Pleurisy

Pleurisy is an inflammation of the membrane that surrounds and protects the lungs (the pleura). Inflammation occurs when an infection or damaging agent irritates the pleural surface. Sharp chest pains are the primary symptom of pleurisy.

Pleurisy, also called pleuritis, is a condition that generally stems from an existing respiratory infection, disease, or injury. In people who have otherwise good health, respiratory infections or pneumonia are the main causes of pleurisy. This condition used to be more common, but with the advent of antibiotics and modern disease therapies, pleurisy has become less prevalent.

The pleura is a double-layered structure made up of an inner membrane, which surrounds the lungs, and an outer membrane, which lines the chest cavity. The pleural membranes are very thin, close together, and have a fluid coating in the narrow space between them. This liquid acts as a lubricant, so that when the lungs inflate and deflate during breathing, the pleural surfaces can easily glide over one another.

Pleurisy occurs when the pleural surfaces rub against one another, due to irritation and inflammation. Infection within the pleural space is the most common irritant, although the abnormal presence of air, blood, or cells can also initiate pleurisy.

These disturbances all act to displace the normal pleural fluid, which forces the membranes to rub, rather than glide, against one another. This rubbing irritates nerve endings in the outer membrane and causes pain. Pleurisy also causes a chest noise that ranges from a faint squeak to a loud creak. This characteristic sound is called a "friction rub".

Pleurisy cases are classified either as having pleural effusion or as being “dry.” Pleural effusion is more common and refers to an accumulation of fluid within the pleural space; dry pleurisy is inflammation without fluid build-up.

Less pain occurs with pleural effusion because the fluid forces the membrane surfaces apart. However, pleural effusion causes additional complications because it places pressure on the lungs. This leads to respiratory distress and possible lung collapse.

Causes and symptoms

A variety of conditions can give rise to pleurisy. The following represent the most common sources of pleural inflammation:

• infections, including pneumonia, tuberculosis, and other bacterial or viral respiratory infections
• immune disorders, including systemic lupus erythematosus, rheumatoid arthritis, and sarcoidosis
• diseases, including cancer, pancreatitis, liver cirrhosis, and heart or kidney failure
• injury, from a rib fracture, collapsed lung, esophagus rupture, blood clot, or material such as asbestos
• drug reactions, from certain drugs used to treat tuberculosis (isoniazid), cancer (methotrexate, procarbazine), or the immune disorders mentioned above (hydralazine, procainamide, phenytoin, quinidine).

The hallmark symptom of pleurisy is sudden, intense chest pain that is usually located over the area of inflammation. Although the pain can be constant, it is usually most severe when the lungs move during breathing, coughing, sneezing, or even talking. The pain is usually described as shooting or stabbing, but in minor cases it resembles a mild cramp.

When pleurisy occurs in certain locations, such as near the diaphragm, the pain may be felt in other areas such as the neck, shoulder, or abdomen (referred pain). Another indication of pleurisy is that holding one’s breath or exerting pressure against the chest causes pain relief.

Pleurisy is also characterized by certain respiratory symptoms. In response to the pain, pleurisy patients commonly have a rapid, shallow breathing pattern. Pleural effusion can also cause shortness of breath, as excess fluid makes expanding the lungs difficult. If severe breathing difficulties persist, patients may experience a blue-colored complexion (cyanosis).

Diagnosis

The distinctive pain of pleurisy is normally the first clue physicians use for diagnosis. Doctors usually feel the chest to find the site of inflammation. A stethoscope is used to listen for abnormal chest sounds (such as the friction rub) as the patient breathes. Sometimes, a friction rub is masked by the presence of pleural effusion and further examination is needed for an accurate diagnosis.

To diagnose the illness that is causing pleurisy, doctors must evaluate the patient’s history, additional symptoms, and laboratory test results. A chest x ray may also be taken to look for signs of accumulated fluid and other abnormalities. Computed tomography (CT) scan and ultrasound scans are more powerful diagnostic tools used to visualize the chest cavity.

The most helpful information in diagnosing the cause of pleurisy is a fluid analysis. Once the doctor knows the precise location of fluid accumulation, a sample is removed using a procedure called thoracentesis. In this technique, a fine needle is inserted into the chest to reach the pleural space and extract fluid.

Several laboratory tests are performed to analyze the chemical components of the fluid and determine whether bacteria or viruses are present. Pleurisy associated with rheumatoid arthritis produces a distinctive pattern of tissue cells in the pleural fluid.

Cancerous growths also shed cells into the tissue fluid. While most cases of pleurisy associated with cancer are secondary developments from a primary tumor, in some instances the pleurisy is the first indication of a malignancy.

In certain instances a biopsy of the pleura may be needed for microscopic analysis. A sample of pleural tissue can be obtained several ways: with a biopsy needle, by making a small incision in the chest wall, or by using a thoracoscope (a video-assisted instrument for viewing the pleural space and collecting samples).

Treatment

Alternative treatments can be used in conjunction with conventional treatment to help heal pleurisy. Acupuncture and botanical medicines are alternative approaches for alleviating pleural pain and breathing problems.

Herbal remedies

Poultices (crushed herbs applied directly to the skin) of respiratory herbs can assist in the healing process. An herbal remedy commonly recommended is pleurisy root (Asclepias tuberosa), so named because of its use by early American settlers who learned of this medicinal plant from Native Americans.

Pleurisy root helps to ease pain, inflammation, and breathing difficulties brought on by pleurisy. This herb is often used in conjunction with mullein (Verbascum thapsus) or elecampane (Inula helenium), which serve as expectorants to clear excess mucus from the lungs.

Other respiratory herbs that are used in the treatment of pleurisy include boneset (Eupatorium perfoliatum), catnip (Nepata cataria), and feverfew (Chrysanthemum parthenium).

Herbs thought to combat infection, such as echinacea (Echinacea species), are also included in herbal pleurisy remedies. Antiviral herbs, such as Lomatium dissectum and Ligusticum porteri, can be used if the pleurisy is of viral origin.

Chinese medicine

Traditional Chinese treatments are chosen based upon the specific symptoms of the patient. The treatment principles are to harmonize the collaterals, regulate the qi, and possibly to treat stagnation of Phlegm and Blood. Acupuncture, ear acupuncture, and herbal remedies are used to treat chest pains.

The herb ephedra (Ephedra sinica) opens air passages and alleviates respiratory difficulties in pleurisy patients. One pill of Xue Fu Zhu Yu Wan (Blood Mansion Eliminating Stasis Pill) can be taken twice daily to treat stabbing chest pain. The basic herbal formula, to which additional herbs are added for specific symptoms, is:

• Chuan Lian Zi (Fructus meliae toosendan), 10 g
• Jiang Xiang (Ligum dalbergiae odoriferae), 3 g
• Jie Geng (Radix platycodi), 5 g
• Xiang Fu (Rhizoma cyperi), 10 g
• Xuan Fu Hua (Flos inulae), 6 g
• Yan Hu Suo (Rhizoma corydalis), 10 g
• Yu Jin (Tuber curcumae), 10 g
• Zhi Ke (Fructus aurantii) 5 g

Other remedies

Other alternative remedies for pleurisy include:

• Aromatherapy. Essential oils can be effective when used as massage oils or inhaled with steaming water. Rosemary relieves pain. Peppermint relieves pain and decreases inflammation. Eucalyptus eliminates infection.
• Diet. Dietary recommendations include eating fresh fruits and vegetables, and adequate protein. The patient should ingest omega–3 fatty acids’ which are fats with anti-inflammatory activity found in salmon, mackerel, herring, and flaxseed oil.
• Homeopathy. Homeopathic treatment, chosen by a trained practitioner based on the pattern of symptoms experienced by the patient, can be effective in resolving pleurisy.
• Hydrotherapy. Contrast hydrotherapy applied to the chest and back, along with compresses (cloths soaked in an herbal solution), can assist in the healing process. • Supplements. Taking certain nutritional supplements, especially large doses of vitamin C, may also provide health benefits to persons with pleurisy.

Allopathic treatment

The pain of pleurisy is usually treated with analgesic and anti-inflammatory drugs, such as acetaminophen, ibuprofen, and indomethacin. Sometimes, a painful cough will be controlled with codeine-based cough syrups. However, as the pain eases, a person with pleurisy should try to breathe deeply and cough to clear congestion, otherwise pneumonia may occur.

The treatment used to cure pleurisy is determined by the underlying cause. Pleurisy from a bacterial infection is treated with antibiotics. Specific therapies designed for more chronic illnesses can often cause pleurisy to subside. In some cases, excess fluid must be removed by thoracentesis or a chest tube. If left untreated, a more serious infection, called empyema, may develop.

Expected results

Prompt diagnosis, followed by appropriate treatment, ensures a good recovery for most pleurisy patients. Generally speaking, the prognosis for pleurisy is linked to the seriousness of its cause.

Prevention

Preventing pleurisy is often a matter of providing early medical attention to conditions that can cause pleural inflammation. Maintaining a healthy lifestyle and avoiding exposure to harmful substances (for example, asbestos) are more general preventative measures.

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Pneumonia

Pneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infections. These include bacteria, amoebae, viruses, fungi, and parasites.

In the United States, pneumonia is the sixth most common disease leading to death; 2 million Americans develop pneumonia each year, and 40,000–70,000 die from it.

Pneumonia is also the most common fatal infection acquired by already hospitalized patients. In developing countries, pneumonia ties with diarrhea as the most common cause of death.

Even in nonfatal cases, pneumonia is a significant economic burden on the health care system. One study estimates that people in the American workforce who develop pneumonia cost employers five times as much in health care as the average worker.

According to the Centers for Disease Control and Prevention (CDC), however, the number of deaths from pneumonia in the United States has declined slightly since 2001.

Description

Anatomy of the lung

To better understand pneumonia, it is important to understand the basic anatomic features of the respiratory system. The human respiratory system begins at the nose and mouth, where air is breathed in (inspired) and out (expired). The air tube extending from the nose is called the nasopharynx.

The tube carrying air breathed in through the mouth is called the oropharynx. The nasopharynx and the oropharynx merge into the larynx. The oropharynx also carries swallowed substances, including food, water, and salivary secretion that must pass into the esophagus and then the stomach.

The larynx is protected by a trap door called the epiglottis. The epiglottis prevents substances that have been swallowed, as well as substances that have been regurgitated (thrown up), from heading down into the larynx and toward the lungs.

A useful method of picturing the respiratory system is to imagine an upside-down tree. The larynx flows into the trachea, which is the tree trunk, and thus the broadest part of the respiratory tree.

The trachea divides into two tree limbs, the right and left bronchi. Each one of these branches off into multiple smaller bronchi, which course through the tissue of the lung.

Each bronchus divides into tubes of smaller and smaller diameter, finally ending in the terminal bronchioles. The air sacs of the lung, in which oxygen-carbon dioxide exchange actually takes place, are clustered at the ends of the bronchioles like the leaves of a tree. They are called alveoli.

The tissue of the lung that serves only a supportive role for the bronchi, bronchioles, and alveoli is called the lung parenchyma.

Function of the respiratory system

The main function of the respiratory system is to provide oxygen, the most important energy source for the body’s cells. Inspired air (the air taken in when a person breathes) contains oxygen, and travels down the respiratory tree to the alveoli. The oxygen moves out of the alveoli and is sent into circulation throughout the body as part of the red blood cells.

The oxygen in the inspired air is exchanged within the alveoli for the waste product of human metabolism, carbon dioxide. The air you breathe out contains the gas called carbon dioxide. This gas leaves the alveoli during expiration. To restate this exchange of gases simply, you breathe in oxygen, you breathe out carbon dioxide

Respiratory system defenses

The healthy human lung is sterile. There are normally no resident bacteria or viruses (unlike the upper respiratory system and parts of the gastrointestinal system, where bacteria dwell even in a healthy state).

There are multiple safeguards along the path of the respiratory system. These are designed to keep serious, pathogenic organisms from invading, and leading to infection.

The first line of defense includes the hair in the nostrils, which serves as a filter for larger particles. The epiglottis is a trap door of sorts, designed to prevent food and other swallowed substances from entering the larynx and then trachea. Sneezing and coughing, both provoked by the presence of irritants within the respiratory system, help to clear such irritants from the respiratory tract.

Mucus produced by the respiratory system also serves to trap dust and infectious organisms. Tiny hairlike projections (cilia) from cells lining the respiratory tract beat constantly. They move debris trapped by mucus upwards and out of the respiratory tract. This mechanism of protection is referred to as the mucociliary escalator.

Cells lining the respiratory tract produce several types of immune substances that protect against various organisms. Other cells (called macrophages) along the respiratory tract actually ingest and kill invading organisms.

The organisms that cause pneumonia, then, are usually carefully kept from entering the lungs by virtue of these host defenses. However, when an individual encounters a large number of organisms at once, the usual defenses may be overwhelmed. Infection may happen either by inhaling contaminated air droplets, or by aspiration of organisms inhabiting the upper airways.

CONDITIONS PREDISPOSING TO PNEUMONIA. In addition to exposure to sufficient quantities of causative organisms, certain conditions may make an individual more likely to become ill with pneumonia. Certainly, the lack of normal anatomical structure could result in an increased risk of pneumonia.

For example, there are certain inherited defects of cilia which result in less effective protection. Cigarette smoke, inhaled directly by a smoker or second-hand by an innocent bystander, interferes significantly with ciliary function, as well as inhibiting macrophage function.

Stroke, seizures, alcohol, and various drugs interfere with the function of the epiglottis. A weak epiglottis leads to a leaky seal on the trap door, with possible contamination by swallowed substances and/or regurgitated stomach contents.

Alcohol and drugs also interfere with the normal cough reflex. This inteference further decreases the chance of clearing unwanted debris from the respiratory tract.

Viruses may interfere with ciliary function, allowing themselves or other microorganism invaders (such as bacteria) access to the lower respiratory tract. One of the most important viruses is HIV (Human Immunodeficiency Virus), the causative virus in AIDS (acquired immunodeficiency syndrome). In recent years this virus has resulted in a huge increase in the incidence of pneumonia.

Because AIDS results in a general decreased effectiveness of many aspects of the host’s immune system, a patient with AIDS is susceptible to all kinds of pneumonia. This includes some previously rare parasitic types that would be unable to cause illness in an individual possessing a normal immune system.

The elderly have a less effective mucociliary escalator, as well as changes in their immune system. This causes this age group to be more at risk for the development of pneumonia.

Various chronic conditions predispose a person to infection with pneumonia. These include asthma, cystic fibrosis, and neuromuscular diseases that may interfere with the seal of the epiglottis. Esophageal disorders may result in stomach contents passing upwards into the esophagus.

This increases the risk of aspiration into the lungs of those stomach contents with their resident bacteria. Diabetes, sickle cell anemia, lymphoma, leukemia, and emphysema also predispose a person to pneumonia.

Genetic factors also appear to be involved in susceptibility to pneumonia. Certain changes in DNA appear to affect some patients’ risk of developing such complications of pneumonia as septic shock.

Pneumonia is also one of the most frequent infectious complications of all types of surgery. Many drugs used during and after surgery may increase the risk of aspiration, impair the cough reflex, and cause a patient to underfill their lungs with air. Pain after surgery also discourages a patient from breathing deeply enough, and from coughing effectively.

Radiation treatment for breast cancer increases the risk of pneumonia in some patients by weakening lung tissue.

In addition, the use of mechanical ventilators to assist patients in breathing after surgery increases their risk of developing pneumonia. The mortality rate among ventilated patients who develop pneumonia is 46%.

Causes and symptoms

Causes

The list of organisms that can cause pneumonia is very large, and includes nearly every class of infectious organism: viruses, bacteria, bacteria-like organisms, fungi, and parasites (including certain worms). Different organisms are more frequently encountered by different age groups.

Further, other characteristics of an individual may place him or her at greater risk for infection by particular types of organisms:

• Viruses cause the majority of pneumonias in young children (especially respiratory syncytial virus, parainfluenza and influenza viruses, and adenovirus).
• Adults are more frequently infected with bacteria (such as Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus).
• Pneumonia in older children and young adults is often caused by the bacteria-like Mycoplasma pneumoniae (the cause of what is often referred to as "walking" pneumonia).
• Pneumocystis carinii is an extremely important cause of pneumonia in patients with immune problems, such as patients being treated for cancer with chemotherapy, or patients with AIDS. Classically considered a parasite, it appears to be more related to fungi.
• People who have reason to come into contact with bird droppings, such as poultry workers, are at risk for pneumonia caused by the organism Chlamydia psittaci.
• A very large, serious outbreak of pneumonia occurred in 1976, when many people attending an American Legion convention were infected by a previously unknown organism. Subsequently named Legionella pneumophila, it causes what is now called “Legionnaire’s Disease.” The organism was traced to air conditioning units in the convention’s hotel.

Symptoms

Pneumonia is suspected in any patient who has fever, cough, chest pain, shortness of breath, and increased respirations (number of breaths per minute). Fever with a shaking chill is even more suspicious. Many patients cough up clumps of sputum, commonly known as spit.

These secretions are produced in the alveoli during an infection or other inflammatory condition. They may appear streaked with pus or blood. Severe pneumonia results in the signs of oxygen deprivation. This includes blue appearance of the nail beds or lips (cyanosis).

The invading organism causes symptoms, in part, by provoking an overly strong immune response in the lungs. In other words, the immune system that should help fight off infections, kicks into such high gear, that it damages the lung tissue and makes it more susceptible to infection. The small blood vessels in the lungs (capillaries) become leaky, and protein-rich fluid seeps into the alveoli.

This results in less functional area for oxygencarbon dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide. The patient breathes faster and faster, in an effort to bring in more oxygen and blow off more carbon dioxide.

Mucus production is increased, and the leaky capillaries may tinge the mucus with blood. Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The alveoli fill further with fluid and debris from the large number of white blood cells being produced to fight the infection.

Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris.

Viral pneumonias and mycoplasma pneumonias do not result in consolidation. These types of pneumonia primarily infect the walls of the alveoli and the parenchyma of the lung.

Severe acute respiratory syndrome (SARS)

Severe acute respiratory syndrome, or SARS, is a contagious and potentially fatal disease that first appeared in the form of a multi-country outbreak in early February 2003.

Later that month, the CDC began to work with the World Health Organization (WHO) to investigate the cause(s) of SARS and to develop guidelines for infection control. SARS has been described as an “atypical pneumonia of unknown etiology;” by the end of March 2003, the disease agent was identified as a previously unknown coronavirus.

The early symptoms of SARS include a high fever with chills, headache, muscle cramps, and weakness. This early phase is followed by respiratory symptoms, usually a dry cough and painful or difficult breathing. Some patients require mechanical ventilation. The mortality rate of SARS is thought to be about 3%.

As of the end of March 2003, the CDC did not have clearly defined recommendations for treating SARS. Treatments that have been used include antibiotics known to be effective against bacterial pneumonia; ribavirin and other antiviral drugs; and steroids.

Diagnosis

For the most part, diagnosis is based on the patient’s report of symptoms, combined with examination of the chest. Listening with a stethoscope will reveal abnormal sounds, and tapping on the patient’s back (which should yield a resonant sound due to air filling the alveoli) may instead yield a dull thump if the alveoli are filled with fluid and debris.

Laboratory diagnosis can be made of some bacterial pneumonias by staining sputum with special chemicals and looking at it under a microscope. Identification of the specific type of bacteria may require culturing the sputum (using the sputum sample to grow greater numbers of the bacteria in a lab dish).

X-ray examination of the chest may reveal certain abnormal changes associated with pneumonia. Localized shadows obscuring areas of the lung may indicate a bacterial pneumonia, while streaky or patchy appearing changes in the x-ray picture may indicate viral or mycoplasma pneumonia. These changes on x ray, however, are known to lag in time behind the patient’s actual symptoms.

Treatment

Pneumonia is a potentially serious condition that requires prompt medical attention. Patients should contact their doctors for immediate diagnosis and treatment. Alternative treatment such as nutritional support, however, can help alleviate some of the symptoms associated with pneumonia and boost the body’s immune function.

Diet and nutrition

The following nutritional changes are recommended:

• Avoid all potentially allergenic foods, and determine allergenic foods with an elimination diet.
• Reduce intake of sugar and processed foods.
• Give yourself plenty of rest.
• Get plenty of fluids to prevent dehydration and help loosen phlegm.
• Nutritional supplements such as vitamin C, bioflavonoids, vitamin A, beta-carotene, and zinc may help.

Herbal treatment

Over-the-counter herbal preparations such as glycerol guaiacolate can help clear the lungs of phlegm and speed up the recovery process. Antimicrobial herbs, such as goldenseal (Hydrastis canadenis) and Chinese herbs, which stimulate the immune system, may be taken for treatment.

Other treatment

Other treatments, such as yoga, help with breathing, movement, and relaxation. Also recommended is meditation and the use of guided imagery. Contact local practitioners to enroll in such therapies.

Allopathic treatment

Prior to the discovery of penicillin antibiotics, bacterial pneumonia was almost always fatal. Today, antibiotics, especially given early in the course of the disease, are very effective against bacterial causes of pneumonia.

Erythromycin and tetracycline improve recovery time for symptoms of mycoplasma pneumonia. They do not, however, eradicate the organisms. Amantadine and acyclovir may be helpful against certain viral pneumonias.

A newer antibiotic named linezolid (Zyvox) is being used to treat penicillin-resistant organisms that cause pneumonia. Linezolid is the first of a new line of antibiotics known as oxazolidinones. Another new drug known as ertapenem (Invanz) is reported to be effective in treating bacterial pneumonia.

Expected results

Rate of recovery varies according to the type of organism causing the infection. Recovery following pneumonia with Mycoplasma pneumoniae is nearly 100%. Staphylococcus pneumoniae has a death rate of 30–40%.

Similarly, infections with a number of gram negative bacteria (such as those in the gastrointestinal tract which can cause infection following aspiration) have a high death rate of 25–50%.

Streptococcus pneumoniae, the most common organism causing pneumonia, produces a death rate of about 5%. More complications occur invery young or very old individuals who have multiple areas of the lung infected simultaneously.

Individuals with other chronic illnesses (including cirrhosis of the liver, congestive heart failure, individuals without a functioning spleen, and individuals who have other diseases that result in a weakened immune system) experience complications. Patients with immune disorders, various types of cancer, transplant patients, and AIDS patients also experience complications.

Prevention

Because many bacterial pneumonias occur in patients who are first infected with the influenza virus, yearly vaccination against influenza can decrease the risk of pneumonia for the elderly and people with chronic diseases such as asthma, cystic fibrosis, diabetes, kidney disease and cancer.

Maintaining a healthy diet that includes whole foods and vitamin C and B-complex vitamins will aid in prevention. Also helpful in terms of both good health and prevention of pneumonia is developing a regular exercise regimen, as well as reducing stress.

A specific vaccine against Streptococcus pneumoniae is very protective, and should also be administered to patients with chronic illnesses.

Patients who have decreased immune resistance are at higher risk for infection with Pneumocystis carinii. They are frequently put on a regular drug regimen of Trimethoprim sulfa and/or inhaled pentamidine to avoid Pneumocystis pneumonia.

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Rhinitis

Rhinitis is inflammation of the mucous lining of the nose.

Rhinitis is a nonspecific term that covers nasal congestion due to infections, allergies, and other disorders. In rhinitis, the mucous membranes of the nose become infected or irritated, producing a discharge, congestion, and swelling of the tissues.

The most widespread form of infectious rhinitis is the common cold. The common cold is the most frequent viral infection in the general population. Colds are self-limited, lasting about three to 10 days, although they are sometimes followed by a bacterial infection.

Causes and symptoms

Colds can be caused by as many as 200 different viruses which are transmitted by sneezing and coughing, by contact with soiled tissues or handkerchiefs, or by close contact with an infected person.

The onset of a cold is usually sudden. The virus causes the lining of the nose to become inflamed and produce large quantities of thin, watery mucus. The inflammation spreads from the nasal passages to the throat and upper airway, producing a dry cough, headache, and watery eyes.

After several days, the nasal tissues become less inflamed and the watery discharge is replaced by a thick, sticky mucus. This change in the appearance of the nasal discharge helps to distinguish rhinitis caused by a viral infection from allergic rhinitis.

Allergies are another frequent cause of rhinitis which is called allergic rhinitis. Allergies occur when a person’s immune system overreacts to a substance called an allergen. Airborne allergens can be just about anything but are commonly mold, pollen, dust mites, and pet dander. Symptoms of allergy include watery eyes, nasal discharge, sneezing, and headache.


Diagnosis

Viral rhinitis is diagnosed based on symptoms. Symptoms that last longer than a week may require further testing to rule out a secondary bacterial infection, or an allergy. Allergies can be evaluated by blood tests, skin testing for specific substances, or nasal smears.

Treatment

The many alternative treatments for colds and allergies will not be addressed here. Treatments specifically for rhinitis, regardless of the cause, are described.

Herbal remedies

Flavonoids have anti-inflammatory activities and can be found in many plants including licorice, parsley, legumes (beans), onions, garlic, berries, and citrus fruits.

Herbals which may help lessen the symptoms of rhinitis include:

• astragalus (Astragalus membranaceous) root
• baical skullcap (Scutellaria baicalensis) decoction
• echinacea (Echinacea spp.)
• elderflower (Sambucus nigra) tea
• garlic, which contains anti-inflammatory compounds
• goldenseal (Hydrastis canadensis)
• horehound (Marrubium vulgare) tea relieves congestion
• licorice (Glycyrrhiza glabra) has anti- inflammatory activity
• mullein (Verbascum thapsus) is a decongestant and soothes mucous membranes
• nettle (Urtica dioica) tea stops nasal discharge
• onion, which contains anti-inflammatory compounds
• thyme (Thymus vulgaris) tea, which is anti- inflammatory and soothes sore nasal tissues
• walnut (Juglans nigra or regia) leaf tea, which stops nasal discharge

Other remedies

Other natural remedies for rhinitis include those from traditional Chinese medicine. Chronic rhinitis is treated with acupuncture, ear acupuncture, and herbals taken internally or used externally.

The most common rhinitis remedy is Bi Yan Pian (Bi is for nose.) There are many others, depending on the specific pattern of the patient. Magnolia flower and xanthium are commonly used herbs for rhinitis.

Less common Chinese remedies include Huo Dan Wan (Agastache and Pig’s Gall Bladder Pill) taken three times daily. A decoction of Yu Xing Cao (Herba houttuyniae) may be taken internally.

The patient can apply 30% Huang Lian Shui (Coptis Fluid), Huang Bai Shui (Phellodendron Fluid), Yu Xing Cao (Herba houttuyniae) juice, E Bu Shi Cao (Herba centipedae) decoction, or 1% ephedrine solution directly to the nose.

Colored light therapy is based upon the theory that an unhealthy body is lacking a specific color frequency. Green colored light therapy may relieve chronic rhinitis.

Homeopathic physicians prescribe any of 10 different remedies, depending on the appearance of the nasal discharge, the patient’s emotional state, and the stage of infection.

Vitamin C is a natural antihistamine. Vitamin A and zinc may also be helpful.

Allopathic treatment

There is no cure for the common cold; treatment is given for symptom relief. Medications include aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for headache and muscle pain, and decongestants to relieve stuffiness or runny nose. Antibiotics are ineffective against viral infections. Allergies are treated with antihistamines (Benadryl).

Expected results

Most colds resolve completely in about a week. Complications are unusual but may include sinusitis (inflammation of the nasal sinuses), bacterial infections, or infections of the middle ear. Allergies may resolve or may be lifelong.

Prevention

There is no vaccine effective against colds, and infection does not prevent one from getting colds. Prevention depends on washing hands often, minimizing contact with persons already infected, and not sharing hand towels, eating utensils, or water glasses.

In 2002, researchers discovered a new antiseptic skin cleanser that may prevent hand-to-hand transmission of the rhinovirus that causes colds. The cleaner’s active ingredient is salicylic or pyroglutamic acid, and each showed promising results for killing the virus on subject’s hands.

Allergies may be prevented by avoiding the cause of the allergy, although this is not always possible or practical. Patients may become desensitized to the offending allergen by receiving a series of injections.

In 2002, Australian researchers discovered a new potential vaccine that might boost immune response to allergens without the risk of side effects that come with some desensitizing vaccines available today.

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Tuberculosis

Tuberculosis (TB) is a contagious and potentially fatal disease that can affect almost any part of the body but manifests mainly as an infection of the lungs. It is caused by a bacterial microorganism, the tubercle bacillus or Mycobacterium tuberculosis. TB infection can either be acute and short-lived or chronic and long-term.

Although TB can be prevented, treated, and cured with proper treatment and medications, scientists have never been able to eliminate it entirely. The organism that causes tuberculosis, popularly known as consumption, was discovered in 1882.

Because antibiotics were unknown, the only means of controlling the spread of infection was to isolate patients in private sanatoria or hospitals limited to patients with TB—a practice that continues to this day in many countries. TB spread very quickly and was a leading cause of death in Europe.

At the turn of the twentieth century more than 80% of the people in the United States were infected before age 20, and tuberculosis was the single most common cause of death. Streptomycin was developed in the early 1940s and was the first antibiotic effective against the disease.

The number of cases declined until the mid- to late-1980s, when overcrowding, homelessness, immigration, decline in public health inspections, decline in funding, and the AIDS epidemic caused a slight resurgence of the disease. The increase in TB in the United States peaked in 1992, and new cases reported in the United States continue to decrease as of 2004.

Yet the number of cases in foreign-born individuals is rising, and the number of deaths from TB has been rising, making TB a leading cause of death from infection throughout the world. It is estimated that in the next 10 years 90 million new cases of TB will be reported, with the result of 30 million deaths, or about 3 million deaths per year.

Several demographic groups are at a higher risk of contracting tuberculosis. Tuberculosis is more common in elderly persons. More than one-fourth of the nearly 23,000 cases of TB in the United States in 1995 were reported in people above age 65. TB also is more common in populations where people live under conditions that promote infection, such as homelessness and injection drug use.

In the late 1990s, two-thirds of all cases of TB in the United States affected African Americans, Hispanics, Asians, and persons from the Pacific Islands. Finally, the high risk of TB includes people who have a depressed immune system.

High-risk groups include alcoholics, people suffering from malnutrition, diabetics, and AIDS patients — and those infected by human immunodeficiency virus (HIV) — who have not yet developed clinical signs of AIDS. TB is the number one killer of women of childbearing age worldwide. In poor countries, women with TB often don’t know they have the disease until symptoms become severe.

As of late 2002, TB is a major health problem in certain immigrant communities, such as the Vietnamese in southern California. One team of public health experts in North Carolina maintains that treatment for tuberculosis is the most pressing healthcare need of recent immigrants to the United States.

In some cases, the vulnerability of immigrants to tuberculosis is increased by occupational exposure, as a recent outbreak of TB among Mexican poultry farm workers in Delaware indicates. Other public health experts are recommending tuberculosis screening at the primary care level for all new immigrants and refugees.

Causes and symptoms

Transmission

Tuberculosis spreads by droplet infection, in which a person breathes in the bacilli released into the air when a TB patient exhales, coughs, or sneezes.

However, TB is not considered highly contagious compared to other infectious diseases. Only about one in three people who have close contact with a TB patient, and fewer than 15% of more remote contacts, are likely to become infected.

Unlike many other infections, TB is not passed on by contact with a patient’s clothing, bed linens, or dishes and cooking utensils. Yet if a woman is pregnant, her fetus may contract TB through blood or by inhaling or swallowing the bacilli present in the amniotic fluid.

Once inhaled, water in the droplets evaporates and the tubercle bacilli may reach the small breathing sacs in the lungs (the alveoli), then spread through the lymph vessels to nearby lymph nodes. Sometimes the bacilli move through blood vessels to distant organs.

At this point they may either remain alive but inactive (quiescent), or they may cause active disease. The likelihood of acquiring the disease increases with the concentration of bacilli in the air, and the seriousness of the disease is determined by the number of bacteria with which a patient is infected.

Ninety percent of patients who harbor M. tuberculosis do not develop symptoms or physical evidence of the disease, and their x rays remain negative. They are not contagious; however, these individuals may get sick at a later date and then pass on TB to others.

Though it is impossible to predict whether a person’s disease will become active, researchers surmise that more than 90% of cases of active tuberculosis come from this pool of people. An estimated 5% of infected persons get sick within 12-24 months of being infected.

Another 5% heal initially but, after years or decades, develop active tuberculosis. This form of the disease is called reactivation TB, or post-primary disease. On rare occasions a previously infected person gets sick again after a second exposure to the tubercle bacillus.

Pulmonary tuberculosis

Pulmonary tuberculosis is TB that affects the lungs, and represents about 85% of new cases diagnosed. It usually presents with a cough, which may or may not produce sputum. In time, more sputum is produced that is streaked with blood.

The cough may be present for weeks or months and may be accompanied by chest pain and shortness of breath. Persons with pulmonary TB often run a low-grade fever and suffer from night-sweats. The patient often loses interest in food and may lose weight.

If the infection allows air to escape from the lungs into the chest cavity (pneumothorax) or if fluid collects in the pleural space (pleural effusion), the patient may have difficulty breathing. The TB bacilli may travel from the lungs to lymph nodes in the sides and back of the neck. Infection in these areas can break through the skin and discharge pus.

Extrapulmonary tuberculosis

Although the lungs are the major site of damage caused by tuberculosis, many other organs and tissues in the body may be affected. About 15% of newly diagnosed cases of TB are extrapulmonary, with a higher proportion of these being HIV-infected persons. The usual progression of the disease is to begin in the lungs and spread to locations outside the lungs (extrapulmonary sites).

In some cases, however, the first sign of disease appears outside the lungs. The many tissues or organs that tuberculosis may affect include:

• Bones. TB is particularly likely to attack the spine and the ends of the long bones.
• Kidneys. Along with the bones, the kidneys are probably the most common site of extrapulmonary TB. There may, however, be few symptoms even though part of a kidney is destroyed.
• Female reproductive organs. The ovaries in women may be infected; TB can spread from them to the peritoneum, which is the membrane lining the abdominal cavity.
• Abdominal cavity. Tuberculous peritonitis may cause pain ranging from the mild discomfort of stomach cramps to intense pain that may mimic the symptoms of appendicitis.
• Joints. Tubercular infection of joints causes a form of arthritis that most often affects the hips and knees.
• Meninges. The meninges are tissues that cover the brain and the spinal cord. Infection of the meninges by the TB bacillus causes tuberculous meningitis, a condition that is most common in young children and the elderly. It is extremely dangerous. Patients develop headaches, become drowsy, and eventually comatose. Permanent brain damage can result without prompt treatment.
• Skin, intestines, adrenal glands, and blood vessels. All these parts of the body can be infected by M. tuberculosis. Infection of the wall of the body’s main artery (the aorta), can cause it to rupture with catastrophic results. Tuberculous pericarditis occurs when the membrane surrounding the heart (the pericardium) is infected and fills up with fluid that interferes with the heart’s ability to pump blood.
• Miliary tuberculosis. Miliary TB is a life-threatening condition that occurs when large numbers of tubercle bacilli spread throughout the body. Huge numbers of tiny tubercular lesions develop that cause marked weakness and weight loss, severe anemia, and gradual wasting of the body.

Diagnosis

TB is diagnosed through laboratory test results. The standard test for tuberculosis infection, the tuberculin skin test, detects the presence of infection, not of active TB. Skin testing has been done for more than 100 years. In this process, tuberculin is an extract prepared from cultures of M. tuberculosis.

It contains substances belonging to the bacillus (antigens) to which an infected person has been sensitized. When tuberculin is injected into the skin of an infected person, the area around the injection becomes hard, swollen, and red within one to three days.

Today skin tests utilize a substance called purified protein derivative (PPD) that has a standard chemical composition and is therefore a good measure of the presence of tubercular infection.

The PPD test, also called the Mantoux test, is not always 100% accurate; it can produce false positive as well as false negative results. The test may indicate that some people who have a skin reaction are not infected (false positive) and that some who do not react are in fact infected (false negative).

The PPD test is, however, useful as a screener and can be used on people who have had a suspicious chest x ray, on those who have had close contact with a TB patient, and persons who come from a country where TB is common.

Because of the multiple and varied symptoms of TB, diagnosis on the basis of external symptoms is not always possible. TB is often discovered by an abnormal chest x ray or other test result rather than by a claim of physical discomfort by the patient. After an irregular x ray, a PPD test is always done to show whether the patient has been infected.

To verify the test results, the physician obtains a sample of sputum or a tissue sample (biopsy) for culture. In cases where other areas of the body might be infected, such as the kidney or the brain, body fluids other than sputum (urine or spinal fluid, for example) can be used for culture.

One important new advance in the diagnosis of TB is the use of molecular techniques to speed the diagnostic process as well as improve its accuracy. As of late 2002, four molecular techniques are increasingly used in laboratories around the world.

They include polymerase chain reaction to detect mycobacterial DNA in patient specimens; nucleic acid probes to identify mycobacteria in culture; restriction fragment length polymorphism analysis to compare different strains of TB for epidemiological studies; and genetic-based susceptibility testing to identify drug-resistant strains of mycobacteria.

Treatment

Because of the nature of tuberculosis, the disease should never be treated by alternative methods alone. Alternative treatments can help support healing, but treatment of TB must include drugs and will require the care of a physician. Any alternative treatments should be discussed with a medical practitioner before they are applied.

Supportive treatments include:

• Diet. Nutritionists recommend a whole food diet including raw foods, fluids, and particularly pears and pear products (pear juice, pear sauce), since pears may help heal the lungs. Other helpful foods include fenugreek, alfalfa sprouts, garlic, pomegranate, and yogurt or kefir. Four tablespoons of pureed steamed asparagus at breakfast and dinner taken for a few months may also be helpful.
• Nutritional therapy. Nutritionists may recommend one or many of the following vitamins and minerals: vitamin A at 300,000 IU for the first three days, 200,000 IU for the next two days, then 50,000 IU for several weeks; beta-carotene at 25,000-50,000 IU; vitamin E at up to 1,000 IU daily unless the patient is a premenopausal woman with premenstrual symptoms; lipotrophic formula (one daily); deglycerolized licorice; citrus seed extract; vitamin C; lung glandular; essential fatty acids; vitamin B complex; multiminerals; and zinc.
• Herb therapy may use the tinctures of echinacea, elecampane, and mullein taken three times per day, along with three garlic capsules three times per day.
• Hydrotherapy may be used up to five times weekly. Dr. Benedict Lust, the founder of naturopathy, supposedly cured himself of tuberculosis by using hydrotherapy.
• Juice therapy. Raw potato juice, may be taken three times daily with equal parts of carrot juice plus one teaspoon of olive or almond oil, one teaspoon of honey, beaten until it foams. Before using the potato juice, starch should be allowed to settle from the juice.
• Topical treatment may use eucalyptus oil packs, grape packs or grain alcohol packs.

Professional practitioners may also treat tuberculosis using cell therapy, magnetic field therapy, or traditional Chinese medicine. Fasting may be undertaken, but only with a doctor’s supervision.

Allopathic treatment

Drug therapy

Five drugs are most commonly used today to treat tuberculosis: isoniazid (INH), rifampin, pyrazinamide, streptomycin, and ethambutol. Of the five medications, INH is the most frequently used drug for both treatment and prevention. The first three drugs may be given in the same capsule to minimize and treat active TB the number of pills in the dosage.

As of 1998, many patients are given INH and rifampin together for six months, with pyrazinamide added for the first two months. Hospitalization is rarely necessary because many patients are no longer infectious after about two weeks of combination treatment. A physician must monitor side effects and conduct monthly sputum tests.

In 2002, the Centers for Disease Control (CDC) worked with medical organizations to release new guidelines that better individualize the drug regimens received by TB patients depending on their disease symptoms and severity. Many can now receive once-weekly doses of rifapentine in the continuation phase of treatment.

The first large scale trial of a new agent to treat TB began in 2002. The promising new drug, called moxifloxacin, may mean a shorter treatment course for TB sufferers in the near future.

It will also be tested in combination with rifapentine, and researchers believe that using the drugs together will mean a less frequent dosing schedule for patients.

Drug resistance has become a problem in treating TB. When patients do not take medication properly or for long enough periods of time, the TB organisms may become drug resistant. This makes the patient vulnerable to further infection and allows the TB organism to develop resistance.

Surgery

Surgical treatment of TB may be used if medications are ineffective. There are three surgical treatments for pulmonary TB: pneumothorax, in which air is introduced into the chest to collapse the lung; thoracoplasty, in which one or more ribs are removed; and removal of a diseased lung, in whole or in part. It is possible for patients to survive with one healthy lung.

Expected results

The prognosis for recovery from TB is good for most patients, if the disease is diagnosed early and given prompt treatment with appropriate medications on a long-term regimen.

According to a 2002 Johns Hopkins study, most patients in the United States who die of TB are older—average age 62— and suffer from such underlying diseases as diabetes and kidney failure.

Modern surgical methods are usually effective when necessary. Miliary tuberculosis is still fatal in many cases but is rarely seen today in developed countries.

Even in cases in which the bacillus proves resistant to all of the commonly used medications, other seldom-used drugs may be tried because the tubercle bacilli have not yet developed resistance to them.

Prevention

Vaccination is widely used as a prevention measure for TB. A vaccine called BCG (Bacillus Calmette-Guérin, named after its French developers) is made from a weakened mycobacterium that infects cattle.

Vaccination with BCG does not prevent infection, but it does strengthen the immune system of first-time TB patients. As a result, serious complications are less likely to develop. BCG is used more widely in developing countries than in the United States.

Though the vaccine has been proven beneficial and fairly safe, its use is still controversial. It is not clear whether the vaccine’s effectiveness depends on the population in which it is used or on variations in its formulation. Recently, efforts have been focused on developing a new vaccine.

Generally, prevention focuses on the prevention of transmission, skin-testing high-risk persons and providing preventive drug therapy to people at risk.

Measures such as avoidance of overcrowded and unsanitary conditions are necessary aspects of prevention. Hospital emergency rooms and similar locations can be treated with ultraviolet light, which has an antibacterial effect.

INH is also given to prevent TB, and decreases the incidence of TB by about 60% over the life of the patient. INH is effective when taken daily for 6 to 12 months by people in high-risk categories who are under 35 years of age.

About 1% of patients in preventive treatment develop toxicity. Because INH carries the risk of side effects (liver inflammation, nerve damage, changes in mood and behavior), it is important for its use to be monitored and to give it only to persons at special risk.

Unfortunately, failure of TB patients to complete the full course of their drugs adds to TB incidence and encourages development of drug-resistant strains of the disease.

As scientists try to develop drugs that require shorter courses, physicians must work with patients to encourage compliance with their treatments. Even if symptoms go away, patients often have to continue their drug treatment for six months to be sure to stop the spread of their TB infection to others.

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