Introduction To Sexually Transmitted Infections

Sexually transmitted infections refers to the mode of transmission of infection and the the reproductive tract infection refers to the site where the infection occurs. All Reproductive tract infections cannot be sexually transmitted infections.

The STI are spread through sexual contact with infected partners and the common examples include:

  • Gonorrhoea
  • Chylamydia
  • Syphilis
  • Trichomoniasis
  • Chancroid
  • Genital herpes
  • Genital warts caused by HPV

Risk factors

  • Age less than 25 years
  • Young age at first sex
  • Non barrier contraception method
  • New, multiple or symptomatic sexual partners.

Incidence

The incidence of STD’s is increasing by 10% every year where safe sex practices are being ignored. 448 million new cases of curable STD’s occur annually through out the world in persons aged 15 to 49 years.

Women at more risk

Women are physiologically more vulnerable than men. If they are asymptomatic they might not seek proper medical care and later it may lead to serious complications. Use of traditional vaginal medications and douching may also increase the risk for acquiring the STD’s in women.  With the exception of HIV all STD’s have more threatening consequences in women than in men. In women it usually leads to infertility, ectopic pregnancy and cervical cancer.

Clinical Presentation

Patient with a STI usually presents with one of theses symptoms:

  • Vaginal or urethral discharge.
  • Genital lesions
  • Genital warts
  • HIV
  • Infertility

History and Physical Examination

During the history and physical examination it is important to ask about the timing of last intercourse, contraceptive method used, number of sexual partners, duration of relationship, past STD”S, menstrual and medical history as well as any antimicrobial treatment taken by the patient. Continue reading “Introduction To Sexually Transmitted Infections”

Investigations Helpful In The Diagnosis Of Rheumatoid Arthritis

There is no specific test for the diagnosis of rheumatoid arthritis but a number of different investigations are helpful. When ever a patient i suspected to have rheumatoid arthritis on the basis of clinical symptoms and physical examination following tests are usually ordered:

1. RA Factor

Rheumatoid(RA)  factor is an IgM autoantibody against Fc fragment of IgG and is present in about 70% of cases of rheumatoid arthritis. RA factor is not specific as it may be positive in other connective tissues disorders as well.  Presence of RA factor thus does not establish the diagnosis but it can be of prognostic value with patients who have a high titre having a more severe  and progressive disease with extra articular manifestations.

2. ANA

Antinuclear antibodies (ANA) are positive in 30% of cases of rheumatoid arthritis.

3. Blood CP

Complete blood count shows anemia and thrombocytosis in proportion to the severity of joint inflammation. White cell count may be normal, high or low.

3. ESR

ESR is raised in proportion to the activity of inflammatory process. Other markers of inflammation like C-reactive protein are also raised.

4. Radiography

X rays taken during the first six months of the disease are usually normal. The earlies changes on x ray are seen in the wrist or feet and consists of :  Continue reading “Investigations Helpful In The Diagnosis Of Rheumatoid Arthritis”

Herpes Simplex Virus Infection

Herpes Simplex virus infection may be caused by type I or type II virus and the infection may be primary or recurrent.

Primary Infection

The manifestations of primary Infection includes:

1. Systemic infection: e.g fever, sore throat and lymphadenopathy that may pass unnoticed. If the patient is immunocompromised, then the disease may become life threatening with fever, lymphadenopathy, pneumonitis and hepatitis.

2. Gingivostomatitis: Ulcers filled with yellow slough appear in the mouth.

3. Herpetic Whitlow: A breach in the skin that may be due to any minor trauma allows the virus to enter the finger, causing a vesicle to form. Often this condition is seen in children nurses.

4. Traumatic Herpes: Also known as Herpes gladiatorum. In this condition vesicles develop at any site where herpes simplex virus have been inoculated on the skin by brute force.

5. Eczema Herpeticum: HSV infection superimposed on eczematous skin. Usually seen in children.

6. Herpes Simplex Meningitis: This is uncommon and if occurs it is usually self limiting.

7. Genital Herpes: It is usually caused by HSV type II. In males it presents as grouped vesicles and papules that develop around anus and penis associated with fever, pain and dysuria. In females the symptoms are more severe and there are blisters and vesicles appearing on the on the external genitalia, labia majora, labia minora, vaginal vestibule, and introitus. In moist areas, the vesicles rupture, leaving exquisitely tender ulcers. The vaginal mucosa is inflamed and edematous. There is severe burning and pain on micturition and there is associated flu like symptoms including fever, headache and lymphadenopathy.  Continue reading “Herpes Simplex Virus Infection”

Introduction To Analgesic Nephropathy

Analgesic Nephropathy is a condition that is associated with prolonged, heavy use of analgesics that leads to decline in renal function due to chronic papillary necrosis and chronic diffuse tubulointerstitial damage to renal cortex.

The incidence of analgesic nephropathy has declined significantly after the withdrawal of phenacetin use.

Clinical Features

  • Patients with analgesic nephropathy are unable to produce maximally concentrated urine due to underlying medullary and papillary damage.
  • They present with repeated UTI’s and or urinary abnormalities on urinalysis like hematuria, proteinuria, casts etc.
  • Anemia is more severe as compared to level of renal insufficiency.
  • Distal tubular acidosis associated with analgesic nephropathy contributes to the development of nephrocalcinosis.
  • Kidneys become shrunken and calyces are deformed producing “ring sign” on IVP that is pathognomonic of papillary necrosis.
  • Transitional cell carcinoma may develop in the urinary pelvis or ureters as a late complication of analgesic abuse.

Treatment

  • Stop the analgesics.
  • Antibiotics for infection.
  • Drainage for obstruction.
  • Dialysis or transplantation for end stage renal disease.

Introduction to Renal Biopsy

Renal biopsy is not a commonly performed procedure in medical practice but it is sometimes indicated when it has diagnostic value in certain kidney diseases.  Most cases of acute renal failure are due to pre renal causes or acute tubular necrosis and recovery of renal function typically occurs over a course of few weeks. Renal biopsy should only be performed if knowing the histology will help in the management. Once chronic renal failure is established, the kidneys are small, may be hard to biopsy, and theresults are usually unhelpful.

Indications

  • To determine the cause of unexplained renal failure.
  • Persistent Heavy proteinuria >1gm/24hrs
  • Investigating the cause of adult nephritic syndrome with persistent hematuria.
  • Childhood nephritic or nephrotic syndrome that are unresponsive to treatment.
  • Systemic disease with renal involvement like sarcoidosis, amyloidosis.
  • Post transplant renal dysfunction.

Contraindication

  • Underlying disorder of coagulation.
  • Thrombocytopenia.
  • Uncontrolled hypertension.
  • Solitary kidney (except in transplanted kidneys).
  • Small contracted kidneys i.e < 60% of expected bipolar length because it is technically difficult, histology is hard to interpret and prognosis cannot be altered.
  • Uncooperative patient.

Procedure

1. All the basic investigations including CBC, coagulation screen, bleeding time, blood group and ultrasound of the kidneys is done.

2. A full explanation of procedure is given to the patient and informed consent is taken.

3. Biopsy is done under ultrasound guidance with the patient lying in the prone position and the breath held.

4. Local anaesthetic is injected along the biopsy track.

5. A pressure dressing is applied to the biopsy site and the patient rests in bed for 24 hrs.  Continue reading “Introduction to Renal Biopsy”

A Brief Discussion On Urinalysis

Urinalysis means examining or testing the urine and it is one of the most common and easy method used for medical diagnosis. It involves the physical, chemical, and microscopic examination of urine.

A part of a urinalysis can be performed by using urine test strips, known as Dipstick in which the test results can be read as color changes. Another method is examination of the urine sample under light microscopy.

Physical Or Macroscopic Examination Of urine

The first part of a urinalysis is direct visual observation:

1. Colour

Normal color of the urine ranges from colorless to deep yellow depending on the concentration of the urochorme pigment. Different colors may be observed in different conditions like red with blood in the urine or certain food colors e.d beetroot. orange with rifampicin, yellow in jaundice or dehydration and black with severe hemoglobinuria.

2. Volume

Normal volume is 800-2600 ml/day and it is referred to be oligouria if its < 300 ml/day and anuria if < 100 ml/day.

3. Appearance

A normal urine sample appears clear on visual inspection. Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator. Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of tubidity.

Urine Dipstick Chemical Analysis

1. Specific Gravity

Normal range is 1.000 to 1.030. It varies with the quantity of urine and a persistently low specific gravity suggests chronic renal failure or diabetes insipidus while a high specific gravity suggests dehydration.

2. pH

Fresh urine specimen is acidic with an average pH of 6 and a normal range of 4.5-8. The pH is usually important in investigation and management of renal tubular acidosis. Infection with urea splitting organism Proteus causes alkaline urine that favors renal stone formation.

3.Protein

Normal protein loss from urine is 150 mg/24 hrs and it may sometimes rise upto 300 mg/24hrs in fever or with exercise. Other common causes of proteinuria are nephrotic syndrome, diabetic nephropathy, hypertention and certain infections e.g Hepatitis B, HIV etc. Continue reading “A Brief Discussion On Urinalysis”

Transient Ischemic Attacks

Transient-Ischemic-AttackTransient Ischemic Attack is defined as a condition in which the symptoms of stroke are lasting less than 24 hours. The symptoms usually reach their peak in seconds and lasts for minutes or hours (but by definition less than 24 hours).

TIA has a tendency to recur and to predispose to a complete stroke. There is a complete functional recovery after a TIA and the focal neurological deficits during the episode depend on the artery involved.

Etiology

Transient ischemic attacks are caused by the passage of emboli in about 90% of cases and less commonly it is due to a fall in cerebral perfusion (e.g due to a cardiac dysrhythmia, postural hypotension or reduced blood flow through atheromatous vertebral arteries).

The principal source of emboli is atheromatous plaque within the carotid or vertebral arteries or from mural thrombus formed on diseased heart muscle.

Clinical features

  • TIA’s cause sudden loss of function in one region of the brain depending on the artery involved.
  • Consciousness is usually preserved.
  • On examination of the patient there may be flaccid weakness, sensory loss, hyperreflexia and extensor plantar response on the affected side.
  • Sources of emboli may be evident such as valvular heart disease, endocarditis, recent MI or atrial fibrillation.
  • Associated diseases may be diagnosed like atheroma, hypertension, braydycardia or diabetes.
  • Sometimes patients present with transient monoocular blindness termed as Amaurosis fugas.
  • Some patients may experience episode of amnesia with confusion lasting for several hours caused by ischemia of posterior circulation.

Investigations

The patient should have the initial basic laboratory workup that includes:

Salivary Gland Tumors

Different types of tumor may occur in the salivary gland and may be benign or malignant. A brief discription of the common tumors occuring in the salivary gland is given here:

1. Pleomorphic Adenoma

The pleomorphic adenoma- mixed salivary gland tumor- is a benign tumor, and the commonest salivary gland tumor. It is most commonly seen in the parotid gland and typically forms a mass in the lateral lobe, which slowly enlarges over many years, women in their forties are most often being affected.

Clinical Features

On palpation the tumor is firm, non tender and smooth or lobulated in texture. initially spherical and encapsulated, it may eventually spread more deeply, with the result that recurrence after resection is common. On oral examination the deep part of the gland may have pushed the tonsil and pillar of the fauces towards the midline.

2. Adenolymphoma (Warthin’s Tumor)

It is a bening tumor and the second most common salivary tumor and is found exclusively in the parotid gland. It usually affects males in their fifties, forming a slow growing, painless swelling over the angle of the jaw, there is a high incidence of bilateral disease.

Clinical features

The tumor is smooth, soft and often fluctuant, its superficial nature and slight mobility sometimes giving the appearance that it is separate from the gland.

3. Less Common Benign Tumors

The other less common benign tumors occurring in the salivary glands include

Conditions Causing Skin Hyper pigmentation

Skin Hyper pigmentationSometimes in medical practice patients presents with skin hyperpigmentation or pigmented spots. There are many underlying different causes and they are briefly discussed here:

1. Endocrine Disorders

  • Addison’s disease
  • Cushing’s syndrome
  • Acromegaly
  • Nelson’s syndrome
  • Pregnancy
  • Porphyria

2. Renal Failure

3. Cirrhosis

4. Haemochromatosis

5. Nutritional Causes:

  • Vitamin B12 deficiency
  • Pellagra

6.. Amyloid

7. Acanthosis nigricans

8. Lymphoma

9. Peutz-Jegher’s syndrome (perioral) Continue reading “Conditions Causing Skin Hyper pigmentation”

Brief Summary of Polycystic Ovarian Syndrome

Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders.These patients have a steady state of relatively high estrogen, androgen and LH levels rather than the fluctuating levels seen in ovulating women.

Definition

There are two definitions or diagnostic criteria that are commonly used:

In 1990 a consensus workshop sponsored by the NIH(National Institutes of Health)/NICHD(National Institute of Child Health and Human Disease) suggested that a patient has PCOS if she has all of the following:

  1. Oligoovulation
  2. Signs of androgen excess (clinical or biochemical)
  3. Other entities are excluded that can result in menstrual irregularity and hyperandrogenism.
In 2003 a consensus workshop sponsored by ESHRE(European Society for Human Reproduction and Embryology)/ASRM(American Society for Reproductive Medicine) in Rotterdam indicated PCOS to be present if any 2 out of 3 criteria are met.
  1. Oligoovulation and/or anovualation manifested as oligomenorrhea or amenorrhea
  2. Excess androgen activity (clinical or biochemical evidence)
  3. polycystic ovaries (as seen on gynecologic ultrasound)

Pathophysiology

Increased level of estrogen comes from obesity due to conversion of ovarian and adrenal androgen to estrone in body fat. High estrogen level suppresses FSH and causes relative increase in LH. Constant LH stimulation of ovary results in anovulation, multiple cysts and theca cell hyperplasia with excess androgen production.

Clinical Presentation

A patient with polycystic ovary syndrome presents with following clinical features:

  • Hirsutism (male pattern of hair growth).
  • Obesity
  • Virilization (development of male-like characteristics).
  • Amenorrhea  (no menstrual periods).
  • Abnormal uterine bleeding.
  • Insulin resistance and hyperinsulinemia with increased risk of type II diabetes.
  • Infertility (This generally results directly from lack of ovulation)
  • Increased risk of cancer of breast and endometrium due to unopposed estrogen production.  Continue reading “Brief Summary of Polycystic Ovarian Syndrome”