with epilepsy than in the general population.
• Cooperation and understanding among the parents, physician, teacher, and child. Enhance the outlook for the patients with epilepsy.
• Counselling should also include first aid measures to be used if the seizure recurs.
• Patients should be instructed to avoid high risk activities like swimming, driving, roof tops, fire places etc. for at least 6 months after the last seizure.
• Explain that medications should be taken exactly as prescribed.
• Irregular intake of drugs or sudden stoppage can lead to status epilepticus and will also prolong the duration of the treatment.
• To report immediately in case of status epilepticus, if seizure frequency increases, develops any intermittent illness especially fever and behavioural problem.
• Young women on AED must consult doctor before conceiving.
• Explain possible long-term side effects of the AEDs: Phenytoin – gingival hypertrophy, hirsutism, acne, chloasma, coarsening of facial features, sedation and ataxia. Carbamazepine – Sedation, ataxia, diplopia. Valproic acid – Sedation, ataxia, diplopia and hair loss. Hepatotoxicity can occur in children.
• Explain special precautions to be taken with AEDs: In patients on valproic acid frequent liver function test to be done at beginning and first six months of drug therapy.
• For prevention of gum hypertrophy, patient should be advised to maintain good oral hygiene and frequent rinsing of mouth.
• In patients on AEDs – explain possible risk of drug interactions especially oral contraceptives and antitubercular drugs.

1. New Antiepileptic Drugs. In: A Systematic Review of their Efficacy and Tolerability. British Medical Journal, 313, 1996.
2. Surgical Treatment of Epilepsies: Engel J., Jr. (Ed). Raven press, New York .
3. Seizures and Epilepsy. In: Harrison’s Principles of Internal Medicine. Wilson, Braunwald, Isselbacher et al. (eds). 15th Edition, 2001, McGraw Hill Company Inc., pp 2013-2325.
4. Seizures in Childhood. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds). 15th Edition, 1999, pp 1813-1829.
5. Manual of Pediatric Therapeutics, John W. Graef and Thomas W. Cone (eds), 2nd edition, pp 40-42 and 481-493.
6. Age Dependent Epileptic Encephalopathy (ADDE). In: Essentials of Paediatric Neurology. B. Talukdar (ed), 1997, New Age International (P) Ltd., pp 183-196.

Dengue

1. Tab. Paracetamol 500 mg 6 hourly (not more than 4 times in 24 hours) (for details see section on fever). (CAUTION: No role of antibiotic; do not give aspirin or ibuprofen)
2. ORS in patients with dehydration.

1. Immediate hospitalization.
2. As above in dengue fever.
3. Send sample for blood grouping and cross matching
4. IV fluids if patient has persistent vomiting or Hct rise >20%, continue IV fluids for 12-24 hours.
   (CAUTION: IV fluid therapy before leakage is not recommended)

Monitor vitals and urine output on an hourly basis. Based on periodic haematocrit/platelet counts and vital signs, review and revise treatment.
DHF grade III (with circulatory failure) and grade IV (profound shock with undetectable blood pressure and pulse)
Immediately admit the patient to a hospital where trained personnel can manage shock and have blood transfusion facilities available (for management of shock, see section of shock).

If patient has already received about 1000 ml of IV fluids and vitals are still not stable, the haematocrit should be repeated and (a) if the haematocrit is increasing, IV fluids should be changed to colloidal solution preferably dextran or (b) if haematocrit is decreasing, fresh whole blood transfusion 10 ml/kg/dose should be given.

In case of continued or profound shock give colloidal fluid following the initial fluid bolus.
In case of persistent shock when, after initial fluid replacement and resuscitation with plasma or plasma expanders, the haematocrit continues to decline, internal bleeding should be suspected. It may be difficult to recognize and estimate the degree of internal blood loss in the presence of haemoconcentration. Give fresh whole blood in small volumes of 120 ml/kg at one time. Give platelet rich plasma transfusion in exceptional cases when platelet counts are below 5,000 – 10,000/mm3. Monitor pulse, BP and temperature every 15-30 minutes. After blood transfusion, continue fluid therapy at 10 ml/kg/h and reduce stepwise to bring it down to 3 ml/kg/h and maintain for 24-48 hours.

During convalescent phase (2-3 days) after recovery from crucial/shock stage advise rest, normal diet. Signs of recovery are stable pulse, BP and respiratory rate, normal temperature, no evidence of bleeding, return of appetite, no vomiting, good urinary output, stable haematocrit and convalescent confluent petechial rash.

• Absence of fever for at least 24 hours without the use of antipyretic agents.
• Return of appetite.
• Visible clinical improvement.
• Good urine output.
• Minimum of three days after recovery from shock.
• No respiratory distress from pleural effusion and no ascites.
• Platelet count of more than 50,000/cu.mm.

• Since this disease can rapidly become very serious and lead to a medical emergency, carefully watch for danger signs and immediately report to a doctor. Do not wait.
• The complications usually appear between the third and fifth day of illness
• Watch the patient for two days after the fever disappears.
• Give large amounts of fluids (water, soups, milk and juices) along with normal diet.
• All control efforts should be directed against the mosquitoes. Efforts should be intensified before the transmission season (during and after the rainy season) and during epidemics.

Guidelines for Treatment of Dengue fever / Dengue Haemorrhagic Fever in Small Hospitals, 1999, World Health Organization Regional Office for South-East Asia, New Delhi.

Malaria

1. All fever cases without any other obvious causes should be presumed as malaria cases and antimalarial drug be given preferably after taking blood smear.
2. Chloroquine is the main antimalarial drug and it is to be used as first line of treatment for the treatment of uncomplicated malaria.
3. In high-risk areas presumptive treatment 25 mg/kg of Chloroquine base is to be given on 3 consecutive days with a single dose of Primaquine 0.75 mg/kg on the first day. High risk area is defined as follows:
   1. Recorded deaths due to malaria (on clinical diagnosis or microscopic confirmation) with P. falciparum infection during the transmission period in an endemic area during any of the last 3 years.
   2. Doubling of slide positivity rate (SPR) during the last 3 years provided the SPR in second or third year reaches 4% or more or the average SPR of the last year is 5% or more.
   3. P. falciparum is 30% or more provided SPR is 3% or more during any of the last 3 years.
   4. An area having a focus of chloroquine resistant P. falciparum.
4. In the low risk areas, presumptive treatment 10 mg/kg Chloroquine single dose.
5. Resistance should be suspected if inspite of full treatment and no history of vomiting and diarrhoea, patient does not respond within 72 hours parasitologically. Such patients should be given alternative drug i.e. Sulfa-pyrimethamine (S-P) combination.
6. S-P combination is the antimalarial drug of choice in P. falciparum resistant to chloroquine. The dose is 25 mg/kg of sulfa + 1.25 mg/kg of pyrimethamine which is 3 tablets for the adult (single dose).
7. The dose of Primaquine for P. vivax cases is 0.25 mg/kg daily for 5 days to prevent relapse and for P. falciparum 0.75 mg/kg single dose for gametocidal action.
8. Mefloquine can be given to chloroquine/other antimalarial resistant uncomplicated P. falciparum cases only.
9. Resistance to Chloroquine

• There must be an evidence of falciparum positive blood slide on the first and third days of treatment. WHO classifies resistance to chloroquine into 3 types.
• R1: total disappearance followed by reappearance of the parasite.
• R2: noticeable fall without disappearance of the parasite.
• R3: parasite level almost unchanged, indeed, increased.
  Before labeling resistance verify
• that treatment has in fact been taken.
• that the correct dose for weight has been prescribed.
• the patient has not vomited within 30 min of taking medication.
• that there has not been under-dosage due to confusion between the expression of the dosage as a chloroquine base and as a chloroquine salt. Equivalence between salt and base:
  130 mg sulphate=150 mg phosphate or diphosphate = 100 mg base.
  200 mg sulphate=250 mg phosphate or disphosphate= 150 mg base.

10. In Pregnant woman and infants, primaquine is contraindicated. As no data is available to suggest the safety of artemisinin derivatives in this group, the same is not recommended.

Treatment

Patients of uncomplicated malaria can be managed at primary level but patients with severe malaria with complications should be admitted and managed in a hospital where facilities for detailed investigations and blood transfusion exists.

A. Presumptive treatment in uncomplicated malaria

Low Risk Area: Single dose of Tab. Chloroquine phosphate 10 mg/kg, (maximum dose is 600 mg) to all suspected malaria cases.

High Risk Area

B. Confirmed cases of malaria

1. Tab. Chloroquine as in presumptive treatment in “high risk area”.
   (a) In P. vivax Tab. Primaquine 0.25 mg/kg/day for 5 days.
   (b) In P. falciparum Primaquine 0.75 mg/kg as a stat (single dose).
   In high risk areas where presumptive treatment with 500 mg Chloroquine base and 45 mg Primaquine (adult dose) has been given, Chloroquine need not be administered again, but Primaquine must be given for 5 days.

C. Chloroquine resistant P. falciparum case: In P. falciparum cases not responding to chloroquine, second line of treatment must be given as a single dose of Sulphalene/Sulphadoxine (1500 mg) + Pyrimethamine (75 mg) in dose of 25 mg/kg of Sulpha (3 tablets in adults) followed by Primaquine (45 mg).

D. In severe and complicated malaria cases
In severe and complicated P. falciparum malaria, irrespective of chloroquine resistance status of the area Inj. Quinine salt 10 mg/kg 8 hourly IV in 5% dextrose saline is preferred. Patients should be switched over to oral quinine as early as possible and oral dose 10 mg/kg 8 hourly not exceeding 2 g in a day in any case.
Minimum total duration for quinine therapy should be for 7 days including both parenteral and oral doses.
Or
In nonpregnant adults and in case of G-6 PD deficiency (capsule and tablet forms of these derivatives are not recommended for use in India)

Artemisinin derivatives (any of the following)
Dosages are as follows:
Inj. Artemisinin: 10 mg/kg once a day IV for 5 days, with a double divided dose administered on the first day;
Inj. Artesunate: 1 mg/kg (two doses) IM/IV at an interval of 4-6 hours on the first day followed by 1 mg/kg once daily for 5 days.
Inj. Artemether: 1.6 mg/kg (two doses) IM at an interval of 4-6 hours on the first day followed by 1.6 mg/kg once daily for 5 days. Inj. Artether: 150 mg daily IM for 3 days.

Supportive treatment
Treat fever (Acute fever & fever in children), hypoglycemia, electrolyte imbalance (Adults & Children), hypotension, renal failure (Acute & Chronic), anaemia (in pregnancy & in children), convulsions appropriately (for details see respective sections).

Chemoprophylaxis in selective cases
Chemoprophylaxis is recommended for a) pregnant women in high risk areas and b) travelers including service personnel who temporarily go on duty to high malarious areas. Chemoprophylaxis is to be started a week before arriving to malarious area for visitors and for pregnant women prophylaxis, it should be initiated from second trimester.

Chloroquine sensitive area

• Start with loading dose of Tab. Chloroquine 10 mg/kg, followed by a weekly dose of 5 mg/kg. This is to continue till 1 month after delivery in case of pregnancy and in travelers till one month after return from endemic area. The terminating dose should be 10 mg/kg along with 0.25 mg/kg of Primaquine for five days.
  (CAUTION: In pregnancy, Primaquine should not be given)
• Chemoprophylaxis with chloroquine is not recommended beyond 3 years because of its cumulative toxicity.
• In chloroquine resistant areas Chloroquine 5 mg/kg weekly and Proguanil 100 mg daily.

Patient education

• To take measures to stop mosquito breeding and protection from mosquitos e.g. mosquito nets, repellents, long sleeves, long trousers etc.
• Fever without any other signs and symptoms should be reported to nearest health facility.
• Chloroquine should be given with plenty of water after food and not on empty stomach. If chloroquine syrup is not available for children, the tablet should be crushed and given with honey or thick syrup.
• Watch for side effects of drugs prescribed. Chloroquine may cause nausea, vomiting and diarrhoea, mild headache and skin allergy/rash.
• If vomiting occur within 30 minutes of chloroquine intake repeat the dose of chloroquine.
• Chloroquine and sulphadoxine + pyrimethamine should not be given if patient is suffering from G-6 PD deficiency.
• Patients should be educated about symptoms of cerebral malaria, and should seek medical help immediately on occurance of these symptoms.

References

1. NAMP Drug Policy.
2. Malaria (Plasmodium). In: Nelson’s Textbook of Paediatrics. Behrman, Kliegman, Jenson (eds), 16th Edition, 2000, Harcourt Publishers International Company, pp 1049-1052.

Tuberculosis

Tuberculosis (TB) is one of the most prevalent chronic infection in our country and responsible for high morbidity and mortality. TB is caused by Mycobacterium tuberculosis, and afflicts the lungs most commonly. In one-third or more extra-pulmonary involvement is seen.

Site of lesion: This is of importance when a more intensive treatment is suggested for certain sites e.g. pulmonary compared to extra-pulmonary or a prolonged continuation therapy may be required for certain extrapulmonary disease like tuberculous spine or tuberculous meningitis.

Bacteriology: The treatment of tuberculosis is based on the dictum – more the bugs, more the drugs. So the AFB positive patients get higher number of drugs (initial 4 drug regime).

Type of patient

• All patients who have never been treated with antitubercular therapy (ATT) or for a period of less  than 4 weeks in the past are new cases
• Certain sets of patients listed below are more likely to have drug resistant disease and therefore require a different and more powerful regime (Initial 5 drugs and 3 drugs in continuation).
  - Defaulter – Patient who was previously inadequately treated patient.
  - Relapse - Patient who has been previously completely treated/cured patient now with active disease.
  - Treatment failure – Patient who, while on treatment, remained or again became smear positive 5 months or later after commencing treatment or patient who was smear negative before starting the therapy, but becomes smear positive after 2 months of treatment.
  In Children after 3 months of intensive phase therapy if patient does not show signs of recovery or deteriorates and where alternative diagnosis has been ruled out and compliance is ensured, it should be considered as treatment failure even if AFB has not been demonstrated.
• Severity of lesion.
  - Bacteriologically positive pulmonary tuberculosis is considered as severe disease. The bacteriologically negative pulmonary primary complexes, isolated   lymphadenitis or pleural effusions are considered less severe.
  - Following types of bacteriologically negative cases are also considered to have severe disease: extensive pulmonary lesions, and disease of the organs which can   cause severe morbidity or mortality e.g. meningitis, miliary, spinal disease, pericardial effusion, bilateral or extensive pleural effusions, peritonitis, intestinal and   genitourinary tuberculosis.
  - Severe cases get 4 drug intensive phase compared to 3 drug for the others.

•  High protein diet, however, routine use of vitamin supplements is not required.
•  Rest, depending upon patient’s symptoms.

1. Tab. Paracetamol 500 mg 6-8 hourly till fever resolves.

1. New Cases with primary complex, isolated lymphadenitis and pleural effusion. 2HRZ + 4HR i.e., 2 months of intensive phase (IP) therapy with HRZ and 4
   months of continuation phase (CP) therapy with HR.
2. New cases:
   a. Bacteriologically positive pulmonary tuberculosis.
   b. Severe extrapulmonary or pulmonary disease (see above), irrespective of AFB status. 2(3) HRZE + 4HR* – IP extendable by 1 month for the patients who fail to convert bacteriologically or still having active disease after 2 months of initial therapy.
   *Intracranial/meningeal tuberculosis, spinal tuberculosis, tuberculous osteomyelitis may be treated for a longer period of 9 months 2HRZE + 7HR
3. Retreatment cases (relapses/defaulters/failures) 2SHRZE + 1 HRZE + 5HRE.

• Re-treatment (susceptibility testing NA) SHRZE for 3 months, followed by EHR for 5 months.
• Intolerance to H RZE for 2 months followed by RE for 7 months.
• Intolerance to R HEZ (S) for 2 months followed by HE for 16 months.
• Intolerance to Z HER for 2 months followed by HR for 7 months.
• Resistance to H and R EZ + Ofloxacin 400 mg BD or Ciprofloxacin 750 mg BD for 12-18 months.
• Resistance to all first line drugs Request drug susceptibility testing.
  - Inj. Streptomycin/Kanamycin/Capreomycin 0.75-1 g/OD (10-15 mg/kg/day) + 3 of the following four drugs:
  Tab. Ethionamide 250-500 mg BD, Cycloserine 15 mg/kg/day as BD dosage,
  Ofloxacin/Ciprofloxacin, PAS granules 4 g 8 hourly for 24 months. Treatment of relapse

• 5 first-line drug regimen as mentioned earlier.Treatment of MDR tuberculosis

• Very important to prevent MDR by avoiding monotherapy/poor compliance to treatment.
• Drugs susceptibility testing should be done. If not available, treatment regimen as above. Patients with meningitis, bone and joint tuberculosis and miliary TB should receive minimum of 12 months of treatment.Pregnant women
  Avoid Z, S. HRE for 2 months followed by HR for 7 months. Lactating women can continue to breast feed.

  Patients with renal disease

• Avoid aminoglycosides.
• Avoid E and monitor for side effects.
• Reduce doses of H, Z in cases of severe renal failure.Patient with hepatic disease
  Avoid H, R, Z.

  Silico tuberculosis
  Increase duration of treatment by at least 2 weeks.

  Patients with HIV/AIDS

• May need prolongation of treatment if response is inadequate.
• Avoid rifampicin in patients on protease inhibitors.Patients with pericardial effusion, severe pleural effusion, meningitis
  Steroid (oral/injectable) to be given along with the antitubercular therapy.

• In tubercular meningitis
  - Inj. Dexamethasone 12 mg/d for 2 weeks, gradual tapering over next 4 weeks depending upon the response.
• TB pericarditis
  - Tab. Prednisolone 40-60 mg for 2 weeks with gradual tapering over next 4 weeks.
• Pleural effusion
  - Tab. Prednisolone in same dose as above, in patients who are toxic or with large effusions.
  DOTS therapy is a part of Revised National TB Control Programme (RNTCP) – 2 RHZE+4 RH drug is administered 3 days in a week in the designated DOTS centre in the presence of the doctor.

1. The short course chemotherapy as enlisted above leads to a rapid clinical response in most patients in 2-4 weeks. Inadequate combination or dosage of this can lead to emergence of resistance and should be avoided at all cost.
2. The response to therapy should be monitored by bacteriological conversion in positive cases and by other markers like clinical and/or radiological improvement in AFB negative cases at the end of 2 months of intensive phase. A bacteriological conversion in over 80% of cases after 2 months of therapy is expected. If the patient continues to excrete bacteria after 2 months, the intensive phase needs to be extended by a month, and also ensure patient compliance, as non-adherence is the most common cause for non-response. If a patient continues to be symptomatic or bacteriologically positive after an extended phase of IP, then the patient should be extensively reevaluated and treatment failure/drug resistance should be suspected. The patient should be referred to a higher centre for further management. Remember persistence or recurrence of symptoms or radiological shadow could be due to secondary or co-infection with other organisms or due to a non tuberculous lesion. Radiologic response may lag behind bacteriologic cure and hence should not be the deciding factor for stopping of treatment. In patients with extrapulmonary tuberculosis, the response to treatment is assessed clinically.
3. All patients should have baseline LFTs and it should be monitored regularly in patients at high risk of hepatitis e.g. old patients, alcoholics, diabetics and malnourished.
4. align Monitoring and management of side effects: The suggested therapy is usually well tolerated. However, some patients can develop GI intolerance, vomiting etc. for which only symptomatic therapy is required. Commonest major side effect with suggested regime is drug induced hepatitis. The easily recognisable symptom of high coloured urine in jaundiced patient is masked due to discolouration of urine because of rifampicin. Suspect hepatitis if vomiting is persistent and associated with anorexia. Clinically, icterus may be evident. In such a situation, stop the treatment and refer to a higher center.In most patients the drugs can be reintroduced after the hepatitis has resolved. Pyrazinamide induced arthralgia or arthritis usually responds suitably to analgesic therapy. Drug rash and  hypersensitivity is a major side effect where patient needs to be referred to a higher center. Peripheral neuropathy due to INH is treated with oral vitamin B6. Ethambutol can cause optic neuritis particularly when used in high doses and requires omissionof the drug once this side effect occurs.
5. In case of hypersensitivity reaction, discontinue all drugs, re-challenge with individual drug to determine the likely offending drug. Do not reintroduce rifampicin in patients who develop thrombocytopenia.
   Hyperuricemia can occur due to pyrazinamide. Needs to be discontinued only in case of secondary gout.

• Rifampicin colors the urine as well as other body secretions red. Patient must be warned about this to avoid unnecessary alarm. The patient should also be advised to take rifampicin empty stomach and not to take any meals for about 1 hour afterwards for good absorption of the drug.
• The patient or the primary caregiver must be advised regarding the probable side effects and explained when to contact the treating doctor.
• A health functionary should preferably supervise the treatment of tuberculosis as far as possible. However, it is of utmost importance that the patient and the family is informed about the need to complete all the treatment for whole of the duration. They must be explained the need for prolonged therapy even after the sickness disappears (symptoms abate). Inadequate or incomplete treatment increases the chance of multi drug resistance which is difficult to treat.
• A survey of the family/household contacts should be done to trace the infecting open case and other diseased in the family.
• Proper sputum disposal and personal hygiene (covering the mouth while coughing) should be explained for infectious patients.
• The fears of the patient and/or the caregiver regarding the disease should be removed as this disease has a lot of social stigma.
• Ethambutol is a hygroscopic drug which tends to crumble if not properly stored, particularly during rainy season.

References

1. Tuberculosis. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc. 2001; p.1024-34.
2. Leismaniasis In.: Oxford Textbook of Medicine. Weatherall DJ Ledingham JGG, Warrell DA (eds) , 1996, Oxford University Press, pp. 638-61.
3. TB – A clinical manual for South-East Asia. WHO/ TB./96.200
4. Treatment of tuberculosis, Paediatrics Today 1999; 2(1): 77-80.

Acute Viral Hepatitis

1. Tab. Domperidone 10 mg SOS (maximum 3 times a day).
   Or
   Tab. Mosapride 5 mg SOS (maximum 3 times a day).
   Or
   If patient has severe nausea or vomiting.
   Inj. Metoclopramide 10 mg 3 times a day IM or IV.
2. IV fluids as required in case of uncontrolled nausea or vomiting.

• Repeat LFT at weekly interval.
• Patient can resume activity when the enzyme levels have come down to less than 3-5 times normal.
• In patient with HBV infection, check for disappearance of HBs Ag at 3-6 months.

Patient education

• Explain the relatives to report and hospitalize the patient if there is alteration in behaviour or sensorium of patient.
• There is no need to isolate the patient.
• Pregnant woman in contact with patient should be given normal human immunoglobulins.
• Patient should avoid taking alcohol for 4-6 months after recovery.
• Spouse of the patient with acute viral hepatitis (B), should use barrier method to prevent sexual transmission.

1. Acute Viral Hepatitis. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill, New York, pp 1721-1737.
2. Jaundice. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York pp 255-259.

Jaundice

• Increased production due to excessive haemolysis, results in unconjugated hyperbilirubinaemia (>80% unconjugated serum bilirubin), jaundice is mild (bilirubin <10 mg%) and associated with absence of bilirubin in urine (achlouric jaundice).
• Impaired conjugation in hepatocellular damage (usually results in increase in both fractions of bilirubin due to impaired conjugation and associated decreased canalicular excretion).
• Impaired excretion due to intra- or extra-hepatic cholestasis, resulting in conjugated hyperbilirubinaemia (>50% conjugated serum bilirubin), associated with absence of urobilinogen and bile salts in urine.

Common causes of jaundice in clinical practice include acute viral hepatitis, alcoholic hepatitis, chronic hepatitis/cirrhosis, gall stones and malignancy of gall bladder/pancreas or extra-hepatic biliary system.

Chronic haemolytic anaemias are less common and usually present in childhood or some time in young adults.

Approach to diagnosis of jaundice includes initial differentiation between the three types of jaundice by appropriate clinical history, examination and investigations including full blood counts, liver function tests (LFTs), viral markers, ultrasound examination of liver and biliary tract and if indicated CT scan of abdomen/ERCP.

Dizziness And Vertigo

Reassure the patient and in cases where positional vertigo cannot be ruled out, advise the patient to take complete rest with minimal movements only.

Pharmacological

Tab. Cinnarizine 25 mg three times a day till resolution of symptoms.
Or
Tab. Betahistine 8 mg three times a day.
Or
Tab. Prochlorperazine 25 mg three times a day.
The duration of drug administration depends on the disease entity as well as the persistence of symptoms.
If patient has acute, severe nausea and vomiting:
Inj. Prochlorperazine 25 mg by deep IM injection stat, may be repeated after eight hours, if required.
If there is no response to medical treatment -

• Refer to ENT specialist for Canthrone-Cooksey exercises. These are special exercises which facilitate the process of adaptation of the vestibule.
• Meniere’s disease for surgery to eliminate the offending labyrinth.

• Explain that the antivertigo drugs are likely to cause sedation

References

1. Vertigo. In: Scott Brown’s Otolaryngology, J.B. Boothy(ed), 6th Edition, Vol 3, 1997.

Anaemia

• Reduced production due to deficiency of iron, folic acid, rarely vitamin B12 or an ineffective erythropoiesis secondary to many causes (anaemia of chronic disease, secondary to infections and inflammation endocrinal disorders, primary bone marrow disorders like infiltration or hypoplasia).
• Blood loss (which also leads to iron deficiency).
• Increased destruction of RBCs (haemolysis due to many causes of which thalassemia is the commonest).

1. Treat the cause: Dietary deficiency, increased requirement as in pregnancy and children, haemolytic anaemia.
2. Tab. Folic acid 5 mg daily. This dose is adequate even in malabsorption syndromes.

1. Treat the cause: Dietary deficiency in vegetarians, pernicious anaemia. Although uncommon, it is also underdiagnosed due to lack of facilities.
2. Tab. Vitamin B12 as in haematinic tablets.
   Or
   Inj. B12 1000 mcg (in most B complex vitamins) IM one injection on alternate days for total 5 injections, then once a week for 5 weeks, then once in 3 to 6 months will be adequate for most patients.

• Educate the patient about preventive measures for worm infestation.
• Inform about importance of taking adequate food with green leafy vegetables to meet the nutritional requirement.
• Cooking food in iron utensils may increase iron content in the diet.
• Instruct the patient to take iron tablets after food; iron tablets sometimes produce stomach upset.
• Inform the patient that the stools could turn black during iron therapy.
• Reduce the dose of iron if it produces stomachache, diarrhoea or constipation.
• Explain that the response to iron if it therapy is gradual and it takes weeks or months for blood to become normal. Continue iron tablets for six months.
• Keep iron tablets out of the reach of children. They may swallow the tablets as candies causing adverse reactions including death.

1. Anaemia and Polycythaemia. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS,     Kasper DL, et al, (eds), 15th Edition, 2001, The McGraw Hill Companay Inc., pp 348-354.

Fever Of Unknown Origin (FUO)

FUO is defined as the presence of fever of 38.3º C or more recorded on several occasions, evolving for at least 3 weeks with no diagnosis reached even after one week of relevant and intelligent investigations. FUO is usually an uncommon presentation of common diseases.
Further, Durrack and Street have classified FUO into four main categories.

1. Classic FUO – corresponds to the previous definition except that instead
   of one week of investigations, it requires upto 3 outpatient visits or 3 days in the
   hospital.
2. HIV related FUO – the duration of fever is increased to 4 weeks instead of 3 weeks.
3. Nosocomial FUO – fever of >38.30 C on several occasions lasting for more than 72 hours, developing after admission in a hospitalized patient and remains undiagnosed after 3 days of investigation including 2 days incubation of cultures.
4. Neutropenic FUO – similar to the previous definition, except that it occurs in a patient who has neutrophil count of less than 500/cu.mm or expected to fall to this level in 1-2 day

• Give only one set of trial at a given time·
• The doses of drugs and period of therapeutic trial must be adequate·
• The patient must be followed closely for response.

• Self medication should be avoided.
• Antibiotics should be taken only on advise of a physician.
• Avoid covering the patient with high fever with a blanket etc.
• Plenty of fluids should be taken. Stay in a cool environment. Cold sponging of face and limbs should be done repeatedly.

1. Fever of Unknown Origin. In: An old friend revisited, 1992, Arch Intern Med, pp 152: 21.
2. Fever of Unknown Origin – re-examined and redefined. In: Current Clinical Topics in Infectious Diseases. 1991, pp 11:35-51.
3. Prolonged Undiagnosed Fever in Northern India. In: Trop Geog Med. Sharma BK, Kumari S, Verma S et al (eds), 1992, pp 44:32-6.
4. Fever of Unknown Origin in the 80s – An Update of the Diagnostic Spectrum. In: Arch Intern Med. Knockaert DC, Vanneste LJ, Vanneste SB, et al (eds), 1992, pp 152:51-55.
5. Tuberculous Mediastinal Adenopathy Presenting as Fever of Unknown Origin. In: Lancet. Sood R, Agarwal V, Mukhopadhayay S. (eds), 1997, pp 350:1782.
6. Tuberculosis as a Cause of Fever of Unknown Origin. In: Int J Infect Disease. Sood R., 1998, pp 2 (4):237.
7. Fever of Unknown Origin. In: Harrison’s Principles of Internal medicine. Braunwald E., Fauci AS, Kasper DL, et al, (eds), 15th Edition, 2001, McGraw Hill Company Inc., pp 8049.

Fever In Children

• Oral temperature is accurate provided no hot/cold drinks have been consumed in preceding 20 minutes. Axillary temperatures are least accurate and rectal thermometers are uncomfortable, especially in older children. Their use should be restricted to children < 6 months.
• Thermometer must be left in place for 2 minutes for rectal, 3 minutes for oral and 5-6 minutes for recording axillary temperature.
• Mercury thermometer is accurate and inexpensive. Digital thermometers may measure temperature within 2 seconds and are accurate but expensive. Liquid crystal strips applied to forehead for recording temperature are not accurate.

• Try to find a focus of infection by careful history and physical examination.
• Short duration fevers (less than 2 weeks) are usually due to infections. Look for any characteristic feature suggesting involvement of a particular system. Character of the fever (such as relapsing, pel ebstein, step ladder etc) may give a clue to the cause. Heat hyperpyrexia, dehydration fever, allergy to drug (drug fever), and hemolytic crisis are less common causes of short fevers.
• Long duration fevers lasting more than 2 weeks should be investigated for infections, malignancies, connective tissue disorders, autoimmune diseases and metabolic causes.
• Appropriate laboratory investigations such as total and differential leucocyte count, peripheral smear, urinalysis, serological tests, radiological investigations, and cultures of blood and body fluids are carried out as indicated by the signs and symptoms related with fever.

• Child is 3-6 months old (unless fever occurs within 48 hours after a DPT vaccination and has no other serious symptom), fever>40°C, burning/pain occurs during micturition, fever has been present for >24 hours and then returned and in case of fever present for more than 72 hours.

• Assure parents and explain that low grade fever need not be treated.
• Give more fluids.
• Dress in only one layer of light clothing.
• Place in a cool and airy environment.
• Sponging. Sponge with lukewarm water (never alcohol) in children with febrile delirium, febrile seizure, and fever > 41.1°C. Give paracetamol 30 minutes before sponging. Until paracetamol has taken effect, sponging will cause shivering, which may ultimately increase the temperature.
• Heat stroke requires immediate cold water sponging.
• The body may be massaged gently so that the cutaneous vessels dilate and body heat is dissipated.
• For children less than 3 months of age:
  Identify the low risk febrile infant as per Table I. These children can
  be managed on outpatient basis.
  Hospitalize, if appears toxic or does not fulfill the criteria in Table I.

1. Fever. In: Current Pediatric diagnosis and treatment. Hay WW, Hayward AR, Levin MJ, Sandheimer    JM (eds). 15th ed. New York, Lange Medical Books 2001; pp211-212.
2. Fevers in Childhood. In: Ghai’s Essential Pediatrics. Ghai OP, Gupta P, Paul VK (eds).New Delhi,     Interprint. 2000; pp 175-178.
3. Fever in the Young Infant. In: Evidence based Pediatrics and Child health. Eds Meyer VA, Elliott EJ,  Davis RL, Gilbert R, Klassen T, Logan S et al. London, BMJ Books 2000; pp 168-177.
4. Fever Without Focus in the Older Infant. In: Evidence based Pediatrics and Child health. Meyer VA,     Elliott EJ, Davis RL, Gilbert R, Klassen T, Logan S et al (eds),London,     BMJ Books 2000; pp 178-185.
5. Kramer MS, Shapiro ED. Management of the young febrile child. A commentary on recent practice     guidelines. Pediatrics 1997; 100: 128.

Acute Fever

The overall mean oral temperature for healthy adult individuals is 36.8 + 0.4ºC, with a nadir at 6 AM and a peak at 4-6 PM. An AM temperature of greater than 37.2ºC and a PM temperature of greater than 37.7ºC is defined as fever. Fever may be continuous, intermittent or remittent. However, with frequent self-medication with antipyretics, classic patterns are not generally seen.

Diagnosis

It is important to work towards finding the cause of fever. A meticulous history of chronology of symptoms, any associated focal symptom(s), exposure to infectious agents and occupational history may be useful. A thorough physical examination repeated on a regular basis may provide potentially diagnostic clues.

Diagnostic tests

A large range of diagnoses may possibly be the cause of fever. If the history and physical examination suggest that it is likely to be more than a simple URI or viral fever, investigations are indicated. The extent and focus of diagnostic work-up will depend upon the extent & pace of illness, diagnostic possibilities and the immune status of the host. If there are no clinical clues, the work-up should include a complete haemogram with ESR, smear for malarial parasite, blood culture, Widal test, urine analysis including urine culture. If the febrile illness is prolonged to more than 2 weeks, an x-ray chest is indicated even in the absence of respiratory symptoms. Any abnormal fluid collection should be sampled.

Treatment

Routine use of antipyretics in low-grade fever is not justified. This may mask important clinical indications. However, in acute febrile illnesses suggestive of viral or bacterial cause, fever should be treated.

Nonpharmacological

Hydrotherapy and rest.

Pharmacological

Non-Specific
Tab. Paracetamol 500-1000 mg 6-8 hourly.
Or
Tab. Ibuprofen 400-600 mg 8 hourly.
Or
Tab. Nimesulide 100 mg 12 hourly.

Specific
Antibiotics/antimalarials depending upon the cause suggested by clinical and laboratory evaluation.

Outcome
In most cases of fever, patient may either recover spontaneously or a diagnosis is reached after repeated clinical evaluation and investigations. If no diagnosis is reached in upto 3 weeks, patient is said to be having fever of unknown origin (FUO) and is managed accordingly.

Patient education

Self medication should be avoided.
Antibiotics should be taken only on advise of a physician.
Avoid covering the patient having high fever with blanket etc.
Plenty of fluids should be taken. Stay in cool environment. Cold sponging of face and limbs should be done repeatedly.

References

Alterations in Body Temperature. In: Harrison’s Principles of Internal Medicine.
Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill
Company Inc., pp 90-94.
Physiological Changes in Infected Patients. In: Oxford Textbook of Medicine.
Weatherall DJ, Ledingham JGG, Warrell DA (eds), 1996, Oxford University Press, pp 290-95.