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The condition high blood pressure quiz metoprolol 25mg with amex, associated with circulatory collapse with intravascular coagulation pulse pressure of 78 buy 25mg metoprolol visa, is invariably fatal blood pressure 10060 order metoprolol without a prescription. It is most commonly seen in persons suffering from deficiency of C5­C9 components of the complement heart attack romance cheap metoprolol. Maternal antibodies provide protection to infants for the first 3­6 months of life. Later, colonization with nonpathogenic meningococci appears to produce cross-reacting, protective antibodies. Specific IgG antibodies are produced against meningococcal polysaccharides in combination with the complement mediate bactericidal activity against the meningococci. Individuals lacking the bactericidal antibodies and those suffering from complement deficiencies-such as C5, C6, C7, or C8 components of the complement-show increased susceptibility to meningococcal disease. An episode of meningitis confers group-specific immunity, but a second episode may be caused by another meningococcal serogroup. Nonsuppurative arthritis, usually of the knee joint, is seen in approximately 10% of the patients with meningococcal disease. This condition is observed within the first 48 hours of treatment and is believed to be immunologically mediated. Recurrent meningococcal meningitis is another condition which is associated with hereditary deficiency of various components of complement system. Other conditions include meningococcal pneumonia (which probably results from the aspiration of the organisms), septic arthritis, purulent pericarditis, and endophthalmitis. It is a febrile illness of short duration characterized by headache and stiff neck. Mental obtundation, stupor, and coma due to increased intracranial pressure are some of the noted complications at the end stage of the disease. Prognosis of meningitis is good, and the patients recover completely on immediate treatment with appropriate antimicrobial therapy. However, prognosis is bad in comatose patients and in patients with local neurological findings. Endemic meningitis is more common in children below the age of 5 years and in elderly people. Large outbreaks of meningococcal disease have occurred in central African countries with attack rate as high as 400­500 cases per 100,000 population. Meningococci of group A are associated with diseases in underdeveloped countries; meningococci of group B, C, or Y are responsible for most (90%) of the cases of meningococcal diseases in the developed countries (Table 26-5). The carriage rates are highest in schoolgoing children, in young adults, and in the population with low economic status. The third part is incubated overnight with an equal volume of glucose broth and then subcultured onto the blood agar and chocolate agar. Meningococci are transmitted by airborne droplets of infected nasopharyngeal secretions (the most common source of infection). Family members living in crowded conditions or the people who live in close populations (such as military barracks and prisons) and older people are more susceptible to infection. Meningococci are seen as Gram-negative diplococci present mainly inside the leukocytes and some may even be present extracellularly. In fulminant meningococcemia, Gram staining of the peripheral blood buffy coat may reveal Gram-negative diplococci. Culture Laboratory Diagnosis Laboratory diagnosis depends on demonstration of meningococci in clinical specimens by microscopy and culture. Chapter 26 Specimens Cerebrospinal fluid and blood are the specimens of choice for demonstration of meningococci in the early stage of meningitis. Similarly, blood is collected in blood culture media containing either glucose broth or sodium taurocholate broth. The colonies of meningococci are small, round, translucent, and convex with a smooth glistening surface. Blood is inoculated immediately into blood culture bottles containing either glucose broth or sodium taurocholate broth and incubated at 35­36°C. Blood culture is often positive during early stage of meningitis and in meningococcemia. Serogrouping of the bacterial isolates grown on culture is carried out by slide agglutination with specific hyperimmune serum. The total glucose level, which is normally 60% of simultaneous blood glucose level, is lowered (hypoglycorrhachia).

The name "Proteus" (after the Greek god Proteus who could assume any shape) refers to their property of pleomorphism blood pressure value chart order metoprolol amex. All the members of the tribe Proteeae with few exceptions are Gram negative blood pressure kiosk locations purchase metoprolol amex, noncapsulated heart attack enzyme order metoprolol online pills, pleomorphic heart attack jack black widow generic metoprolol 25 mg overnight delivery, and motile bacilli. Most of these bacteria, except for some strains of Providencia, produce the enzyme urease which rapidly hydrolyses urea to form ammonia and carbon dioxide. They do not decarboxylate amino acids, such as arginine or lysine or dehydrogenase ornithine. The differentiating features of different genera in the tribe Proteeae are summarized in Table 31-11. The genus Proteus has four species: Proteus mirabilis, Proteus vulgaris, Proteus penneri, and Proteus myxofaciens. They are isolated from patients with chronic debilitating diseases and from those who are immunocompromised. Culture Proteeae organisms are aerobic bacteria, which grow well on ordinary media, such as nutrient agar. Proteus colonies on the medium emit a characteristic putrefactive ("fishy" or "seminal") odor. They spread on the surface of the plate in successive waves to form a thin filmy layer in concentric circles. The exact mechanism responsible for swarming shown by Proteus species is not known. Swarming, shown by Proteus, is a problem when mixed growth on a solid medium is obtained in which Proteus bacilli are present with other bacteria. Hence, several methods are available to inhibit swarming; these include the use of increased concentration of agar in the medium from 1­2% to 6%, and the use of chloral hydrate (1:500), sodium azide (1:500), alcohol (56%), sulfonamide, surface active agents, or boric acid (1:1000). Swarming does not occur on MacConkey medium, on which Proteus produces colorless nonlactose-fermenting colonies. Proteus species show variable reactions in the production of hydrogen sulfide and indole. Proteus possesses following virulence factors: Pili: Fimbriae or pili are the important virulence factors that facilitate adherence of P. Hydrolysis of urea to ammonia makes the urine alkaline, which provides a suitable environment for Proteus to survive. Subsequently, alkalization of urine leads to precipitation of organic and inorganic compounds, which in turn leads to formation of stones in renal calculi. These stones are composed of a combination of magnesium ammonium phosphate (struvite) and calcium carbonate-apatite. Cell Wall Components and Antigenic Properties Motile Proteus strains possess somatic O and flagellar H antigens. Somatic O antigens are heat-stable proteins, which are resistant to heating at 100 °C. The alkali-stable component is polysaccharide in nature and shows cross-reactivity with certain rickettsial antigens. The sharing of antigens with rickettsial antigens was first observed by Weil and Felix. This heterophilic agglutination by certain Proteus strains formed the basis of the Weil­Felix reaction for the diagnosis of some rickettsial infections. Flagellar antigens are heat-labile proteins sensitive to ethanol and to dilute hydrochloric acid. Pathogenesis of Proteus infection depends on the interaction between the bacteria and the host defense mechanisms. Adherence of the bacteria to host tissue mediated by fimbriae is the first step in the disease process. The attachment of Proteus species to uroepithelial cells causes secretion of interleukin-6 and interleukin-8. The infection of the urinary tract is facilitated further by production of the enzyme urease and also motility of the bacteria. Chapter 31 Clinical Syndromes Patients with multiple antibiotic treatments, urinary tract obstruction, or infection developing after catheterization or instrumentation frequently become infected with Proteus spp. Proteus species cause (a) urinary tract infections, (b) hospital-acquired infections, and (c) other miscellaneous infections. These O groups are further subdivided into a large number of O types depending on their flagellar or H antigens.

Corticosteroid therapy in IgA nephropathy with nephrotic syndrome: a long-term controlled trial blood pressure chart philippines purchase metoprolol 12.5mg on line. Factors that determine an incomplete recovery of renal function in macrohematuria-induced acute renal failure of IgA nephropathy pulse pressure 70-80 metoprolol 25 mg lowest price. Acute worsening of renal function during episodes of macroscopic hematuria in IgA nephropathy blood pressure medication missed dose generic metoprolol 100 mg without prescription. Macroscopic hematuria in mesangial IgA nephropathy: correlation with glomerular crescents and renal dysfunction how quickly do blood pressure medication work order 100mg metoprolol overnight delivery. Risk of long term renal impairment and duration of follow up recommended for Henoch-Schonlein purpura with normal or minimal urinary findings: a systematic review. Predictive factors for nephritis, relapse, and significant proteinuria in childhood Henoch-Schonlein purpura. The adult kidney 24 years after childhood Henoch-Schonlein purpura: a retrospective cohort study. Early prednisone therapy in Henoch-Schonlein purpura: a randomized, double-blind, placebocontrolled trial. Methylprednisolone pulse therapy in the treatment of severe forms of Schonlein-Henoch purpura nephritis. Effective therapy for severe Henoch-Schonlein purpura nephritis with prednisone and azathioprine: a clinical and histopathologic study. Henoch-Schonlein purpura nephritis: course of disease and efficacy of cyclophosphamide. Efficacy of methylprednisolone and urokinase pulse therapy combined with or without cyclophosphamide in severe Henoch-Schoenlein nephritis: a clinical and histopathological study. Response of crescentic HenochSchoenlein purpura nephritis to corticosteroid and azathioprine therapy. Treatment of HenochSchonlein Purpura glomerulonephritis in children with high-dose corticosteroids plus oral cyclophosphamide. Cyclosporin A therapy for severe HenochSchonlein nephritis with nephrotic syndrome. Comparison of Ё azathioprine vs mofetil mycophenolate for Henoch-Schonlein nephritis treatment (abstract). Prevention and treatment of renal disease in Henoch-Schonlein purpura: a systematic review. Randomised placebo controlled trial to assess the role of early prednisolone on the Ё development and progression of Henoch-Schonlein Purpura Nephritis (abstract). HenochSchonlein purpura in adulthood and childhood: two different expressions of the same syndrome. Henoch-Schoenlein nephritis in adults-clinical features and outcomes in Finnish patients. Clinical manifestations and outcomes of Henoch-Schonlein purpura: comparison between adults and children. Addition of cyclophosphamide to steroids provides no benefit compared with steroids alone in treating adult patients with severe Henoch Schonlein Purpura. Two aspects of the clinical and humanistic burden of systemic lupus erythematosus: mortality risk and quality of life early in the course of disease. Demographic differences in the development of lupus nephritis: a retrospective analysis. Changes in the incidence of endstage renal disease due to lupus nephritis in the United States, 1996­2004. Lupus nephritis among 624 cases of systemic lupus erythematosus in Riyadh, Saudi Arabia. Microalbuminuria and renal morphology in the evaluation of subclinical lupus nephritis. Treatment of diffuse proliferative lupus nephritis with prednisone and combined prednisone and cyclophosphamide. The 10-year follow-up data of the Euro-Lupus Nephritis Trial comparing low-dose and high-dose intravenous cyclophosphamide. Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Long-term outcome of patients with diffuse proliferative lupus nephritis treated with prednisolone and oral cyclophosphamide followed by azathioprine. Outcome and prognostic indicators of diffuse proliferative lupus glomerulonephritis treated with sequential oral cyclophosphamide and azathioprine.

The clostridial toxins typically cause extensive hemolysis and bleeding blood pressure risks buy metoprolol overnight, and finally death occurs due to circulatory failure pulse pressure 72 order 100mg metoprolol with visa. Abundant production of gas by the bacteria further reduces the blood supply and causes anoxia arrhythmia jaw pain buy discount metoprolol online. The alpha-toxin lyses erythrocytes and causes hemolytic anemia and hemoglobinuria blood pressure medication and fatigue order genuine metoprolol on line, observed in the condition. The collagenase destroys tissue matrix and hyaluronidase destroys intercellular substances, thereby facilitating further invasion and spread of the bacteria in tissues. They typically produce enterotoxin, but production of alpha- and theta-toxin is very minimal. Food poisoning is caused by ingestion of cold and warmed up meat dishes contaminated with large numbers (108­109) of C. Abdominal cramps and watery diarrhea-but absence of nausea, vomiting, or fever-are characteristic presentations of this condition. The condition is characterized by abdominal pain, bloody diarrhea, shock, and peritonitis. Immunization with type C toxoid has been reported to protect against this condition. This condition is known as "Pigbel" in Papua New Guinea, where it is very common and as "Darmbrand" (meaning "fire bowels") in Germany. Soft tissue infections Septicemia this is a life-threatening situation with the isolation of bacteria in blood culture. Pus and other exudates from deeper part of the wound and from the sides where infection appears to be most acute; the specimen is collected by a capillary tube and swab. Smears from the muscles at the edge of the affected site, from the pus and/or exudate from deeper parts of the wound, and from the necrotic tissue. Geographical distribution the specimens for gas gangrene include the following: C. These bacteria are excreted in the feces and hence contaminate the skin of the perianal region, buttocks, and thighs. They remain viable for a very long period even in adverse environmental conditions. The specimens for investigation of food poisoning include feces and remnants of food. It provides information regarding the species of clostridia that causes the infection and also indicates relative number of the clostridial species found in clinical specimens: 1. Demonstration of a large number of Gram-positive bacilli without spores, and absence of leukocytes in stained smears of clinical specimens, is suggestive of C. Large-sized Gram-positive bacilli with the presence of oval and subterminal spores suggest Clostridium novyi. Leaf-shaped or boat-shaped pleomorphic bacilli with irregular staining suggest Clostridium septicum. The condition is caused by: Contamination of wound with soil, such as manure soil or cultivated soil, road dusts, or bits of clothing heavily contaminated with C. Clostridium species that are present on the normal skin, especially on the perineum and thighs, which invade through a wound and cause the infection (endogenous infection). Culture Clostridial food poisoning occurs following ingestion of cold or warmed up meat dishes contaminated with spores of C. Foods contaminated with large number of bacteria are the sources of exogenous infection in case of necrotizing enteritis. Laboratory Diagnosis Laboratory diagnosis of gas gangrene and other soft tissue diseases is carried out to: (a) Confirm the diagnosis, (b) Identify the clostridial species, and (c) Differentiate gas gangrene from anaerobic streptococcal myositis. Treatment has to be started immediately in suspected as well as clinically diagnosed cases without waiting for the laboratory results. Specimens are inoculated simulataneously on a set of two fresh and heated blood agar containing 5­6% agar to prevent swarming. One inoculated medium is incubated aerobically and the another inoculated medium is incubated anaerobically for 24 hours or less. Subsequently, subcultures are made on blood agar to detect and differentiate various clostridial species. This reaction demonstrates biological property of the enzyme lecithinase-to produce opalescence in the serum and in the egg yolk media. Ferments lactose with production of acid in litmus milk (stormy fermentation positive).

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