Toxoplasmosis

Most healthy people who are infected with toxoplasmosis have no signs or symptoms and aren't aware
that they're infected. Some people, however, develop signs and symptoms similar to those of the flu,
including:

Body aches

Swollen lymph nodes

Headache

Fever

Fatigue

In people with weakened immune systems

If you have HIV/AIDS, are receiving chemotherapy or have recently had an organ transplant, a previous
toxoplasma infection may reactivate. In that case, you may develop more-severe signs and symptoms of
infection, including:

Headache

Confusion

Poor coordination

Seizures

Lung problems that may resemble tuberculosis or Pneumocystis jiroveci pneumonia, a common
opportunistic infection that occurs in people with AIDS

Blurred vision caused by severe inflammation of your retina (ocular toxoplasmosis)

In babies

If you become infected for the first time just before or during your pregnancy, you can pass the infection to
your baby (congenital toxoplasmosis), even if you don't have signs and symptoms yourself.

Your baby is most at risk of contracting toxoplasmosis if you become infected in the third
trimester and least at risk if you become infected during the first trimester. On the other hand, the
earlier in your pregnancy the infection occurs, the more serious the outcome for your baby.

Many early infections end in stillbirth or miscarriage. Infants who survive are likely to be born with serious
problems, such as:

Seizures
 An enlarged liver and spleen

Yellowing of the skin and whites of the eyes (jaundice)

Severe eye infections

Only a small number of babies who have toxoplasmosis show signs of the disease at birth. Often, infants
who are infected don't develop signs which may include hearing loss, mental disability or serious eye
infections until their teens or later.

Causes

Toxoplasma gondii (T. gondii) is a single-celled parasitic organism that can infect most animals and birds.
Because it reproduces only in cats, wild and domestic cats are the parasite's ultimate host.

When a person becomes infected with T. gondii, the parasite forms cysts that can affect almost any part of
the body often your brain and muscle tissue of different organs, including the heart.

If you're generally healthy, your immune system keeps the parasites in check. They remain in your body
in an inactive state, providing you with lifelong immunity so that you can't become infected with the
parasite again. But if your immune system is weakened by disease or certain medications, the infection
can be reactivated, leading to serious complications.

Although you can't "catch" toxoplasmosis from an infected child or adult, you can become infected if you:

Come into contact with cat feces that contain the parasite. You may accidentally ingest the
parasites if you touch your mouth after gardening, cleaning a litter box or touching anything that has
come in contact with infected cat feces. Cats who hunt or who are fed raw meat are most likely to
harbor T. gondii.

Eat or drink contaminated food or water. Lamb, pork and venison are especially likely to be
infected with T. gondii. Occasionally, unpasteurized dairy products also may contain the parasite.
Water contaminated with T. gondii isn't common in the United States.

Use contaminated knives, cutting boards or other utensils. Kitchen utensils that come into
contact with raw meat can harbor the parasites unless the utensils are washed thoroughly in hot,
soapy water.

Eat unwashed fruits and vegetables. The surface of fruits and vegetables may contain the
parasite. To be safe, thoroughly wash and peel all produce, especially any you eat raw.

Receive an infected organ transplant or transfused blood. In rare cases, toxoplasmosis can
be transmitted through an organ transplant or blood transfusion.
Risk factors

Anyone can become infected with toxoplasmosis. The parasite is found throughout the world.

You're at risk of serious health problems from toxoplasmosis infection if:

 You have HIV/AIDS. Many people with HIV/AIDS also have toxoplasmosis, either a recent
infection or an old infection that has reactivated.

You're undergoing chemotherapy. Chemotherapy affects your immune system, making it

difficult for your body to fight even minor infections.

Most healthy people don't require toxoplasmosis treatment. But if you're otherwise
healthy and have signs and symptoms of acute toxoplasmosis, your doctor may
prescribe the following drugs:

Pyrimethamine (Daraprim). This medication, typically used for malaria, is a folic

acid antagonist. It may prevent your body from absorbing the B vitamin folate (folic
acid, vitamin B-9), especially when you take high doses over a long period. For
that reason, your doctor may recommend taking additional folic acid.

Other potential side effects of pyrimethamine include bone marrow suppression

and liver toxicity.

Sulfadiazine. This antibiotic is used with pyrimethamine to treat toxoplasmosis.

Treating people with HIV/AIDS

If you have HIV/AIDS, the treatment of choice for toxoplasmosis is also pyrimethamine
and sulfadiazine, with folinic acid (leucovorin). An alternative is pyrimethamine taken
with clindamycin (Cleocin).

Treating pregnant women and babies

If you're pregnant and infected with toxoplasmosis, treatment may vary depending on
where you receive medical care.

If infection occurred before the 16th week of pregnancy, you may receive the antibiotic
spiramycin. Use of this drug may reduce your baby's risk of neurological problems from
congenital toxoplasmosis. Spiramycin is routinely used to treat toxoplasmosis in
Europe, but is still considered experimental in the United States.

If infection occurred after the 16th week of pregnancy, or if tests show that your unborn
child has toxoplasmosis, you may be given pyrimethamine and sulfadiazine and folinic
acid (leucovorin). Your doctor will help you determine the optimal treatment.
If your infant has toxoplasmosis or is likely to have it, treatment with pyrimethamine and
sulfadiazine and folinic acid (leucovorin) is recommended. Your baby's doctor will need
to monitor your baby while he or she is taking these medications.

You take steroids or other immunosuppressant drugs. Medications used to treat certain
nonmalignant conditions suppress your immune system and make you more likely to develop
complications of toxoplasmosis.

Complications

If you have a normal immune system, you're not likely to experience complications of toxoplasmosis,
although otherwise healthy people sometimes develop eye infections. Untreated, these infections can
lead to blindness.But if your immune system is weakened, especially as a result of HIV/AIDS,
toxoplasmosis can lead to seizures and life-threatening illnesses such as encephalitis a serious brain
infection.In people with AIDS, untreated encephalitis from toxoplasmosis is fatal. Relapse is a constant
concern for people with toxoplasmosis who also have a weakened immune system.Children with
congenital toxoplasmosis may develop disabling complications, including hearing loss, mental disability
and blindness.

Rubella
The signs and symptoms of rubella are often so mild they're difficult to
notice, especially in children. If signs and symptoms do occur, they
generally appear between two and three weeks after exposure to the
virus. They typically last about two to three days and may include:

Mild fever of 102 F (38.9 C) or lower

Headache

Stuffy or runny nose

Inflamed, red eyes

Enlarged, tender lymph nodes at the base of the skull, the back
of the neck and behind the ears

A fine, pink rash that begins on the face and quickly spreads to
the trunk and then the arms and legs, before disappearing in the
same sequence

Aching joints, especially in young women

The cause of rubella is a virus that's passed from person to person. It
can spread when an infected person coughs or sneezes, or it can
spread by direct contact with an infected person's respiratory
secretions, such as mucus. It can also be transmitted from a pregnant
woman to her unborn child via the bloodstream.

A person with rubella is contagious from 10 days before the onset of

the rash until about one or two weeks after the rash disappears. An
infected person can spread the illness before the person realizes he or
she has it.

However, if you're pregnant when you contract rubella, the

consequences for your unborn child may be severe. Up to 90 percent of
infants born to mothers who had rubella during the first 12 weeks of
pregnancy develop congenital rubella syndrome. This syndrome can
cause one or more problems, including:

Growth retardation

Cataracts

Deafness

Congenital heart defects

Defects in other organs

Mental retardation
The highest risk to the fetus is during the first trimester, but exposure
later in pregnancy also is dangerous.

f you contract rubella while you're pregnant, discuss the risks to your
baby with your doctor. If you wish to continue your pregnancy, you may
be given antibodies called hyperimmune globulin that can fight off the
infection. This can reduce your symptoms, but doesn't eliminate the
possibility of your baby developing congenital rubella syndrome.

Support of an infant born with congenital rubella syndrome varies

depending on the extent of the infant's problems. Children with
multiple complications may require early treatment from a team of
specialists.
HIV
Most people experience a short, flu-like illness 2-6 weeks after HIV infection, which lasts for a week or
two.
After these symptoms disappear, HIV may not cause any symptoms for many years, although the virus
continues to damage your immune system. This means many people with HIV don't know they're
infected.
Anyone who thinks they could have HIV should get tested. Certain groups of people are advised to have
regular tests as they're at particularly high risk, including:
men who have sex with men

Black African heterosexuals

people who share needles, syringes or other injecting equipment

HIV is found in the body fluids of an infected person. This includes semen, vaginal and anal fluids, blood,
and breast milk.
It's a fragile virus and doesn't survive outside the body for long. HIV can't be transmitted through sweat,
urine or saliva.
The most common way of getting HIV in the UK is through having anal or vaginal sex without a condom.
Other ways of getting HIV include:
sharing needles, syringes or other injecting equipment

transmission from mother to baby during pregnancy, birth or breastfeeding

The chance of getting HIV through oral sex is very low and will be dependent on many things, such as
whether you receive or give oral sex and the oral hygiene of the person giving the oral sex.

If you're diagnosed with HIV, you'll have regular blood tests to monitor the progress of the HIV infection
before starting treatment.
Two important blood tests are:
HIV viral load test a blood test that monitors the amount of HIV virus in your blood
CD4 lymphocyte cell count which measures how the HIV has affected your immune system
HIV is treated with antiretroviral medications, which work by stopping the virus replicating in the
body. This allows the immune system to repair itself and prevent further damage.
A combination of HIV drugs is used because HIV can quickly adapt and become resistant.
Some HIV treatments have been combined into one pill, known as a fixed dose combination,
although these often cost more to prescribe.
Usually, people who have just been diagnosed with HIV take between one and four pills a day.
Different combinations of HIV medicines work for different people, so the medicine you take will
be individual to you.
 Many of the medicines used to treat HIV can interact with other medications prescribed by your
GP or bought over-the-counter.
These include herbal remedies like St John's Wort, as well as some recreational drugs. Always
check with your HIV clinic staff or your GP before taking any other medicines.

A lumbar puncture is done to:

Find a cause for symptoms possibly caused by an infection (such

as meningitis), inflammation, cancer, or bleeding in the area around the brain or spinal
cord (such as subarachnoid hemorrhage).

Diagnose certain diseases of the brain and spinal cord, such as multiple
sclerosis or Guillain-Barr syndrome.

Measure the pressure of cerebrospinal fluid (CSF) in the space surrounding the spinal
cord. If the pressure is high, it may be causing certain symptoms.

A lumbar puncture may also be done to:

Put anesthetics or medicines into the CSF. Medicines may be injected to

treat leukemia and other types of cancer of the central nervous system.

Put a dye in the CSF that makes the spinal cord and fluid clearer on X-ray pictures
(myelogram). This may be done to see whether a disc or a cancer is bulging into the
spinal canal.

You will lie on a bed on your side with your knees drawn up toward your chest. Or
you may sit on the edge of a chair or bed and lean forward over a table with your head
and chest bent toward your knees. These positions help widen the spaces between the
bones of the lower spine so that the needle can be inserted more easily. If fluoroscopy is
used, you will lie on your stomach so the fluoroscopy machine can take pictures of your
spine during the procedure.

Your doctor marks your lower back (lumbar area) with a pen where the puncture will
occur. The area is cleaned with a special soap and draped with sterile towels. A numbing
medicine (local anesthetic) is put in the skin.

Then a long, thin needle is put in the spinal canal. When the needle is in place, the solid
central core of the needle (stylet) is removed. If the needle is in the right spot in the
spinal canal, a small amount of cerebrospinal fluid (CSF) will drip from the end of the
needle. If not, the stylet will be put back in and the needle will be moved in a little farther
or at a different angle to get to the fluid. Your doctor may need to move to another area
of your spine if it is hard to get to the spinal fluid.

Risks

A lumbar puncture is generally a safe procedure. In some cases, a leak of cerebrospinal fluid (CSF) may develop
after a lumbar puncture. Symptoms of this problem are a headache that does not go away after 1 to 2 days. A CSF
leak can be treated with a blood "patch," in which the person's own blood is injected into the area where the leak is
occurring in order to seal the leak.
Some people (10% to 25%) develop a headache after having a lumbar puncture. Of those who
do get headaches, only about half report that they are severe. These headaches may last up to
48 hours and then go away on their own. Pain medicine does not help control the headache, but
lying flat in bed for several hours after the procedure may help the headache.

About 1 out of 1,000 people who have a lumbar puncture have a minor nerve injury. This heals
on its own with time. Serious nerve injury is very rare. There is also a small chance of infection
of the CSF (meningitis), bleeding inside the spinal canal, or damage to the cartilage between the
vertebrae. Your doctor will talk with you about these risks.

People who have bleeding problems and those who are taking blood-thinning medicine (such as
warfarin or heparin) have a higher chance of bleeding after the procedure. A lumbar puncture
may not be done unless it is needed for a life-threatening illness.

A lumbar puncture may cause serious problems for people who have high pressure in the brain
caused by a tumor, a pocket of infection in the brain (abscess), or major bleeding inside the
brain. Your doctor will check your nervous system, spinal cord and brain before doing a lumbar
puncture. In some cases, a computed tomography (CT) scan or magnetic resonance imaging
(MRI) scan may be done before the lumbar puncture to know that it is safe to do the puncture.

Normal results 1

Appearan
ce: CSF is normally clear and colorless.

Normal CSF pressure in the lower back for an adult ranges from 90-180
Pressure: millimeters (mm) water. For children younger than 8 years old, the normal
opening pressure range is 80-100 mm water.

The normal protein content of CSF in an adult's lower back (lumbar) region
is 15-45 milligrams per deciliter (mg/dL) or 150-450 milligrams per liter
Protein:
(mg/L). Older adults and children may have higher values that are still in
the normal range.

The normal range for CSF glucose content for adults is 40-70 mg/dL or
Glucose: 2.2-3.9 millimoles per liter (mmol/L). For children, the normal range for
glucose in CSF is 60-80 mg/dL or 3.3-4.4 mmol/L.

Normal CSF contains no red blood cells (RBCs). The white blood cell
Cell counts: (WBC) count for adults is 0-5 WBCs per cubic millimeter (mm3). Children
may normally have a higher WBC count. No neutrophilsare present.

Other No infectious organisms (such as bacteria, fungi, or a virus) are found in

results: the CSF sample. No tumor cells are present.

Abnormal results
 Blood in the CSF can result from bleeding (hemorrhage) in or around the
spinal cord or brain, but it may also be caused by tiny blood vessel poked
during the spinal tap. If a brain hemorrhage has occurred, the color of the
CSF may change from red to yellow to brown over several days. Bleeding
caused by the lumbar puncture itself will show more red blood cells in the
Appearan first sample collected than in later samples. Cloudy CSF may mean an
ce: infection (such as meningitis or a brain abscess) is present.

High CSF pressure may occur as a result of swelling (edema) or bleeding

(hemorrhage) in the brain, infection (such as meningitis), stroke, or other
Pressure:
circulatory problems. Below-normal pressure may mean a blocked spinal
canal.

A high level of protein may be caused by bleeding in the CSF, a tumor or

spread of a cancer from another area of the body, diabetes, infection,
injury, Guillain-Barr syndrome, severe hypothyroidism, or other nerve
Protein:
diseases. An increase in antibodies (immune system proteins) may be
caused by inflammation in people who have multiple sclerosis, immune
system disorders, or bacterial and viral infections.

Low glucose levels in the CSF are abnormal and may be caused
by bacterial meningitis. Viral meningitis does not often cause low glucose
Glucose: levels in the CSF. Brain hemorrhage may also cause low glucose levels
several days after bleeding begins. Higher-than-normal glucose levels are
often caused by diabetes.

Red blood cells (RBCs) in the CSF can result from bleeding. High levels of
Cell counts:
white blood cells (WBCs) can indicate meningitis.

Bacteria or other organisms in the CSF means that an infection (such

as syphilis) or disease is present. Bacterial markers (bacterial antigens)
Other
that show up mean meningitis. Cultures or stains of the CSF may also help
results:
show the cause of meningitis or encephalitis. Identifying tumor cells can
show cancer is present.

Normal-Pressure Hydrocephalus (NPH), or Adult Communicating Hydrocephalus.

NPH is a result of an imbalance between how much CSF is produced by the brain and how
much is reabsorbed. When too much fluid is produced and/or not enough fluid is reabsorbed,
fluid backs up inside the skull and can damage the brain.
The most common symptoms that result are problems with walking, urinary incontinence,
and cognitive slowing such as short term memory loss and dementia. These symptoms often
indicate the need for surgery

The surgical treatment for NPH involves the placement of a one-way valve, called a shunt, to
remove excess fluid from the brain. The most common type of shunt drains fluid from its
source inside the brains ventricles directly into the abdomen. This is called
a ventriculoperitoneal (VP) shunt.

Another method (and the subject of this paper) uses a ventriculoatrial (VA) shunt. Here,
the excess fluid is drained out of the ventricles of the brain directly into the heart. This type
of shunting is rarely used, however, due to reports in the pediatric literature that indicate it
may be associated with cardiopulmonary (heart and lung) complications.

Dr. Guy McKhann and co-authors*, including neurosurgery resident Dr. Robert McGovern,
have taken a second look at this claim in their paper, Should ventriculoatrial shunting be the
procedure of choice for normal-pressure hydrocephalus?. They published their findings last
month in the Journal of Neurosurgery.

These complications have typically been limited to adults in whom VA shunts had been
placed when they were children, they said. Few studies have directly compared VA
shunting to ventriculoperitoneal (VP) shunting in cases of normal pressure hydrocephalus
(NPH).

The authors looked at patients with NPH treated by Dr. McKhann at Columbia University
Medical Center/New York Presbyterian Hospital from 2002 and 2011: thirty patients
underwent VA shunting and 157 underwent VP shunting.

The authors found no significant differences in complication rates between VA and VP

shunting, and they said, VA shunting was not associated with any cardiopulmonary
complications. Thus, in the authors experience, VA shunting is at least as safe as VP
shunting for treating NPH.

This is good news, according to Dr. McKhann who says:

In the past, we reserved VA shunting for adult hydrocephalus patients who had a relative
contraindication to VP shunting [That is, they had a medical condition that would make it
relatively unsafe]. Now we are reconsidering it as a potential first line option. For example, it
is preferable in patients who have had prior abdominal surgery or are overweight. VA
shunting is technically simple and safe, and draining spinal fluid into the venous system [via
the heart] rather than the abdominal cavity may provide more effective shunt function.
Hopefully other large volume centers like ours will contribute their experience to help us
determine, as a neurosurgical community if there is a definite advantage to one type of
shunting over the other.

Ventriculoatrial shunt placement is indicated for patients with shunt-dependent hydrocephalus in whom
the peritoneum is not an acceptable site for distal catheter placement. Some surgeons may prefer to
position the distal portion of the shunt into the pleural space rather than the cardiac atrium.
A retrospective analysis by McGovern et al found that for normal-pressure hydrocephalus, ventriculoatrial
shunting appeared to be at least as safe as the more commonly used ventriculoperitoneal shunting
Contraindications for ventriculoatrial shunt placement include the following:
Bacteremia
CSF infection
Endocarditis
History of immune complex glomerulonephritis (eg, shunt nephritis)
Prothrombotic state
Pulmonary hypertension
Congestive heart failure
Relative contraindications may include a history of pulmonary embolism and systemic anticoagulation.

Contraindications vp shunt

Absolute
See the list below:
Infection over the entry site
Relative
See the list below:
Coagulopathy
Lack of shunt imaging or information
Because shunt aspiration removes cerebrospinal fluid (CSF) from the supratentorial compartment,
increased intracranial pressure is not a contraindication.

Resiko semua shunt saat kateter ditembusin ke otak bias hemorrhage between the skull and brain, in brain, in
ventricle, dead brain tissue(stroke), bacterial infection