Multiple Myeloma

Multiple Myeloma is a malignant tumor of plasma cell. Plasma cell produce poly-clonal immunoglobulin. But plasma cell tumor is monoclonal. In Multiple Myeloma they can produce pure immunoglobulin or only heavy chain or only light chain.

Clinical Feature:
Diagnosis of MM requires two of the following criteria

1. Increased malignant plasma cells in the bone marrow
2. Serum and/or urinary paraprotein
3. Skeletal lytic lesions.

Other features and investigation of MM:

• Generalized bony pain
• Recurrent infection
• Severe anemia with features of anemia
• Hypercalcemia
• Pathological calcification
• Features of hypercalcemia
• Retinal bleeds
• Bruising
• Heart failure
• Cerebral ischaemia
• Pancytipenia
• Raised ESR.

Plasma alkaline phosphatase and isotope bone scan will be normal despite the lytic action because there is no osteoblastic activity.

Management:

1. If patients are asymptomatic treatment may not be required.
2. Immediate support

• High fluid intake to treat renal impairement
• Analgesia for bone pain
• Biphosphonates for hypercalcaemia and to delay other skeletal related events
• Allopurinol to prevent urate nephropathy
• Plasmapheresis for hyperviscosity

1. Chemotherapy: Thalidomide
2. Bone marrow transplantation

Adverse effect of Thalidomide: Somnolence, Constipation, Peripheral neuropathy, Teratogenic effect.

Prognosis:
Low prognostic features include 

• High Microglobulin
• Low albumin
• Low Haemoglobin
• High calcium;  at presentation.

Median life expectancy: 2 Years.

• Absence of monoclonal band in plasma electrophoresis exclude MM.
• Amyloidosis is Only light chain producer.
• Another cause of very high ESR is Temporal arteritis.

          

Hydrocarbon Poisoning

Hydrocarbon includes:
Petrol, Kerosene, Lighter Fluid, Mineral turpentine, Paraffin Oil, Lubricating oil, Furniture Polishes, 2 stroke fuel, Diesel, White spirit.

Assessment:
1. Main complication is aspiration pneumonitis.
2. CNS toxicity can be evident, either by depressor or excitement.

Symptoms:
Coughing, Choking, respiratory distress, ataxia, drowsiness, coma, convulsions, persistent burping. 

Management:

1. Stabilizing the airway.
2. O2 inhalation
3. Early intubation, mechanical ventilation in patient in whom oxygenation is adequate or in patient who has severe respiratory distress or a decreased level of consciousness.
4. Precaution to minimize risk of vomiting and further aspiration.
5. Decontamination by removing involved clothing and thoroughly washing skin with soap water.
6. Gastric lavage is not indicated.
7. No antidote is available for hydrocarbon.
8. Steroids may be harmful
9. If there is aspiration pneumonitis -- than treatment is accordingly:
       Inj. Clindamycin or Inj Amoxicillin + Inj. Metronidazole.    

Avian influenza

Bird flu; H5N1

Avian influenza is flu infection in birds. The virus that causes the bird infectin can change (mutate) to infect humans. Such mutation could start a deadly worldwide epidemic.

The following people have a higher risk for developing the bird flu:

• Farmers and others who work with poultry
• Travelers visiting affected countries
• Those who touch an infected bird
• Those who eat raw or undercooked poultry meat, eggs, or blood from infected birds

Health care workers and household contacts of patients with avian influenza may also be at an increased risk of the bird flu.

The avian flu virus (H5N1) has been shown to survive in the environment for long periods of time. Infection may be spread simply by touching contaminated surfaces. Birds who were infected with this flu can continue to release the virus in their feces and saliva for as long as 10 days.

Symptoms

Symptoms of avian flu infection in humans depend on the strain of virus.

Infection with the H5N1 virus in humans causes typical flu-like symptoms, which might include:

• Cough (dry or productive)
• Diarrhea
• Difficulty breathing
• Fever greater than 100.4°F (38°C)
• Headache
• Malaise
• Muscle aches
• Runny nose
• Sore throat

Treatment

oseltamivir (Tamiflu) or zanamivir (Relenza)

Complications

• Acute respiratory distress
• Organ failure
• Pneumonia
• Sepsis

Asymptomatic bacteriuria

Asymptomatic bacteriuria is a significant number of bacteria in the urine that occurs without usual symptoms such as burning during urination or frequent urination.

Asymptomatic bacteriuria may not need treatment, which makes it different from a bacterial urinary tract infection.

Causes, incidence, and risk factors

Asymptomatic bacteriuria occurs in a small number of healthy individuals. It more often affects women than men. The reasons for the lack of symptoms are not well understood.

Most patients with asymptomatic bacteriuria do not need treatment because the bacteria are not causing any harm. Persons who have urinary catheters often will have bacteriuria, but most will not have symptoms.

Certain people are at a higher risk for kidney infections if they develop asymptomatic bacteriuria. The following increases your risk:

• Diabetes
• Infected kidney stones
• Kidney transplant
• Older age
• Pregnancy -- up to 40% of pregnant women with untreated asymptomatic bacteriuria will develop a kidney infection
• Vesicoureteral reflux in young children

Symptoms

By definition, asymptomatic bacteriuria causes no symptoms. The symptoms of a urinary tract infection include burning during urination, an increased urgency to urinate, and increased frequency of urination.

Signs and tests

Asymptomatic bacteriuria is detected by the discovery of significant bacterial growth in a urine culture taken from a urine sample.

Treatment

Not all patients with asymptomatic bacteriuria need treatment. Pregnant women, kidney transplant recipients, children with vesicoureteral reflux, and those with infected kidney stones appear to be more likely to benefit from treatment with antibiotics.

Giving antibiotics to persons who have long-term urinary catheters in place may cause additional problems. The bacteria may be more difficult to treat and the patients may develop a yeast infection.

If asymptomatic bacteriuria is found before a urological procedure, it should be treated to prevent complications. The course of treatment in these cases depends on the person's risk factors.

Complications

Untreated, asymptomatic bacteriuria can lead to a kidney infection in high-risk individuals. In some cases, particularly in those who have had kidney transplants, such infections may lead to the loss of kidney function.

What are the parasitic diseases of liver

Amebiasis

Hydatid Cyst

Schistosomiasis

Biliary Tree Parasites

Liver Flukes

Other Parasites

The reticuloendothelial system of the liver may be involved in leishmansias, malaria and others.

Indications For Cultures

Blood cultures should be obtained (PRIOR to initiation of antimicrobial therapy) for any patient in whom there is suspicion of bacteremia, including hospitalized patients with fever and leukocytosis or leukopenia. Circumstances in which blood cultures are especially important include sepsis, meningitis, osteomyelitis, arthritis, endocarditis, pneumonia, and fever of unknown origin.

I. INDICATIONS

Routine blood cultures should be performed on any patient in whom there is a suspicion of bacteremia or candidemia.

Isolator blood cultures should be performed on any patient suspected of having one of the following:

1. Subacute or chronic endocarditis with multiple negative BACTEC system cultures. It is appropriate to use the BACTEC system for the initial workup of endocarditis of any suspected etiology. Isolators should be used after multiple BACTEC cultures are obtained and fail to reveal an etiologic agent (including HACEK).

2. Suspected deep fungal infection, such as histoplasmosis, blastomycosis, and coccidioidomycosis. Ordinarily, cultures of other sites, such as tissue biopsy, and in some cases serological tests such as antigen and antibody tests, are more helpful than blood culture.

3. Suspected mycobacteremia, particularly in HIV patients with CD4 counts <50 .="." span="span">

4. Suspected disseminated gonococcal infection.

5. Suspected bartonellosis.

6. Suspected candidemia or disseminated cryptococcosis in patients for whom routine cultures have not detected Candida species or Cryptococcus neoformans, respectively.

7. Suspected Malassezia furfur infection, an agent of catheter-associated infection in patients receiving intravenous lipid.