Infections

Infections

An infection is a condition in which viruses, bacteria, fungi, or parasites enter the body and cause a state of disease. Such invaders are called pathogens. They damage cells of the body by adhering to and damaging the cell walls, releasing toxic substances or causing allergic reactions.

The body has a set series of responses to infection, which mostly involve body chemicals, body tissues, and the immune system. It was recently reported that infection is the fourth leading cause of death in the United States and kills more people than cancer and heart disease combined.

Pathogens are everywhere in a person’s daily environment: They may enter the body through breathing, ingested food or water, sexual contact, open wounds, or contact with contaminated objects. Having entered the body, pathogens begin to reproduce.

Most pathogens are kept in check before they have a chance to multiply. If, however, the body is unable to keep the pathogens in balance, serious disease and even death may occur. Chronic infections may develop if the body has only limited control over a given pathogen.

In that case, the infection will have a tendency to flare up in response to stress and weakness. Sepsis is a serious condition in which pathogens spread and circulate throughout the body via the bloodstream. This type of infection affects the entire body.

The body has many natural barriers to infection. For example, the harmless bacteria normally found on the skin, known as commensals, inhibit the growth of many pathogens. Sweat and oil gland secretions also protect the skin; and the skin itself offers a significant physical barrier that no bacteria are able to penetrate.

Damage to the skin from burns, insect bites, surgery, or injuries may leave the skin open to infection. In addition to the physical barrier of the skin, many of the body’s secretions such as tears, sweat, urine, and saliva contain chemicals that destroy pathogens.

The mucous membranes that line the passageways of the body secrete mucus, which contains enzymes and chemicals that kill or disable pathogens. The pathogens are then trapped in the mucus and filtered out or swallowed. Commensal bacteria also live on the mucous membranes; there they inhibit the spread and multiplication of pathogens just as they do on the skin.

The digestive tract contains stomach acid, pancreatic enzymes, and other secretions that protect against infection. Peristalsis and the shedding of the lining of the intestinal tract also help to remove pathogens. The acid pH of the stomach and vagina is protective, as well as the length of the urethra in males. The flushing action of urine and feces as they are excreted also protect against infection.

A fever is defined as the elevation of the body temperature to at least 100°F (37.8°C). Fevers are a helpful part of the body’s response to an infection, since most pathogens do not thrive at higher temperatures while the immune system’s white blood cells (WBCs) work best in a warm environment. If the fever reaches levels of 102°F (38.9°C) or higher, it may have to be brought down to avoid seizures, dehydration, and tissue damage.

The second level of the body’s defenses is the immune system. The white blood cells are a major part of this system. In response to the invasion of pathogens, WBCs are released from the bone marrow into the bloodstream.

The main function of these WBCs, depending on their type, is to engulf pathogens and render them harmless, detoxify poisons, produce and release antibodies and chemicals, and clean up wastes left by other WBCs. The spleen, thymus, lymph system, and liver all have roles in the immune response. Successful removal of pathogens from the body often gives immunity against infection by that pathogen in the future.

Pathogens can be persistent. They may secrete enzymes, destroying tissues in the body to spread the infection more quickly and effectively. They may secrete chemicals that counteract the actions of the WBCs. Some pathogens release toxins that kill the surrounding cells. Many also have methods to evade being engulfed and destroyed.

In addition, the body’s own commensal bacteria may become pathogenic if something upsets their balanced state in the body. This loss of balance may often result from chronic illness, low stomach acid, recurrent use of antibiotics, cross-contamination through medical or sexual exploration, or a compromised immune system.

Causes and symptoms

Infections are caused by pathogens invading the tissues of the body and beginning to multiply. Headaches, muscle aches, fever, chills, and fatigue are common symptoms of infections. Many of these symptoms are due to inflammation and the response of the immune system to the pathogens.

For example, during an infection, the blood supply is increased to the affected areas; as the blood rushes to the site of infection, it causes the skin to redden. The blood vessels also become more readily able to release WBCs into the tissues; when the WBCs die and decay they form a thick fluid known as pus. Enzymes released by the WBCs may also be responsible for pain and swelling.

More specific symptoms of infection vary according to the site and type of the infection. Some of these symptoms include:

• Gastrointestinal system: Diarrhea, vomiting, nausea, stomachaches, cramps, gas pains, and dehydration.
• Respiratory system: Coughing, sneezing, sore throat, congestion, fever, bronchitis, and runny nose.
• Urinary system: Increased frequency and urgency of urination; pain on urination; blood, pus, or other discharge in the urine; bad-smelling urine or discharge; and vaginal itching.
• Skin: Rashes, sores, itching, and blisters; redness, swelling, tenderness, and pain.
• Joints: Local pain, stiffness, redness, and swelling.

Risk factors for infections include chronic disease; severe emotional stress; broken skin; changes in the pH of various body fluids; malnutrition; surgery; rupture of amniotic membranes; invasive medical or dental procedures; tissue injuries or destruction; decreased flow of body fluids; changes in peristalsis; decreased output of stomach acid; recurrent use of antibiotics; and suppressed immune function.

Many infections have a high probability of being passed from person to person. This is especially true of respiratory diseases, which can be transmitted through contact with the sputum and droplets produced by coughing or sneezing. Contact with infected waste products, open sores, skin eruptions, infected clothing and bedclothes, and sexual contact are circumstances which often lead to the further spread of infections.

New concerns about infections continue to baffle researchers and clinicians into the twenty-first century. First, the world faces the threat of infection from bioterrorism, and Americans faced a scare from deliberate distribution of anthrax spores through the United States postal system following the September 11, 2001, terrorist attack.

The year 1999 saw the first reports of the West Nile virus in the United States, and reported cases of the disease began spreading after that date. Further, clinicians worry about widespread antibiotic resistance, as individuals and the public at large become exposed to more antibiotics for longer periods of time.

Diagnosis

Many infections are minor and self-limiting. Some infections, however, are serious; some can even lead to permanent impairment or death. If an infection does not clear up within a few days, or if it gets worse, a healthcare provider should be consulted. Infections are initially diagnosed by the patient’s presentation and by a history of the illness or injury and the symptoms.

A complete blood count (CBC) is a simple clinical test that can be used to diagnose an infection. Increases in the total WBC count usually indicate a bacterial infection; decreases tend to indicate a viral infection or a very severe infection, both of which may cause the destruction of WBCs faster than they can be produced.

Increases in specific types of white blood cells known as neutrophils, lymphocytes, and monocytes also point to an infection. An increase in eosinophils may be due to a parasitic infection. A blood chemistry panel may be taken to determine whether there are chemical changes that may have been brought on by an infection.

A serious illness may require further evaluation and diagnostic tests. Additional laboratory tests can be performed using blood, feces, or samples of the infected tissue. Ultrasound, computed tomography (CT) scans, and magnetic resonance imaging (MRI) may also be used. In some cases, a tissue sample (biopsy) is taken from the affected site for microbial culture tests and microscopic examination.

Treatment

Herbal therapy

Echinacea spp. enhances the action of the immune system. It can be taken for up to six weeks to prevent or heal infections. Goldenseal (Hydrastis canadensis) has strong antibiotic qualities. Garlic (Allium sativum) is also antibiotic.

Licorice (Glycyrrhiza glabra) has significant antiviral activity. It reduces the bad effects of stress on the health, and has been used to treat herpes, staphylococcal and streptococcal infections, typhus, cholera, pneumonia, and infections caused by Candida albicans.

Astragalus membranaceus is a Chinese herb that may be used to enhance the immune system as well as to prevent the recurrence of chronic infections. Pau d’arco (Tabebuia impetiginosa) is recommended for internal fungal infections, while the topical use of tea tree oil (Melaleuca alternfolia) is recommended for some external infections.

Dietary modifications

A healthful balanced diet and lifestyle are important supports of the immune function. Reishi (Ganoderma lucidum), shiitake (Lentinus edodes), and maitake (Grifola frondosa) mushrooms are renowned for their ability to strengthen the immune system and their antimicrobial properties. Regular supplementation with vitamin C, vitamin A or beta-carotene, zinc, and bioflavonoids is also recommended to boost the immune response.

Sugary foods, including honey, may depress the immune system. Very high levels of fat in the diet may also interfere. Alcohol decreases the functioning of the immune system. All of these substances should be avoided during the course of an infection.

Food allergies should be considered, especially in the case of chronic colds, throat infections, and ear infections. Once allergens have been identified, they should be avoided. Patients should increase their intake of fluids, including soups, teas, diluted fruit and vegetable juices, and pure water.

Aromatherapy

Aromatherapy may be a useful supportive measure in infectious conditions. An essential oil of cedarwood (Cedrus atlantica) is recommended in fungal infections; essential oils of tea tree (Melaleuca alternifolia) and patchouli are also recommended. It should be remembered, however, that essential oils are very concentrated, toxic to the liver and kidneys, and should be used only in very small doses (drops).

Acupuncture

Acupuncture is helpful in stimulating the immune system. It reduces the effects of stress, improves circulation, and increases the production of RBCs and WBCs. It has been used for thousands of years to treat infectious diseases.

Hydrotherapy

Constitutional hydrotherapy is the use of applications of hot water alternated with cold. It is effective in respiratory infections and in stimulating the immune system. For proper administration of hydrotherapy, a naturopath or other healthcare provider familiar with its techniques should be consulted.

Allopathic treatment

Minor infections are often relieved by over-the-counter medications. A high fever or joint pain may be a sign of an infection spreading throughout the body. A physician should be contacted. Infections from bites and puncture wounds should also receive medical attention and possibly a tetanus injection.

Serious infections may be treated with antibiotics. Antibiotics are effective against many parasitic and fungal infections as well as bacteria. Antibiotics may also be given during a viral infection even though they have no effect on viruses.

This measure is taken to prevent bacterial infections, which may occur due to the weakened state brought on by the virus. In the case of viral infections, antiviral drugs are used to reduce symptoms. Their usefulness, however, is limited because viruses quickly mutate and develop resistance to them.

Antifungal drugs are often applied directly to fungal infections. They may be taken orally, applied topically, or injected. Fungal infections often require several weeks of treatment and repeated courses of the drug. Both antifungal and antiviral drugs tend to be somewhat toxic to people as well as to the pathogens.

Expected results

Most minor infections resolve within a week. Chronic infections may last for years. Serious infections need to be attended by a physician, as tissue damage and death may be an imminent outcome. Anemia may result from severe infections, since RBCs or their production may be affected.

Prevention

Various vaccines are available to prevent major infections. These vaccines are made from deactivated parts of viruses or bacteria that confer future immunity to infection by those pathogens. Vaccinations for mumps, measles, chicken pox, tetanus, hepatitis, diphtheria, whooping cough, and pneumonia are widely available in the United States.

They are routinely given to infants and children to provide lifetime immunity from these diseases. An anthrax vaccine is available but as of early 2002, reports say that a new, improved vaccine is needed in the United States, since the vaccine requires six doses over 18 months for full protection, with a booster every 12 months.

Good hygienic practices should be maintained. They include keeping the body clean as well as keeping food, utensils, and areas of preparation clean and free of contamination. Meat, seafood, and dairy products should be properly refrigerated. Breaks in the skin should be cleaned and disinfected to avoid further infection. Direct contact with people known or suspected to have infections should be limited, depending on the nature of the disease.

The health of the immune system should be maintained. A positive mental outlook is important, together with appropriate amounts of sleep, relaxation, and stress reduction. A healthful diet should be followed, with decreased sugar, salt, saturated fats, and chemical additives. Good lifestyle habits, such as giving up smoking and taking regular physical exercise, should be cultivated.

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Kidney Infections

Kidney infection is a general term used to describe infection of the kidney by bacteria, fungi, or viruses. The infecting microbe may have invaded the kidney from the urinary bladder or from the bloodstream. The disease is characterized by fever, chills, back pain, and, often, the symptoms associated with bladder infection.

As the principle part of the urinary system, the kidneys process the fluid component of blood (called plasma) to maintain appropriate water volume and concentrations of chemicals. The waste product formed from this process is called urine.

Urine travels from the kidney, through tubes called ureters, to the urinary bladder, and is eliminated from the body through a tube called the urethra. The kidneys and ureters comprise the upper urinary tract, and the bladder and urethra comprise the lower urinary tract.

Kidney infection, also called pyelonephritis and upper urinary tract infection, occurs when microbes, usually bacteria, invade the tissues of the kidney and multiply. One or both kidneys may be infected. Infection originating directly from the bladder is called an ascending infection.

Inflammation occurs in response to the infection. As a result of the infection and inflammation, scarring and other tissue damage may occur. Most cases of acute kidney infection resolve without any permanent kidney damage. In severe cases, kidney damage is so extensive that the kidneys can no longer function, a state called renal failure.

Types of kidney infections:

• Acute pyelonephritis: uncomplicated kidney infection that has a short and relatively severe course.
• Chronic pyelonephritis: long-standing disease associated with either active or inactive (healed) kidney infection.
• Emphysematous pyelonephritis: acute infection associated with gas in and around the kidney. This type almost always occurs in persons with diabetes.
• Pyonephrosis: acute or chronic pyelonephritis associated with blockage of the ureter.
• Renal and perinephric abscesses: abscesses (pockets of pus) in and around the kidney.

Kidney infections occur most often in adult females who are otherwise healthy. Urinary tract infections are uncommon in males until old age, when bladder catheterization and other urinary procedures are more commonly performed.

Causes and symptoms

Kidney infection is usually caused by bacteria, although infection by fungi (yeasts and molds) or viruses does occur. The bacteria Escherichia coli (E. coli) is responsible for about 85% of the cases of acute pyelonephritis. Other common causes include Klebsiella, Enterobacter, Proteus, Enterococcus, and Pseudomonas species.

Infection by Proteus species can lead to the formation of stones. E. coli causes only 60% of the acute pyelonephritis cases in the elderly. Kidney infection may also be caused by Mycobacterium tuberculosis or other Mycobacterium species or by the yeast Candida. Kidney infection can be caused by Group B streptococci in newborns.

Certain women are inherently more susceptible to urinary tract infections. Researchers have found that women who have recurrent infections possess certain markers on their blood cells.

Also, the bacteria which commonly cause urinary tract infections stick more readily to the vaginal cells of women who have recurrent infections. Other risk factors for kidney disease include:

• bladder catheterization or instrumentation
• diabetes
• pregnancy
• urinary calculi (stones)
• urinary tract abnormalities
• urinary tract obstruction

The symptoms of kidney infection include fever, shaking chills, nausea, vomiting, and middle to lower back pain which may travel to the abdomen and groin. This pain may be severe. These symptoms may be preceded or accompanied by those associated with bladder infection—frequent, painful urination.

Infants and young children may show fever, irritability, straining on urination, and urine odor. Fewer than half of newborns have fever associated with kidney infection, which makes diagnosis difficult.

In more than 20% of elderly patients with kidney infection, the presenting symptoms are gastrointestinal or pulmonary (lung). Also, one-third of elderly patients do not develop fever.

Diagnosis

Kidney infections can be diagnosed by family doctors, OB/GYN doctors, and urologists (doctors who specialize in the urinary system). The diagnosis of kidney infection is based primarily on symptoms, urinalysis, and urine cultures.

Blood tests may also be performed. Approximately 20% of patients have bacteria in the bloodstream, a condition called bacteremia. Urine dipsticks that detect signs of infection are often used right in the doctor’s office.

Urine would be examined with a microscope for the presence of bacteria and leukocytes (white blood cells). Urine culture would identify which microbe is causing the infection and may also be used to determine which antibiotic would be effective.

Other routine diagnostic procedures to look for signs of infection in the kidney may be used. An x ray of the abdomen may be taken. Ultrasound, which uses sound waves to visualize internal organs, may be used to examine the bladder and kidney. Less routinely performed are intravenous urograms, computerized tomography (CT scan), and scintillation scans.

Treatment

Delays in the diagnosis and treatment of kidney infection can lead to permanent kidney damage. Anyone who suspects kidney infection should seek professional care immediately. Alternative medicine may be used as an adjunct to the appropriate antibiotic treatment.

Dietary changes which may help to control and prevent kidney infection include:

• Drinking eight to 12 glasses of water daily helps to wash out bacteria (although this may also dilute antibacterial factors in the urine).
• Acidifying the urine by eating few alkaline foods (dairy and soda).
• Following a diet rich in grains, vegetables, and acidifying juices, like citrus.
• Eliminating high-sugar foods (sweet vegetables, fruits, sugar, and honey).
• Drinking unsweetened cranberry juice to acidify the urine and provide the antimicrobial agent hippuric acid. Cranberry capsules can substitute for the juice.
• Ingesting at least one clove of garlic (or up to 1,200 mg garlic as a tablet) daily for its anti-infective properties.

Magnesium may be helpful in treating renal disease. Zinc may boost the immune system. A study in rats with ascending pyelonephritis found that the addition of vitamins A and E to standard antibiotic therapy significantly reduced kidney inflammation as compared to antibiotic treatment alone.

Traditional Chinese medicine treats pyelonephritis with acupuncture, herbals, and patent medicines. The Chinese patent medicine Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill) is often used to treat kidney infections and disease and bladder infections.

The patient can take eight pills three times daily. Treatment of urinary tract infection often uses one or more of the following herbs in doses of 30 g to 60 g taken once or twice daily (Patients should consult a traditional Chinese medical practioner for the treatment best suited for them.):

• Herba commelinae
• H. plantaginis
• H. patriniae
• H. salviae plebeiae
• H. hedyotis seu oldenlandiae
• H. taraxaci
• H. andrographis

Allopathic treatment

Initiating antibiotic therapy as soon as possible is critical to prevent or reduce damage to the kidneys. Historically, all pyelonephritis patients were treated in the hospital. This has been found to be unnecessary in many cases. Responsible patients who have mild kidney infection can be treated at home with antibiotics taken by mouth.

Patients with high fever, vomiting, evidence of bacteria in the bloodstream, and/or dehydration would be hospitalized and treated with intravenous (IV) antibiotics and fluids. Severe illness, either with or without complications, would require hospitalization for treatment.

The recommended treatment for acute pyelonephritis is two weeks of therapy with the antibiotic combination trimethoprim/sulfamethoxazole. Fluoroquinolones (Cipro, Noroxin, NegGram), ceftriaxone (Rocephin), or gentamicin are other choices. Fluoroquinolones should not be used by pregnant women or children. With treatment, symptoms normally resolve within two to three days.

Abscesses may be resolved with percutaneous (by a needle through the skin) or surgical drainage. Emphysematous pyelonephritis may be treated with antibiotics; however, surgical removal of the kidney (nephrectomy) may be necessary.

Because of the 75% death rate, nephrectomy is the treatment of choice in diabetics with emphysematous pyelonephritis. Urinary stones are eliminated by a percutaneous method which involves stone removal and shock wave treatment.

Expected results

Antibacterial therapy of kidney infection has a 90% cure rate. Severe or chronic infection can lead to kidney damage and renal failure. Renal failure requires hemodialysis, a process which uses a dialysis machine (an artificial kidney) to process the patient’s blood. Patients with severe kidney damage requires kidney transplantation.

Prevention

Researchers are trying to develop a vaccine for UTIs, but as of early 2000, none are ready for human studies. The key to preventing kidney infection is to promptly treat bladder infection. Measures taken to prevent bladder infection may prevent subsequent kidney infection. These include:

• drinking large amounts of fluid
• reducing intake of sugar
• voiding frequently and as soon as the need arises
• proper cleansing of the area around the urethra (females), especially after sexual intercourse
• acupuncture (effective in preventing recurrent lower UTIs in women)
• avoiding use of vaginal diaphragms and spermicidal jelly (females) for contraception

The primary preventive measure specifically for males is prompt treatment of prostate infections. Chronic prostatitis may go unnoticed but can trigger recurrent UTIs. In addition, males who require temporary catheterization following surgery can be given antibiotics to lower the risk of UTIs.

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Malaria

Malaria is a serious infectious disease spread by certain mosquitoes. It is most common in tropical climates. It is characterized by recurrent symptoms of chills, fever, and an enlarged spleen. The disease can be treated with medication, but it often recurs.

Malaria is endemic (occurs frequently in a particular locality) in many third world countries. Isolated, small outbreaks sometimes occur within the boundaries of the United States, with most of the cases reported as having been imported from other locations.

Malaria is a growing problem in the United States. Although only about 1400 new cases were reported in the United States and its territories in 2000, many involved returning travelers. In addition, locally transmitted malaria has occurred in California, Florida, Texas, Michigan, New Jersey, and New York City.

While malaria can be transmitted in blood, the American blood supply is not screened for malaria. Widespread malarial epidemics are far less likely to occur in the United States, but small localized epidemics could return to the Western world.

As of late 2002, primary care physicians are being advised to screen returning travelers with fever for malaria, and a team of public health doctors in Minnesota is recommending screening immigrants, refugees, and international adoptees for the disease—particularly those from high-risk areas.

The picture is far more bleak, however, outside the territorial boundaries of the United States. A recent government panel warned that disaster looms over Africa from the disease.

Malaria infects between 300 and 500 million people every year in Africa, India, southeast Asia, the Middle East, Oceania, and Central and South America. A 2002 report stated that malaria kills 2.7 million people each year, more than 75 percent of them African children under the age of five.

It is predicted that within five years, malaria will kill about as many people as does AIDS. As many as half a billion people worldwide are left with chronic anemia due to malaria infection. In some parts of Africa, people battle up to 40 or more separate episodes of malaria in their lifetimes.

The spread of malaria is becoming even more serious as the parasites that cause malaria develop resistance to the drugs used to treat the condition. In late 2002, a group of public health researchers in Thailand reported that a combination treatment regimen involving two drugs known as dihydroartemisinin and azithromycin shows promises in treating multidrug-resistant malaria in southeast Asia.

Causes and symptoms

Human malaria is caused by four different species of a parasite belonging to genus Plasmodium: Plasmodium falciparum (the most deadly), Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale. The last two are fairly uncommon. Many animals can get malaria, but human malaria does not spread to animals. In turn, animal malaria does not spread to humans.

A person gets malaria when bitten by a female mosquito seeking a blood meal that is infected with the malaria parasite. The parasites enter the blood stream and travel to the liver, where they multiply. When they reemerge into the blood, symptoms appear. By the time a patient shows symptoms, the parasites have reproduced very rapidly, clogging blood vessels and rupturing blood cells.

Malaria cannot be casually transmitted directly from one person to another. Instead, a mosquito bites an infected person and then passes the infection on to the next human it bites. It is also possible to spread malaria via contaminated needles or in blood transfusions. This is why all blood donors are carefully screened with questionnaires for possible exposure to malaria.

It is possible to contract malaria in non-endemic areas, although such cases are rare. Nevertheless, at least 89 cases of so-called airport malaria, in which travelers contract malaria while passing through crowded airport terminals, have been identified since 1969.

The amount of time between the mosquito bite and the appearance of symptoms varies, depending on the strain of parasite involved. The incubation period is usually between eight and 12 days for falciparum malaria, but it can be as long as a month for the other types. Symptoms from some strains of P. vivax may not appear until eight to 10 months after the mosquito bite occurred.

The primary symptom of all types of malaria is the “malaria ague” (chills and fever), which corresponds to the “birth” of the new generation of the parasite. In most cases, the fever has three stages, beginning with uncontrollable shivering for an hour or two, followed by a rapid spike in temperature (as high as 106°F [41.4°C]), which lasts three to six hours.

Then, just as suddenly, the patient begins to sweat profusely, which will quickly bring down the fever. Other symptoms may include fatigue, severe headache, or nausea and vomiting. As the sweating subsides, the patient typically feels exhausted and falls asleep.

In many cases, this cycle of chills, fever, and sweating occurs every other day, or every third day, and may last for between a week and a month. Those with the chronic form of malaria may have a relapse as long as 50 years after the initial infection.

Falciparum malaria is far more severe than other types of malaria because the parasite attacks all red blood cells, not just the young or old cells, as do other types. It causes the red blood cells to become very “sticky.” A patient with this type of malaria can die within hours of the first symptoms.

The fever is prolonged. So many red blood cells are destroyed that they block the blood vessels in vital organs (especially the brain and kidneys), and the spleen becomes enlarged. There may be brain damage, leading to coma and convulsions. The kidneys and liver may fail.

Malaria in pregnancy can lead to premature delivery, miscarriage, or stillbirth.

Certain kinds of mosquitoes belonging to the genus Anopheles can pick up the parasite by biting an infected human. (The more common kinds of mosquitoes in the United States do not transmit the infection.)

This is true for as long as that human has parasites in his/her blood. Since strains of malaria do not protect against each other, it is possible to be reinfected with the parasites again and again. It is also possible to develop a chronic infection without developing an effective immune response.

Diagnosis

Malaria is diagnosed by examining blood under a microscope. The parasite can be seen in the blood smears on a slide. These blood smears may need to be repeated over a 72-hour period in order to make a diagnosis.

Antibody tests are not usually helpful because many people developed antibodies from past infections, and the tests may not be readily available. A new laser test to detect the presence of malaria parasites in the blood was developed in 2002, but is still under clinical study.

Two new techniques to speed the laboratory diagnosis of malaria show promise as of late 2002. The first is acridine orange (AO), a staining agent that works much faster (3–10 minutes) than the traditional Giemsa stain (45–60 min) in making the malaria parasites visible under a microscope.

The second is a bioassay technique that measures the amount of a substance called histadine-rich protein II (HRP2) in the patient’s blood. It allows for a very accurate estimation of parasite development. A dip strip that tests for the presence of HRP2 in blood samples appears to be more accurate in diagnosing malaria than standard microscopic analysis.

Anyone who becomes ill with chills and fever after being in an area where malaria exists must see a doctor and mention their recent travel to endemic areas. A person with the above symptoms who has been in a highrisk area should insist on a blood test for malaria.

The doctor may believe the symptoms are just the common flu virus. Malaria is often misdiagnosed by North American doctors who are not used to seeing the disease. Delaying treatment of falciparum malaria can be fatal.

Treatment


Traditional Chinese medicine

The Chinese herb qiinghaosu (the Western name is artemisinin) has been used in China and southeast Asia to fight severe malaria, and became available in Europe in 1994. It is usually combined with another antimalarial drug (mefloquine) to prevent relapse and drug resistance. It is not available in the United States and other parts of the developed world due to fears of its toxicity, in addition to licensing and other issues.

Western herbal medicine

A Western herb called wormwood (Artemesia annua) that is taken as a daily dose may be effective against malaria. Protecting the liver with herbs like goldenseal (Hydrastis canadensis), Chinese goldenthread (Coptis chinensis), and milk thistle (Silybum marianum) can be used as preventive treatment. These herbs should only be used as complementary to conventional treatment and not to replace it. Patients should consult their doctors before trying any of these medications.

Traditional African herbal medicine

As of late 2002, researchers are studying a traditional African herbal remedy against malaria. Extracts from Microglossa pyrifolia, a trailing shrub belonging to the daisy family (Asteraceae), show promise in treating drug-resistent strains of P. falciparum.

Allopathic treatment

Falciparum malaria is a medical emergency that must be treated in the hospital. The type of drugs, the method of giving them, and the length of the treatment depend on where the malaria was contracted and the severity of the patientís illness.

For all strains except falciparum, the treatment for malaria is usually chloroquine (Aralen) by mouth for three days. Those falciparum strains suspected to be resistant to chloroquine are usually treated with a combination of quinine and tetracycline.

In countries where quinine resistance is developing, other treatments may include clindamycin (Cleocin), mefloquin (Lariam), or sulfadoxone/pyrimethamine (Fansidar). Most patients receive an antibiotic for seven days. Those who are very ill may need intensive care and intravenous (IV) malaria treatment for the first three days.

A patient with falciparum malaria needs to be hospitalized and given antimalarial drugs in different combinations and doses depending on the resistance of the strain. The patient may need IV fluids, red blood cell transfusions, kidney dialysis, and assistance breathing.

A drug called primaquine may prevent relapses after recovery from P. vivax or P. ovale. These relapses are caused by a form of the parasite that remains in the liver and can reactivate months or years later.

Another new drug, halofantrine, is available abroad. While it is licensed in the United States, it is not marketed in this country and it is not recommended by the Centers for Disease Control and Prevention in Atlanta.

Expected results

If treated in the early stages, malaria can be cured. Those who live in areas where malaria is epidemic, however, can contract the disease repeatedly, never fully recovering between bouts of acute infection.

Prevention

Preventing mosquito bites while in the tropics is one possible way to avoid malaria. Several researchers are currently working on a malarial vaccine, but the complex life cycle of the malaria parasite makes it difficult. A parasite has much more genetic material than a virus or bacterium. For this reason, a successful vaccine has not yet been developed.

A new longer-lasting vaccine shows promise, attacking the toxin of the parasite and therefore lasts longer than the few weeks of those vaccines currently used for malaria prevention. However, as of late 2002, the vaccine had been tested only in animals, not in humans, and could be several years from use.

A newer strategy involves the development of genetically modified non-biting mosquitoes. A research team in Italy is studying the feasibility of this means of controlling malaria.

Malaria is an especially difficult disease to prevent by vaccination because the parasite goes through several life stages. One recent, promising vaccine appears to have protected up to 60% of people exposed to malaria. This was evident during field trials for the drug that were conducted in South America and Africa. It is not yet commercially available.

The World Health Organization has been trying to eliminate malaria for the past 30 years by controlling mosquitoes. Their efforts were successful as long as the pesticide DDT killed mosquitoes and antimalarial drugs cured those who were infected.

Today, however, the problem has returned a hundredfold, especially in Africa. Because both the mosquito and parasite are now extremely resistant to the insecticides designed to kill them, governments are now trying to teach people to take antimalarial drugs as a preventive medicine and avoid getting bitten by mosquitoes.

Travelers to high-risk areas should use insect repellant containing DEET for exposed skin. Because DEET is toxic in large amounts, children should not use a concentration higher than 35%. DEET should not be inhaled. It should not be rubbed onto the eye area, on any broken or irritated skin, or on children’s hands. It should be thoroughly washed off after coming indoors.

Those who use the following preventive measures get fewer infections than those who do not:

• Between dusk and dawn, remaining indoors in well-screened areas.
• Sleep inside pyrethrin or permethrin repellent-soaked mosquito nets.
• Wearing clothes over the entire body.

Anyone visiting areas where malaria is endemic should take antimalarial drugs starting one week before they leave the United States. The drugs used are usually chloroquine or mefloquine. This treatment is continued through at least four weeks after leaving the endemic area. However, even those who take antimalarial drugs and are careful to avoid mosquito bites can still contract malaria.

International travelers are at risk for becoming infected. Most Americans who have acquired falciparum malaria were visiting sub-Saharan Africa; travelers in Asia and South America are less at risk.

Travelers who stay in air conditioned hotels on tourist itineraries in urban or resort areas are at lower risk than those who travel outside these areas, such as backpackers, missionaries, and Peace Corps volunteers. Some people in Western cities where malaria does not usually exist may acquire the infection from a mosquito carried onto a jet. This is called airport or runway malaria.

A 2002 report showed how efforts in a Vietnamese village to approach prevention from multiple angles resulted in a significant drop in malaria cases. Health workers distributed bed nets treated with permethrin throughout the village and also made sure they were resprayed every six months. They also worked to ensure early diagnosis, early treatment, and annual surveys of villagers to bring malaria under control.

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Measles

Measles is a viral infection that causes an illness displaying a characteristic skin rash known as an exanthem. Measles is also sometimes called rubeola, five-day measles, or hard measles.

Measles infections appear all over the world. Incidence of the disease in the United States is down to a record low and only 86 confirmed cases were reported in the year 2000.

Of these, 62% were definitely linked to foreigners or international travel. Prior to the current effective immunization program, large-scale measles outbreaks occurred on a two to three year cycle, usually in the winter and spring.

Smaller outbreaks occurred during the off-years. Babies up to about eight months of age are usually protected from contracting measles, due to antibodies they receive from their mothers in the uterus. Once someone has had measles, he or she can never get it again.

Causes and symptoms

Measles is caused by a type of virus called a paramyxovirus. It is an extremely contagious infection, spread through the tiny droplets that may spray into the air when a person carrying the virus sneezes or coughs. About 85% of those people exposed to the virus will become infected with it. About 95% of those people infected with the virus will develop the illness.

Once someone is infected with the virus, it takes about seven to 18 days before he or she actually becomes ill. The most contagious time period is the three to five days before symptoms begin through about four days after the characteristic measles rash has begun to appear.

The first signs of measles infection are fever, extremely runny nose, red, runny eyes, and a cough. A few days later, a rash appears in the mouth, particularly on the mucous membrane that lines the insides of the cheek.

This rash consists of tiny white dots (like grains of salt or sand) on a reddish bump. These are called Koplik’s spots, and are unique to measles infection. The throat becomes red, swollen, and sore.

A couple of days after the appearance of the Koplik’s spots, the measles rash begins. It appears in a characteristic progression, from the head, face, and neck, to the trunk, then abdomen, and next out along the arms and legs.

The rash starts out as flat, red patches, but eventually develops some bumps. The rash may be somewhat itchy. When the rash begins to appear, the fever usually climbs higher, sometimes reaching as high as 105°F (40.5°C).

There may be nausea, vomiting, diarrhea, and multiple swollen lymph nodes. The cough is usually more problematic at this point, and the patient feels awful. The rash usually lasts about five days. As it fades, it turns a brownish color, and eventually the affected skin becomes dry and flaky.

Many patients (about 5–15%) develop other complications. Bacterial infections, such as ear infections, sinus infections, and pneumonia are common, especially in children. Other viral infections may also strike the patient, including croup, bronchitis, laryngitis, or viral pneumonia.

Inflammation of the liver, appendix, intestine, or lymph nodes within the abdomen may cause other complications. Rarely, inflammation of the heart or kidneys, a drop in platelet count (causing episodes of difficult-to-control bleeding), or reactivation of an old tuberculosis infection can occur.

An extremely serious complication of measles infection is the inflammation and subsequent swelling of the brain. Called encephalitis, this can occur up to several weeks after the basic measles symptoms have resolved.

About one out of every 1,000 patients develops this complication, and about 10–15% of these patients die. Symptoms include fever, headache, sleepiness, seizures, and coma. Long-term problems following recovery from measles encephalitis may include seizures and mental retardation.

A very rare complication of measles can occur up to 10 years or more following the initial infection. Called subacute sclerosing panencephalitis, this is a slowly progressing, smoldering, swelling, and destruction of the entire brain.

It is most common among people who had measles infection prior to the age of two years. Symptoms include changes in personality, decreased intelligence with accompanying school problems, decreased coordination, and involuntary jerks and movements of the body.

As the disease progresses, the patient becomes increasingly dependent, ultimately becoming bedridden and unaware of his or her surroundings. Blindness may develop, and the temperature may spike (rise rapidly) and fall unpredictably as the brain structures responsible for temperature regulation are affected. Death is inevitable.

Measles during pregnancy is a serious disease, leading to increased risk of a miscarriage or stillbirth. In addition, the mother’s illness may progress to pneumonia.

Diagnosis

Measles is almost always diagnosed based on its characteristic symptoms, including Koplik’s spots, and a rash that spreads from central body structures out towards the arms and legs.

If there is any doubt as to the diagnosis, then a specimen of body fluids (mucus or urine) can be collected and combined with fluorescent-tagged measles virus antibodies. Antibodies are produced by the body’s immune cells that can recognize and bind to markers (antigens) on the outside of specific organisms, in this case the measles virus.

Once the fluorescent antibodies have attached themselves to the measles antigens in the specimen, the specimen can be viewed under a special microscope to verify the presence of the measles virus.

Treatment

There are a variety of general measures that can be taken to treat measles and help the patient feel more comfortable. These include:

• humidifying the air to ease cough
• drinking plenty of fluids to prevent dehydration
• keeping the room lights dim to relieve sensitivity to light
• getting plenty of rest
• eating nutritious and easily digestible food

Herbals and Chinese medicine

There are specific acupuncture and acupressure therapies for measles. The following herbals can also help relieve the symptoms associated with measles:

• Chamomile tea for restlessness.
• Echinacea plus goldenseal to clear infection, boost the immune system, and soothe skin and mucous membranes.
• A tea of lemon balm leaf, chamomile flower, peppermint leaf, licorice root, and elder flower to reduce fever and chills and increase perspiration.
• Ginger tea to reduce fever.
• Shiitake mushrooms to boost the immune system.
• Witch hazel (Hamamelis virginiana), chickweed (Stellaria media), or oatmeal baths to reduce itching.
• Eyebright (Euphrasia officinalis) eyewash to soothe eyes.
• Garlic to fight infection and boost the immune system.
• Flos lonicerae (10 g) and Radix glycyrrhizae (3 g) decoction to wash the mouth, eyes, and nose.

Supplements

Some studies have shown that children with measles encephalitis or pneumonia benefit from relatively large doses of vitamin A. Vitamin A may also heal mucous membranes.

Bioflavinoids and vitamin C boost the immune system. Zinc promotes healing and is an immune system stimulant. Zinc can cause nausea and vomiting, and chronic use can cause low levels of copper and iron-deficiency anemia.

Homeopathy

Homeopathic remedies cater to the patient’s specific symptoms. Remedies for common measles symptoms are listed. The patient can take 30x or 9c of the following remedies four times daily for two days:

• Apis mellifica: for swollen throat, breathing difficulty, and painful cough.
• Arsenicum album: for restlessness, feeling worse after midnight, and thirst.
• Belladonna: for high fever, red eyes, flushed face, headache, and swallowing difficulty.
• Gelsemium: for fever, droopy eyes, cough, feeling cold, and runny nose.
• Pulsatilla: for eye problems (tears, drainage, light sensitivity), dark red rash, thick yellow nasal discharge, and dry cough.

Allopathic treatment

There are no medications available to cure measles. Treatment is primarily aimed at helping the patient to be as comfortable as possible, and watching carefully so that antibiotics can be started promptly if a bacterial infection develops.

Fever and discomfort can be treated with acetaminophen (Tylenol) or ibuprofen (Advil, Motrin, Nuprin). Children with measles should never be given aspirin, as this increases the risk of the fatal disease Reye’s syndrome.

Expected results

The prognosis for an otherwise healthy, well-nourished child who contracts measles is usually quite good. In developing countries, however, death rates may reach 15–25%, as malnutrition, especially protein deficiency, for six months prior to the onset of measles increases the risk of death. Adolescents and adults usually have a more difficult course.

Women who contract the disease while pregnant may give birth to a baby with a hearing impairment. Although only one in 1,000 patients with measles will develop encephalitis, 10–15% of those who do will die, and about another 25% will be left with permanent brain damage.

Prevention

Measles is a highly preventable infection. A very effective vaccine exists, made of live measles viruses that have been treated so they cannot cause infection. The important markers on the viruses are intact and cause the immune system to produce antibodies.

In the event of a future infection with measles virus the antibodies will quickly recognize the organism and eliminate it. Measles vaccines are usually given at about 15 months of age.

Prior to that age, the baby’s immune system is not mature enough to initiate a reaction strong enough to ensure long-term protection from the virus. A repeat injection should be given at about 10 or 11 years of age. Outbreaks on college campuses have occurred among nonimmunized or incorrectly immunized students.

Measles vaccine should not be given to a pregnant woman, however, in spite of the seriousness of gestational measles. The reason for not giving this particular vaccine during pregnancy is the risk of transmitting measles to the unborn child.

Surprisingly, new cases of measles began being reported in some countries—including Great Britain—in 2001 because of parents’ fears about vaccine safety. The combined vaccine for measles, mumps, and rubella (MMR) was claimed to cause autism or bowel disorders in some children.

However, the World Health Organization (WHO) says there is no scientific merit to these claims. The United Nations expressed concern that unwarranted fear of the vaccine would begin spreading the disease in developing countries, and ultimately in developed countries as well.

Parents in Britain began demanding the measles vaccine as a separate dose and scientists were exploring that option as an alternative to the combined MMR vaccine. Unfortunately, several children died during an outbreak of measles in Dublin because they had not received the vaccine.

Child mortality due to measles is considered largely preventable, and making the MMR vaccine widely available in developing countries is part of WHO’s strategy to reduce child mortality by two-thirds by the year 2015.

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Meningitis

Meningitis is a potentially fatal inflammation of the meninges, the thin, membranous covering of the brain and the spinal cord.

Meningitis is most commonly caused by infection by bacteria, viruses, or fungi, although it can also be caused by bleeding into the meninges, cancer, diseases of the immune system, and an inflammatory response to certain types of chemotherapy or other chemical agents. The most serious and the most difficult to treat types of meningitis tend to be those caused by bacteria.

Meningitis is a particularly dangerous infection because of the very delicate nature of the brain. Brain cells are some of the only cells in the body that, once killed, will not regenerate themselves. Therefore, if enough brain tissue is damaged by an infection, then serious lifelong handicaps will remain.

In order to learn about meningitis, it is important to have a basic understanding of the anatomy of the brain. The meninges are three separate membranes, layered together, which encase the brain and spinal cord:

• The dura is the toughest, outermost layer, and is closely attached to the inside of the skull.
• The middle layer, the arachnoid, is important because of its involvement in the normal flow of the cerebrospinal fluid (CSF), a lubricating and nutritive fluid that bathes both the brain and the spinal cord.
• The innermost layer, the pia, helps direct blood vessels into the brain.
• The space between the arachnoid and the pia contains CSF, which helps insulate the brain from trauma. Many blood vessels, as well as peripheral and cranial nerves course through this space.

CSF, produced within specialized chambers deep in- side the brain, flows over the surface of the brain and spinal cord. This fluid serves to cushion these relatively delicate structures, as well as supplying important nutrients for brain cells. CSF is reabsorbed by blood vessels located within the meninges. A careful balance between CSF production and reabsorption is important to avoid the accumulation of too much CSF.

Because the brain is enclosed in the hard, bony case of the skull, any disease that produces swelling will be damaging to the brain. The skull cannot expand at all, so when the swollen brain tissue pushes up against the skull’s hard bone, the brain tissue becomes damaged and the blood supply is compromised, and this tissue may ultimately die.

Furthermore, swelling on the right side of the brain will not only cause pressure and damage to that side of the brain, but by taking up precious space within the tight confines of the skull, the left side of the brain will also be pushed up against the hard surface of the skull, causing damage to the left side of the brain, as well.

Another way that infections injure the brain involves the way in which the chemical environment of the brain changes in response to the presence of an infection. The cells of the brain require a very well-regulated environment.

Careful balance of oxygen, carbon dioxide, sugar (glucose), sodium, calcium, potassium, and other substances must be maintained in order to avoid damage to brain tissue. An infection upsets this balance, and brain damage can occur when the cells of the brain are either deprived of important nutrients or exposed to toxic levels of particular substances.

The cells lining the brain’s tiny blood vessels (capillaries) are specifically designed to prevent many substances from passing into brain tissue.

This is commonly referred to as the blood-brain barrier. The blood-brain barrier prevents various substances that could be poisonous to brain tissue (toxins), as well as many agents of infection, from crossing from the blood stream into the brain tissue.

While this barrier is obviously an important protective feature for the brain, it also serves to complicate treatment in the case of an infection by making it difficult for medications to pass out of the blood and into the brain tissue where the infection is located.

Causes and Symptoms

The most common infectious causes of meningitis vary according to an individual’s age, habits, living environment, and health status. While nonbacterial types of meningitis are more common, bacterial meningitis is more potentially life-threatening.

Three bacterial agents are responsible for about 80% of all bacterial meningitis cases. These bacteria are Haemophilus influenzae type b, Neisseria meningitidis (causing meningococcal meningitis), and Streptococcus pneumoniae (causing pneumococcal meningitis).

In newborns, the most common agents of meningitis are those that are contracted from the newborn’s mother, including Group B streptococci (becoming an increasingly common infecting organism in the newborn period), Escherichia coli, and Listeria monocytogenes. The highest incidence of meningitis occurs in babies under a month old, with an increased risk of meningitis continuing through about two years of age.

Older children are more frequently infected by bacteria, including Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae.

Adults are most commonly infected by either S. pneumoniae or N. meningitidis, with pneumococcal meningitis the more common. Certain conditions predispose to this type of meningitis, including alcoholism and chronic upper respiratory tract infections (especially of the middle ear, sinuses, and mastoids).

N. meningitidis is the only organism that can cause epidemics of meningitis. For instance, cases have been reported when a child in a crowded day care situation or a military recruit in a crowded training camp has fallen ill with meningococcal meningitis.

There have been case reports in recent years of meningitis caused by Streptococcus bovis, an organism that is ordinarily found in the digestive tract of such animals as cows and sheep; and Pasteurella multocida, an organism that usually infects rabbits. Other atypical cases of meningitis include several caused by the anthrax bacillus. These cases have a high mortality rate.

Viral causes of meningitis include the herpes simplex virus, the mumps and measles viruses (against which most children are protected due to mass immunization programs), the virus that causes chickenpox, the rabies virus, and a number of viruses that are acquired through the bites of infected mosquitoes.

A number of medical conditions predispose individuals to meningitis caused by specific organisms. Patients with AIDS (acquired immunodeficiency syndrome) are more prone to getting meningitis from fungi, as well as from the agent that causes tuberculosis.

Patients who have had their spleens removed, or whose spleens are no longer functional (as in the case of patients with sickle cell disease) are more susceptible to other infections, including meningococcal and pneumococcal meningitis.

The majority of meningitis infections are acquired by transmission through the blood. A person may have another type of infection (for instance, infection of the lungs, throat, or tissues of the heart) caused by an organsm that can also cause meningitis.

If this initial infection is not properly treated, the organism will continue to multiply, find its way into the blood stream, and be delivered in sufficient quantities to invade past the bloodbrain barrier.

Direct spread occurs when an organism spreads to the meninges from infected tissue next to or very near the meninges. This can occur, for example, with a severe, poorly treated ear or sinus infection.

Patients who suffer from skull fractures possess abnormal openings to the sinuses, nasal passages, and middle ears. Organisms that usually live in the human respiratory system without causing disease can pass through openings caused by such fractures, reach the meninges, and cause infection.

Similarly, patients who undergo surgical procedures or who have had foreign bodies surgically placed within their skulls (such as tubes to drain abnormal amounts of accumulated CSF) have an increased risk of meningitis.

Organisms can also reach the meninges via an uncommon but interesting method called intraneural spread. This involves an organism invading the body at a considerable distance away from the head, spreading along a nerve, and using that nerve as a sort of ladder into the skull, where the organism can multiply and cause meningitis. Herpes simplex virus is known to use this type of spread, as is the rabies virus.

The classic symptoms of meningitis (particularly of bacterial meningitis) include fever, headache, vomiting, sensitivity to light (photophobia), irritability, severe fatigue (lethargy), stiff neck, and a reddish purple rash on the skin. Untreated, the disease progresses with seizures, confusion, and eventually coma.

A very young infant may not show the classic signs of meningitis. Early in infancy, a baby’s immune system is not yet developed enough to mount a fever in response to infection, so fever may be absent.

However, checking an infant’s temperature to see if it is high or low could be an indication. Some infants with meningitis have seizures as their only identifiable symptom. Similarly, debilitated elderly patients may not have fever or other identifiable symptoms of meningitis.

Damage due to meningitis occurs from a variety of phenomena. The action of infectious agents on the brain tissue is one direct cause of damage. Other types of damage may be due to the mechanical effects of swelling and compression of brain tissue against the bony surface of the skull.

Swelling of the meninges may interfere with the normal absorption of CSF by blood vessels, causing accumulation of CSF and damage from the resulting pressure on the brain.

Interference with the brain’s carefully regulated chemical environment may cause damaging amounts of normally present substances (carbon dioxide, potassium) to accumulate. Inflammation may cause the blood-brain barrier to become less effective at preventing the passage of toxic substances into brain tissue.

Diagnosis

A number of techniques are used when examining a patient suspected of having meningitis to verify the diagnosis. Certain manipulations of the head (lowering the head, chin towards chest, for example) are difficult to perform and painful for a patient with meningitis.

The most important test used to diagnose meningitis is the lumbar puncture (LP), commonly called a spinal tap. Lumbar puncture involves the insertion of a thin needle into a space between the vertebrae in the lower back and the withdrawal of a small amount of CSF.

The CSF is then examined under a microscope to look for bacteria or fungi. Normal CSF contains set percentages of glucose and protein. These percentages will vary with bacterial, viral, or other causes of meningitis.

For example, bacterial meningitis causes a smaller than normal percentage of glucose to be present in CSF, as the bacteria are essentially “eating” the host’s glucose, and using it for their own nutrition and energy production. Normal CSF should contain no infection-fighting cells (white blood cells), so the presence of white blood cells in CSF is another indication of meningitis.

Some of the withdrawn CSF is also put into special lab dishes to allow growth of the suspected infecting organism, which can then be identified more easily. Special immunologic and serologic tests may also be used to help identify the infectious agent.

In rare instances, CSF from a lumbar puncture cannot be examined because the amount of swelling within the skull is so great that the pressure within the skull (intracranial pressure) is extremely high. This pressure is always measured immediately upon insertion of the LP needle.

If it is found to be very high, no fluid is withdrawn because doing so could cause herniation of the brain stem. Herniation of the brain stem occurs when the part of the brain connecting to the spinal cord is thrust through the opening at the base of the skull into the spinal canal.

Such herniation will cause compression of those structures within the brain stem that control the most vital functions of the body (breathing, heart beat, consciousness). Death or permanent debilitation follows herniation of the brain stem.

Treatment

Because meningitis is a potentially deadly condition, doctors should be contacted immediately for diagnosis and treatment. Alternative treatments should be used only to support the recovery process following appropriate antibiotic treatments, or used concurrently with antibiotic treatments.

General recommendations

Patients should be well rested in bed, preferably in a darkened room. They should be given lots of fluids and nutritious foods. Patients should avoid processed foods and those with high fat and sugar content. Fats are difficult to digest in severely ill patients; sugar tends to depress the immune system and impede recovery process.

Patients should also take vitamin A (up to 10,000 IU per day), B-complex vitamins (up to 1,500 mg per day), and vitamin C (up to 2 g per day) to help keep the body strong and prevent future infections. Additionally, the patient may consider taking other antioxidants, essential fatty acids (EFAs), and/or participate in therapies, such as massage therapy and movement therapies (e.g., t’ai chi).

Other treatments

Alternative therapies, such as homeopathy, traditional Chinese medicine, and Western herbal medicine may help patients regain their health and build up their immune systems.

The recovering individual, under the direction of a professional alternative therapist, may opt to include mushrooms into his or her diet to stimulate immune function. Contact an experienced herbalist or homeopathic practitioner for specific remedies.

Allopathic treatment

Antibiotics are the first line of treatment for bacterial meningitis. In recent years, however, doctors have turned to such newer medications as vancomycin or the fluoroquinolones to treat bacterial meningitis because strains of S. pneumoniae and N. meningitidis have emerged that are resistant to penicillin and the older antibiotics.

Because of the effectiveness of the blood-brain barrier in preventing the passage of substances into the brain, medications must be delivered directly into the patient’s veins (intravenously) at very high doses.

Antiviral drugs (acyclovir) may be helpful in shortening the course of viral meningitis, and antifungal medications are available as well. Patients who develop seizures will require medications to halt the seizures and prevent their return.

Expected results

Viral meningitis is the least severe type of meningitis, and patients usually recover with no long-term effects from the infection. Bacterial infections, however, are much more severe, and progress rapidly.

Without very rapid treatment with the appropriate antibiotic, the infection can swiftly lead to coma and death in less than a day’s time. While death rates from meningitis vary depending on the specific infecting organism, the overall death rate is just under 20%.

The most frequent long-term effects of meningitis include deafness and blindness, which may be caused by the compression of specific nerves and brain areas responsible for the senses of hearing and sight.

Some patients develop permanent seizure disorders, requiring lifelong treatment with antiseizure medications. Scarring of the meninges may result in obstruction of the normal flow of CSF, causing abnormal accumulation of CSF. This may be a chronic problem for some patients, requiring the installation of shunt tubes to drain the accumulation regularly.

Some cases of sudden and unexplained death in adults have been attributed to rapidly developing meningitis.

Prevention

Prevention of meningitis primarily involves the appropriate treatment of other infections an individual may acquire, particularly those that have a track record of seeding to the meninges (such as ear and sinus infections).

Preventive treatment with antibiotics is sometimes recommended for the close contacts of an individual who is ill with meningococcal or H. influenzae type b meningitis. A meningococcal vaccine exists, and is sometimes recommended to individuals who are traveling to very high risk areas. A vaccine for H. influenzae type b is now given to babies as part of the standard array of childhood immunizations.

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Mononucleosis

Infectious mononucleosis is caused by the Epstein-Barr virus, which in teenagers and young adults may result in acute symptoms that last for several weeks. Fatigue and low energy can linger for several months.

Infectious mononucleosis (IM), also called mono or glandular fever, is commonly transmitted among teenagers and young adults by kissing or sexual activity; hence it is sometimes called the “kissing disease.”

By age 35–40, approximately 95% of the population has been infected with the Epstein-Barr virus (EBV) that causes IM. Although anyone can develop mononucleosis, primary (first) infections commonly occur in young adults between the ages of 15 and 35. Symptoms of IM are particularly common in teenagers.

In the developed world, 15–20% of people are infected during adolescence and about half of these teens become ill. Among adults, 30—50% of those contracting IM become ill. Although males and females are equally susceptible, in the United States whites are 30-fold more likely than blacks to contract IM.

Typically IM runs its course in 10–30 days. However people with weakened or suppressed immune systems, such as AIDS or organ-transplant patients, are especially vulnerable to potentially serious complications from mononucleosis.

Following IM, the EBV remains dormant (latent) in a few cells in the throat and blood for the remainder of one’s life. Periodically the virus may reactivate and be transmitted through saliva; however IM symptoms rarely reoccur.


Causes and symptoms


Causes

Infectious mononucleosis is caused by the first infection with the Epstein-Barr virus, also called herpes virus 4. It is one of the most common human viruses and is endemic throughout the world. EBV is a member of the herpes family of DNA viruses.

This family of viruses includes those that cause cold sores, chickenpox, and shingles. Most people are infected with multiple strains of EBV. The different EBV strains are found in separate parts of the body: the circulating lymphocytes (white blood cells), cell-free blood plasma, or the oral cavity.

EBV is spread by contact with viral-infected saliva through coughing, sneezing, kissing, or the sharing of items such as drinking glasses, eating utensils, straws, toothbrushes, or lip gloss.

Some evidence indicates that in teens and young adults IM is primarily transmitted by sexual intercourse. However EBV is not highly contagious and household members have only a very small risk of infection unless there is direct contact with infected saliva.

Symptoms

Less than 10% of children under age 10 develop symptoms with EBV infection. The incubation period after exposure to EBV is generally about 7–14 days in children and teens and 30–60 days in adults. An infected person can transmit EBV during this period and for as long as five months after symptoms disappear.

The first symptoms of IM are usually general weakness and extreme fatigue. An infected person may require 12–16 hours of sleep daily prior the development of other symptoms. IM symptoms are similar to cold or flu symptoms:

• Fever and chills occurs in about 90% of IM cases. EBV is most contagious during this stage of the illness.
• An enlarged spleen, causing pain in the upper left of the abdomen, occurs in about 50–60% of infections.
• Sore throat and/or swollen tonsils occurs in less than 50% of mononucleosis infections.
• Swollen lymph glands (nodes) in the neck, armpits, and/or groin develop in less than 50% of infections.
• Jaundice (yellowing of the skin and eyes) develops in more than 20% of patients, depending on age, and indicates an inflamed or enlarged liver.
• A red skin rash, particularly on the chest, occurs in about 5% of infections.
• loss of appetite
• stomach pain and/or nausea
• muscle soreness and/or joint pain
• headache
• chest pain
• coughing
• rapid or irregular heartbeat

These acute symptoms usually last one to two weeks.

Splenic enlargement generally peaks during the fourth week after symptoms appear and then subsides. However an enlarged spleen may rupture in 0.1–0.2% of cases, causing sharp pain on the left side of the abdomen. Additional symptoms of a ruptured spleen include light-headedness, a fast heart rate, and difficulty breathing.

Splenic rupture most often occurs within the first three weeks and is the most common cause of death from mononucleosis. It requires immediate medical attention and may require emergency surgery to stop the bleeding.

There are other rare—but potentially life-threatening—complications of mononucleosis:

• Neurological complications affecting the central nervous system may develop in 1–2% of infections. Bell’s palsy is a temporary condition caused by weakened or paralyzed facial muscles on one side of the face.
• The heart muscle may become inflamed.
• A significant number of the body’s red blood cells or platelets may be destroyed and there may be reduced number of circulating red and white blood cells.

Diagnosis

A variety of conditions can produce symptoms similar to those of IM; however if cold or flu-like symptoms persist for longer than two weeks, mononucleosis may be suspected.

Mononucleosis usually is diagnosed by a blood test—called a mono spot test—that measures antibodies to EBV. Antibodies may not be detectable until the second or third week after the onset of symptoms. The antibodies peak between weeks two and five and can persist at low levels for up to a year.

About 90% of IM cases show a positive mono spot. Infants and young children do not make the type of antibodies that are measured by the mono test.

If the mono spot is inconclusive, additional blood tests may be performed that measure an increase in the overall number of white blood cells or an increase in abnormal-appearing lymphocytes that make antibodies against EBV. Other tests can identify at least six specific types of EBV antibodies that may be present in the blood.

Treatment

The most effective treatment for infectious mononucleosis is rest, followed by a gradual return to normal activities. If the spleen is enlarged, all contact sports, heavy lifting, and jarring activity such as cheerleading, should be avoided until the enlargement has subsided completely.

However exercise such as swimming, running, and other non-contact sports may be resumed. Since mononucleosis can involve the liver, it is important not to consume alcohol.

Although there is no cure for mononucleosis, alternative remedies may help the body to fight the infection and relieve symptoms. Medical practitioners recommend eating four to six small daily meals of unprocessed foods, fresh fruits, and vegetables. It is important to drink plenty of water.

Meat, sugar, saturated fats, and caffeinated and decaffeinated drinks should be avoided. Gargling with salt water (one half teaspoon in one cup of warm water) or lozenges may relieve a sore throat. Vitamin A, B-complex, and C, and magnesium, calcium, and potassium supplements can boost the immune system and increase energy levels.

Herbals

Herbal remedies may help treat mononucleosis, although they are unproven:

• astragalus (Astragalus membranaceus)for physical weakness
• cleavers (Galium species) to cleanse the lymphatic system
• echinacea (Echinacea augustifolia) to boost the immune system
• elder (Sambucus nigra) flower to reduce fever
• garlic to fight viral infection
• goldenseal (Hydrastis canadensis) to relieve sinus congestion
• slippery elm bark and licorice can be gargled to soothe a sore throat
• St. John’s wort (Hypericum perforatum) to relieve anxiety and depression
• vervain (Verbena officinales) to relieve anxiety and depression and treat jaundice
• wild indigo (Baptisia tinctoria) to cleanse the lymphatic system
• yarrow (Achillea millefolium) to reduce fever

Other remedies

The following treatments may help relieve symptoms of mononucleosis:

• acupressure point Lung 6 may boost lung function and the immune system
• aromatherapy with bergamot, eucalyptus, and lavender essential oils may relieve fatigue and other symptoms
• Chinese medicine utilizes acupuncture and Xiao Chai Hu Wan (Minor Bupleurum pills) in combination with otherherbs.
• Homeopathic physicians choose remedies based on a patient’s specific symptoms
• relaxation techniques such as biofeedback, visualization, meditation, and yoga can reduce fatigue by relieving stress

Allopathic treatment

Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may relieve symptoms of IM. Aspirin should be avoided because mononucleosis has been associated with Reye’s syndrome—a serious illness in children and teens—that is aggravated by aspirin.

Although antibiotics are ineffective for treating EBV, a sore throat from mononucleosis can be complicated by a streptococcal infection, sinus infection, or an abscess or pocket of infection on the tonsils.

Such bacterial infections can be treated with antibiotics. A five—day course of corticosteroid anti-inflammatory medications (Prednisone) occasionally is prescribed for breathing difficulties caused by swollen tonsils or lymph nodes in the neck or throat.


Prognosis

Most people with IM return to their normal daily routines within two to three weeks, although it may take up to six months for normal energy levels to return.

A large study suggested that EBV infection increases the risk for Hodgkin lymphoma, a highly treatable cancer of the lymphatic system. About one-third of Hodgkin tumors contain EBV and about one in 1,000 young adults with mononucleosis will develop the cancer, typically about four years after IM.

The development of two other rare types of cancer—Burkitt’s lymphoma and nasopharyngeal carcinoma—appears to be associated with EBV. There also is some evidence that people with high levels of antibodies against EBV are at a higher risk of developing multiple sclerosis.

Prevention

Even though IM is not highly contagious, there is no way to completely avoid infection with EBV. In the majority of cases, IM is without symptoms. Furthermore EBV can be transmitted long after the symptoms of infection are gone and, indeed, periodically throughout the remainder of life. Good hygiene, particularly hand washing and the habit of not sharing toothbrushes or eating utensils may help prevent EBV infection.

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Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a term used to describe any infection in the lower female reproductive tract that spreads upward to the upper female reproductive tract. The lower female genital tract consists of the vagina and the cervix. The upper female genital tract consists of the body of the uterus, the fallopian or uterine tubes, and the ovaries.

PID is the most common and the most serious consequence of infection with sexually transmitted diseases (STD) in women. Over one million cases of PID are diagnosed annually in the United States, and it is the most common cause for hospitalization of reproductive-age women.

Sexually active women aged 15–25 are at highest risk for developing PID. The disease can also occur, although less frequently, in women having monogamous sexual relationships. The most serious consequences of PID are increased risk of infertility and ectopic pregnancy.

To understand PID, it is helpful to understand the basics of inflammation. Inflammation is the body’s response to disease-causing (pathogenic) microorganisms. The affected body part may swell due to accumulation of fluid in the tissue or may become reddened due to an excessive accumulation of blood.

A discharge (pus) may be produced that consists of white blood cells and dead tissue. Following inflammation, scar tissue may form by the proliferation of scar-forming cells (fibrosis). Adhesions of fibrous tissue form and cause organs or parts of organs to stick together.

PID may be used synonymously with the following terms:

• salpingitis (inflammation of the fallopian tubes)
• endometritis inflammation of the inside lining of the body of the uterus)
• tubo-ovarian abscesses (abscesses in the tubes and ovaries)
• pelvic peritonitis (inflammation inside of the abdominal cavity surrounding the female reproductive organs)

Causes and symptoms

A number of factors affect the risk of developing PID. They include:

• Age. The incidence of PID is very high in younger women and decreases as a woman ages.
• Race. The incidence of PID is 8–10 times higher in nonwhites than in whites.
• Socioeconomic status. The higher incidence of PID in women of lower socioeconomic status is due in part to a woman’s lack of education and awareness of health and disease, and due in part to barriers to her accessibility to medical care.
• Use and method of contraception. Induced abortion, use of an IUD, nonuse of such barrier contraceptives as condoms, and frequent douching are all associated with a higher risk of developing PID.
• Lifestyle.Such high-risk behaviors as drug and alcohol abuse; early age at first intercourse; a high number of sexual partners; and smoking all are associated with a higher risk of developing PID.
• Specific sexual practices. Intercourse during the menses and frequent intercourse may offer more opportunities for the admission of pathogenic organisms to the inside of the uterus.
• The presence of a sexually transmitted disease. Sixty to seventy-five percent of PID cases are associated with STDs. A prior episode of PID increases the chances of developing subsequent infections.

The two major organisms that cause STDs are Neisseria gonorrhoeae and Chlamydia trachomatis. The main symptom of N. gonorrheae infection (gonorrhea) is a vaginal discharge of mucus and pus.

Sometimes bacteria from the colon normally in the vaginal cavity may travel upward to infect the upper female genital organs, facilitated by the infection with gonorrhea. Infections with C. trachomatis and other nongonoccal organisms are more likely to have mild or no symptoms.

Although PID is unusual in women who are not sexually active, disease organisms other than the gonococcus and C. trachomatis can occasionally gain entrance to the upper female reproductive tract and cause PID.

Cases have been reported from Canada, Norway, and South America of PID caused by pinworms, pneumococci, and Entamoeba histolytica, a pathogenic amoeba.

Normally the cervix produces mucus that acts as a barrier to prevent disease-causing microorganisms, called pathogens, from entering the uterus and moving upward to the tubes and ovaries. This barrier may be breached in two ways.

A sexually transmitted pathogen, usually a single organism, invades the lining cells, alters them, and gains entry. Another way for organisms to gain entry happens when trauma or alteration to the cervix occurs.

Childbirth, spontaneous or induced abortion, or use of an intrauterine contraceptive device (IUD) are all conditions that may alter or weaken the normal lining cells, making them susceptible to infection, usually by several organisms. During menstruation, the cervix widens and may allow pathogens entry into the uterine cavity.

Recent evidence suggests that bacterial vaginosis (BV), a bacterial infection of the vagina, may be associated with PID. BV results from the imbalance of normal organisms in the vagina— by douching, for example.

While the balance is altered, conditions then favor the overgrowth of anaerobic bacteria that thrive in the absence of free oxygen. A copious discharge is usually present. Should some trauma occur in the presence of anaerobic bacteria, such as menses, abortion, intercourse, or childbirth, these organisms may gain entrance to the upper genital organs.

The most common symptom of PID is pelvic pain. However, many women with PID have symptoms so mild that they may be unaware that they are infected.

In acute salpingitis, a common form of PID, swelling of the fallopian tubes may cause tenderness on physical examination. Fever may be present. Abscesses may develop in the tubes, ovaries, or in the surrounding pelvic cavity.

Infectious discharge may leak into the peritoneal cavity and cause peritonitis; or abscesses may rupture, causing a life-threatening surgical emergency.

Chronic salpingitis may follow an acute attack. Subsequent to inflammation, scarring and resulting adhesions may result in chronic pain and irregular menses. Due to blockage of the tubes by scar tissue, women with chronic salpingitis suffer a high risk of having an ectopic pregnancy.

An ectopic pregnancy develops when a fertilized ovum is unable to travel down the fallopian tube to the uterus and implants itself in the tube, on the ovary, or in the peritoneal cavity. This condition can also be a life-threatening surgical emergency.

IUDs

The use of intrauterine devices, or IUDs, has been strongly associated with the development of PID. Bacteria may be introduced to the uterine cavity while the IUD is being inserted or may travel up the tail of the IUD from the cervix into the uterus. Surrounding uterine tissue may show areas of inflammation, increasing its susceptibility to pathogens.

Some researchers, however, maintain that the connection between IUDs and PID has been exaggerated and that further research is necessary.


Susceptibility to STDs

Susceptibility to STDs involves many factors, some of which are not known. The ability of the organism to produce disease and the circumstances that place the organism in the right place at a time when a trauma or alteration to the lining cells has occurred are factors. The woman’s own immune response also helps to determine whether infection occurs.

Diagnosis

If PID is suspected, the physician will take a complete medical history and perform an internal pelvic examination. Other diseases that may cause pelvic pain, such as appendicitis and endometriosis, must be ruled out. If pelvic examination reveals tenderness or pain in that region, or tenderness on movement of the cervix, these are good physical signs that PID is present.

Specific diagnosis of PID is difficult to make because the upper pelvic organs are hard to reach for samplings. The physician may take samples directly from the cervix to identify the organisms that may be responsible for infection.

Two blood tests may help to establish the existence of an inflammatory process. A positive C-reactive protein (CRP) and an elevated erythrocyte sedimentation rate (ESR) indicate the presence of inflammation.

The physician may take fluid from the cavity surrounding the ovaries called the cul de sac; this fluid may be examined directly for bacteria or may be used for culture. Diagnosis of PID may also be done using a laparoscope, but laparoscopy is expensive, and it is an invasive procedure that carries some risk for the patient.

A newer diagnostic technique that has dramatically improved the accuracy of laboratory testing for PID and other STDs is the ligase chain reaction (LCR) technique. The LCR technique detects DNA from N. gonorrhoeae and C. trachomatis in a patient’s urine sample. LCR technology is less invasive as well as more accurate.

Treatment

Alternative therapy should be complementary to antibiotic therapy. Because of the potentially serious nature of this disease, a patient should first consult an allopathic physician to start antibiotic treatment for infections.

Traditional medicine is better equipped to quickly eradicate the infection, while alternative treatments can help the body fight the disease and relieve painful symptoms associated with PID. Some of the alternative treatments include diets, nutritional supplements, herbal remedies, homeopathy, acupressure, and acupuncture.

General recommendations

• Bed rest. Patients need to rest and reduce physical activity to help the body recuperate faster.
• Avoid sexual activity. Both patient and her partner should be treated for PID infections. They should also avoid sexual activity until their infections are completely eradicated.
• Healthy diet. Diet should include a variety of fresh fruits and vegetables. These foods contain high amount of phytonutrients and essential vitamins that help keep the body strong and stimulate the immune system to fight infections.

Nutritional supplements

The following nutritional supplements may be helpful:

• Daily vitamin and mineral supplements. These supplements can ensure that the body receives all the essential nutrients for normal body function. They also help keep the body strong to fight diseases including PID.
• Vitamin C. High-dose vitamin C (1–2 g) boost the immune function and help the body fight infection better.

Herbal treatment

The following herbal remedies may be helpful:

• Castor oil packs. Patients can make warm packs by pouring castor oil on a clean piece of cloth wrapped in layers and warming it before placing on the lower part of their abdomen for up to 20 minutes. It is recommended that patients repeat this therapy every day for up to seven days.
• Echinacea spp., goldenseals and Calendula officinalis. These herbs are believed to have antimicrobial activity and may be taken to augment the action of prescribed antibiotics.
• Grapefruit seed extract. This herb has been used to fight a variety of infections including bacterial, viral, fungal, parasitic, and worm infections.
• Blue cohosh (Caulophyllum thalictroides) and false unicorn root (Chamaelirium luteum). These remedies are recommended as tonics for the general well-being of the female genital tract.

Homeopathy

A homeopathic practitioner may prescribe a patientspecific remedy to help reduce some of the symptoms associated with PID. Herbs that are used in PID patients include Apis mellifica, Arsenicum album, Belladonna, Colocynthis, Magnesia phosphorica, and Mercurius vivus.

Acupressure

Acupressure (applying pressure on specific pressure points) can increase blood flow to the pelvic region, reduce pain, and promote general health.

Acupuncture

Acupuncture involves inserting needles at various points on the skin of the body. These needles are like antennae that direct qi (life force) to organs or functions of the body. This treatment may help with pain and also strengthen immunity. It is important that patients request disposable needles to prevent transmission of AIDS, hepatitis, and other infectious diseases.

Allopathic treatment

If acute salpingitis is suspected, treatment with antibiotics should begin immediately. The patient is usually treated with at least two broad-spectrum antibiotics that can kill both N. gonorrhoeae and C. trachomatis plus other types of bacteria that may have the potential to cause infection.

Hospitalization may be required to ensure compliance. Treatment for chronic PID may involve hysterectomy. Early treatment of suspected PID is essential because some strains of N. gonorrhoeae are showing increasing resistance to standard antibiotics as of 2002.

If a woman is diagnosed with PID, she should see that her sexual partner is also treated to prevent the possibility of reinfection.

Expected results

PID can be cured if the initial infection is treated immediately. If infection is not recognized, as frequently happens, the process of tissue destruction and scarring that results from inflammation of the tubes results in irreversible changes in the tube structure that cannot be restored to normal.

Subsequent bouts of PID increase a woman’s risk of complications. Thirty to forty percent of female infertility cases are due to acute salpingitis.

With modern antibiotic therapy, death from PID is almost nonexistent. In rare instances, death may occur from the rupture of tubo-ovarian abscesses and the resulting infection in the abdominal cavity. One recent study has linked infertility, a consequence of PID, with a higher risk of ovarian cancer.

Prevention

The prevention of PID is a direct result of the prevention and prompt recognition and treatment of STDs or of any suspected infection involving the female genital tract. The main symptom of infection is an abnormal discharge. To distinguish an abnormal discharge from the mild fluctuations of normal discharge associated with the menstrual cycle takes vigilance and self-awareness.

Sexually active women must be able to detect symptoms of lower genital tract disease. Frank dialogue regarding sexual history, risks for PID, and treatment options is necessary with a physician. Also, open discussions with sexual partners regarding symptoms and possible infection is imperative.

Lifestyle changes should focus on preventing the transfer of organisms when the body’s delicate lining cells are unprotected or compromised. Barrier contraceptives, such as condoms, diaphragms, and cervical caps, should be used.

Women in monogamous relationships should use barrier contraceptives during menses and take their physician’s advice regarding intercourse following abortion, childbirth, or biopsy procedures.

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